Unlike wards, where chronic and acute pain are regularly managed, comparisons of the most commonly used self-report pain tools have not been reported for the intensive care unit (ICU) setting. The objective of this study was to compare the feasibility, validity and performance of the Visual Analog Scale (horizontal (VAS-H) and vertical (VAS-V) line orientation), the Verbal Descriptor Scale (VDS), the 0-10 oral Numeric Rating Scale (NRS-O) and the 0-10 visually enlarged laminated NRS (NRS-V) for pain assessment in critically ill patients. One hundred and eleven consecutive patients admitted into a medical-surgical ICU were included as soon as they became alert and were able to follow simple commands. Pain was measured using the 5 scales in a randomized order upon enrollment-(T1) and after-(T2) administration of an analgesic or, in absence of pain upon enrollment, after a nociceptive procedure. The rate of any response obtained both at T1 and T2 (success rate) was significantly higher for NRS-V (91%) compared with NRS-O (83%), VDS (78%), VAS-H (68%) and VAS-V (66%). Pain intensity changed significantly between T1 and T2, showing a good validity and responsiveness for the 5 scales, which correlated well between each other. The negative predictive value calculated from true and false negatives defined by real and false absence of pain was highest for NRS-V (90%). In conclusion, the NRS-V should be the tool of choice for the ICU setting, because it is the most feasible and discriminative self-report scale for measuring critically ill patients' pain intensity.

Pain during procedures is perceived even in non-intubated ICU patients with delirium. In those patients, pain level can be assessed with the BPS-NI scale since this instrument exhibited good psychometric properties. Electronic supplementary material The online version of this article (doi:10.1007/s00134-009-1590-5) contains supplementary material, which is available to authorized users.

We read with interest the investigation by Dr. Wan et al. 1 of postoperative impairment of cognitive function in rats. We would like to ask whether the investigators believe there was an adequate control group with which to compare the results of their surgical intervention. In addition to the neuroleptic analgesia group alone, it may have been advantageous to include a sham surgical group that received a similar skin incision to the splenectomized group of rats with postoperative treatment of bupivacaine infiltration. This may have permitted an assessment of the contribution of a surgical incision alone with wound infiltration of 0.25% bupivacaine, because, contrary to the suggestion by the authors, the two groups of rats may not have received identical anesthetic regimens, i.e., there was no assessment of the contribution of the local anesthetic infiltration. Bupivacaine has been shown on its own to suppress systemic cytokine activation when given locally or systemically. 2 The investigators suggest the neuroinflammatory changes are related solely to the splenectomy surgical injury and not to other factors, such as the development of postoperative infection, which may or may not have been recognized in these rats. Splenectomized animals would more likely develop postoperative infections, and that by itself may alter neurocytokine levels. 3 In addition, surgical healing and its potential impairment of full ambulation in the rats after splenectomy may have also contributed to their difficulty in completing the learning maze, which may or may not have been related to neurocognitive impairment. A few animals with postoperative infection or impairment in their ambulation may have skewed the results on days 1 and 3 after surgery and may explain the large range of learning abilities seen in the Y-maze testing on those days. It would be interesting to note whether there were individual animal correlates of increased neuroinflammation with increased learning times in the maze.We appreciate the work presented by Dr. Wan et al. because they raise important issues with regard to postoperative cognitive impairment and the role of inflammatory changes in the central nervous system.

Tramadol's unique mechanism of action suggests efficacy as a local anesthetic adjunct for peripheral plexus blockade. Our study demonstrates that tramadol, added to mepivacaine for brachial plexus anesthesia, extends the duration and improves the quality of postoperative analgesia in a dose dependent fashion with acceptable side effects.

Parecoxib and parecoxib+propacetamol provided significant opioid-sparing efficacy compared with placebo; non-inferiority of parecoxib to parecoxib+propacetamol was not demonstrated. Opioid-sparing efficacy was accompanied by significant reductions in pain intensity on movement, improved functional outcome, and less opioid-related symptom distress. Study medications were well tolerated.