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    Patent Pending

    Critical Care Pain Observation Tool (CPOT)

    Rates critically ill patients’ pain based on clinical observation.
    When to Use
    Why Use

    The CPOT can be used to assess intubated or sedated patients pain based on facial expressions, muscle tension and movement as well as compliance with ventilated breaths for intubated patients or vocalized pain for non-intubated patients.

    The Critical Care Pain Observation Tool (CPOT) was designed to assess the pain of critically ill patients who are incapable of reporting their pain.

    • The gold standard of pain assessment is patient’s self-reported pain.
    • The CPOT was created from retrospective reviews of common pain characteristics and vetted by ICU nurses and physicians.
      • Physiologic finding were removed after initial evaluation.
    • The original study included cardiac patients who were relatively healthy, only 2 data collectors performed the analysis, and one evaluation only included 33 patients out of 105.
    • CPOT scores were higher when conscious and intubated than when unconscious or extubated, which is thought to be due to endotracheal tube discomfort or positive pressure causing incision site pain.
    • CPOT scores were similar for unconscious and conscious extubated patients which may be due to lingering anesthesia or pain resolution from extubation.
    • Further analyses have validated the score in multiple post-surgical and medical ICU settings.
    • It is estimated that up to 71% of ICU patients experience untreated pain. (Gélinas 2007)
    • The Society of Intensive Care Medicine recommends routine monitoring of pain in ICU patients.
    • Treatment of pain is associated with fewer days on mechanical ventilation, decreased infections and increased satisfaction.
    • The CPOT is an innovative pain assessment tool that is based on 2 preliminary studies with expert selected variables, prior research of behavioral indicators for pain and vigorously compared scores at varying levels of consciousness.
    Relaxed, neutral
    Absence of movements
    Tense, rigid
    Very tense or rigid


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    Next Steps
    Creator Insights


    • The CPOT is designed to scale the pain of patients who are unable to report it themselves through objective findings.
    • The CPOT has good interrater reliability in multiple studies and high sensitivity when patients are in pain.


    For those patients with a CPOT score of ≤ 2:

    • There is likely minimal to no pain present. Consider re-evaluation in the future.

    For those patients with a CPOT score of >2:

    • There is an unacceptable level of pain. Consider further or alternative analgesia and sedation.

    Critical Actions

    Regular re-evaluation is crucial to appropriate pain management.


    Addition of selected points, as above.

    Facts & Figures

    Scoring system and definitions of criteria:

      Criteria Score Definition
    Facial expression Relaxed, neutral 0 No muscular tension observed
    Tense 1 Presence of frowning, brow lowering, orbit tightening
    Grimacing 2 All of the above facial movements plus eyelids tightly closed
    Body movements Absence of movements 0 Does not move at all (does not necessarily mean absence of pain)
    Protection 1 Slow cautious movements, touching or rubbing the pain site, seeking attention through movements
    Restlessness 2 Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands
    Muscle tension
    (Evaluation by passive flexion and
    extension of upper extremities)
    Relaxed 0 No resistance to passive movements
    Tense, rigid 1 Resistance to passive movements
    Very tense or rigid 2 Strong resistance to passive movements; inability to complete them
    Compliance with the ventilator
    (Intubated patients only)
    Tolerating ventilator or movement 0 Alarms not activated, easy ventilation
    Coughing but tolerating 1 Alarms stop spontaneously
    Fighting ventilator 2 Asynchrony: blocking ventilation, alarms frequently activated
    (Extubated patients only)
    Talking in normal tone or no sound 0 Talking in normal tone or no sound
    Sighing, moaning 1 Sighing, moaning
    Crying out, sobbing 2 Crying out, sobbing

    Evidence Appraisal

    • Exclusion criteria: included heart transplant, thoracic aortic aneurysm repair, medication for chronic pain or EF <25%, psychiatric illness or neurologic problems, dependence on alcohol or drug use, received neuromuscular blockers or had surgical complications (hemorrhage, delirium).
    • Elements of the CPOT were developed from a chart review on 52 critically ill patients and focus groups of nurses and physicians. Relevance of inclusion criteria was validated with 4 physicians and 13 critical care nurses via a Likert scale, with content validity indexes 0.88-1.0.
    • 105 patients were included in the cohort. Each was tested three times during three periods for a total of 9 assessments. Each of the three tests was performed 1 minute before, during and 1 minute after a positioning procedure.
      • 1-3 were performed while intubated and unconscious.
      • 4-6 was performed 3 hours later while intubated but conscious.
      • 7-9 was performed after extubation.
    Testing Period Assessment Mean CPOT SD
    1 (n=33) 1: 1 min before
    2: positioning
    3: 1 min after
    2 (n=99) 4: 1 min before
    5: positioning
    6: 1 min after
    3 (n=1-5) 7: 1 min before
    8: positioning
    9: 1 min after

