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Can the Nociception Coma Scale-Revised Be Used in Patients With a Tracheostomy?

Published:November 22, 2019DOI:https://doi.org/10.1016/j.apmr.2019.09.020

      Highlights

      • The Nociception Coma Scale-Revised (NCS-R) has been developed to assess nociception in patients with disorders of consciousness.
      • Verbal and total scores of the NCS-R are lower in patients with a tracheostomy.
      • Facial and motor subscores do not differ between patients with or without tracheostomy.
      • NCS-R scores should be cautiously interpreted in the presence of tracheostomy.
      • However, our findings support the use of the NCS-R in real clinical practice.

      Abstract

      Objective

      To investigate the influence of the presence of a tracheostomy tube to assess pain with the Nociception Coma Scale-Revised (NCS-R) in patients with disorders of consciousness (DOC).

      Design

      A cohort study in which patients were evaluated at a single time point.

      Setting

      Patients were evaluated in a tertiary care hospital.

      Participants

      Patients (N=125) (unresponsive wakefulness syndrome [UWS]: 46 patients, minimally conscious state [MCS]: 74 patients, emerging from MCS [eMCS]: 5 patients, mean age: 46±16y, time since injury: 817±1280d) in a convenience sample were evaluated with the NCS-R after noxious stimulation.

      Interventions

      Not applicable.

      Main Outcome Measures

      We compared the NCS-R scores of patients with and without tracheostomy with a Mann-Whitney U test. A secondary outcome was to evaluate the influence of the presence of a tracheostomy on the previously described cutoff score of 2.

      Results

      The presence of a tracheostomy was associated with lower verbal subscores (P=.002) as well as total scores (P=.039). The cutoff score of 2 remained valid for the group of patients with tracheostomy with a high sensitivity (71.43%) and specificity (89.29%), as well as when we excluded the verbal subscore of the NCS-R (sensitivity=83.2% and specificity=92.4%).

      Conclusion

      Our study confirms the validity of the NCS-R in DOC patients with a tracheostomy. However, the presence of a nonspeaking tracheostomy should be clearly mentioned when applying the NCS-R, because it significantly lowers the verbal subscore.

      Keywords

      List of abbreviations:

      DOC (disorders of consciousness), MCS (minimally conscious state), NCS-R (Nociception Coma Scale Revised), UWS (unresponsive wakefulness syndrome)
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