    • Interrater reliability was high (κ>0.6-0.88) for all testing periods except for test 4 (κ=0.52).
    • There was statistically significant increase in CPOT during positioning when compared to “before” in all three testing phases:
      • 1: t(32)=-9.01, p<0.001
      • 2: t(98)=-12.07, p<0.001
      • 3: t(104)=-15.96, p<0.001
        • [α=0.01]
    • With intubated patients during the second testing period, CPOT scores differed between those who reported pain and those who did not. During the final testing period CPOT scores correlated with reported pain intensity scores.
    • Post-Hoc analysis in 2009 showed a sensitivity and specificity of 86% and 78% respectively during positioning. Sensitivity was 83% and 63% before and after positioning, while specificity was 83% and 97%. A cutoff of >2 was established for nociceptive exposure.
    • A 2010 nursing evaluation found that 72.7% of the respondents would recommend the CPOT for routine use, and 78% found it easy to use.
    • A 2011 Spanish study found an average CPOT prior to, during and after positioning of 0.27, 1.93, and 0.10 respectively, with κ = 0.79.
    • The author of the original study performed an implementation study with a 4x increase in pain assessments, suggesting nurses were more alert to pain symptoms.
    • A 2014 validation study compared three pain evaluation scales, with significant associations between the CPOT, the FLACC (0.87-0.92), and the Pain Intensity Numeric Rating Scale (0.50-0.69).
    • A 2014 NSICU study demonstrated significantly higher scores for those patients who reported pain during positioning. AUC analysis showed good discrimination; 0.864, p<0.001 (CI 95%=0.757-0.971).
    • A 2014 study in Amsterdam compared the CPOT to the Behavior Pain Scale (BPS). Intraclass correlation coefficient was 0.6 - 0.81. During non-painful events the BPS had significant increase while the CPOT did not.



    Research PaperGelinas C, Fillion L, Puntillo K, Viens C, Fortier M. Validation of the Critical-Care Pain Observation Tool in adult patients. Am J Crit Care. 2006;15:420-427.Research PaperButtes P, Keal G, Cronin SN, Stocks L, Stout C. Validation of the critical-care pain observation tool in adult critically ill patients. Dimens Crit Care Nurs. 2014 Mar-Apr;33(2):78-81.Research PaperEchegaray-Benites C, Kapoustina O, Gélinas C. Validation of the use of the Critical-Care Pain Observation Tool (CPOT) with brain surgery patients in the neurosurgical intensive care unit. Intensive Crit Care Nurs. 2014. Oct;30(5):257-65.Research PaperGélinas C, Harel F, Fillion L, Puntillo KA, Johnston CC. Sensitivity and specificity of the critical-care pain observation tool for the detection of pain in intubated adults after cardiac surgery. J Pain Symptom Manage. 2009 Jan;37(1):58-67.Research PaperRijkenberg S, et. al. Pain measurement in mechanically ventilated critically ill patients: Behavioral Pain Scale versus Critical-Care Pain Observation Tool. J Crit Care. 2015 Feb;30(1):167-72. doi: 10.1016/j.jcrc.2014.09.007. Epub 2014 Sep 22.

    Other References

    Research PaperPuntillo KA, White C, Morris AB, et al. Patients' perceptions and responses to procedural pain: results from Thunder Project II. Am J Crit Care. 2001;10:238-251.Research PaperGélinas C, Johnston C. Pain assessment in the critically ill ventilated adult:validation of the Critical-Care Pain Observation Tool and physiologic indicators. Clin J Pain. 2007 Jul-Aug;23(6):497-505.Research PaperGélinas C. Nurses' evaluations of the feasibility and the clinical utility of the Critical-Care Pain Observation Tool. Pain Manag Nurs. 2010 Jun;11(2):115-25.Research PaperVázquez M, Pardavila MI, Lucia M, Aguado Y, Margall MÁ, Asiain MC. Pain assessment in turning procedures for patients with invasive mechanical ventilation. Nurs Crit Care. 2011 Jul-Aug;16(4):178-85Research PaperStites M. Observational pain scales in critically ill adults. Crit Care Nurse. 2013 Jun;33(3):68-78.Research PaperGélinas C. Management of pain in cardiac surgery ICU patients: have we improved over time? Intensive Crit Care Nurs. 2007 Oct;23(5):298-303. Epub 2007 Apr 19.
    Dr. Céline Gélinas

    About the Creator

    Céline Gélinas, RN, PhD, is an associate professor at the Ingram School of Nursing, McGill University and a nurse scientist at the Lady Davis Institute of the Jewish General Hospital in Montréal. She evaluates nursing interventions as a co-lead of the Réseau de recherche en interventions en sciences infirmières du Québec (RRISIQ). Dr. Gélinas’ research focuses on critical care nursing and pain assessment, measurement and management.

    To view Dr. Céline Gélinas's publications, visit PubMed

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    About the Creator
    Dr. Céline Gélinas
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