***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Purpose Systematic monitoring of sedation , pain and delirium in the ICU is of paramount importance in delivering adequate patient care . While the use of systematic monitoring instruments is widely agreed upon , these tools are infrequently implemented into daily ICU care . The aim of this study is to compare the effectiveness of two different training strategies ( training according to the local st and ard vs. modified extended method ) on the implementation rate of scoring instruments on the ICU . Methods In this experimental cohort study we analyzed the frequency of scoring on three surgical ICUs before and after training , and in a 1 year follow-up . A modified extended training included establishing a local support team helping to resolve immediate problems . In addition we evaluated the impact on patients ’ outcome . Results ICUs trained by the modified extended method showed increased documentation rates of all scores per patient and day . In a 1 year follow-up , increased scoring rates for all scores were maintained . Scoring rates with training according to the local st and ard training protocol did not increase significantly . Implementation of delirium and pain monitoring were associated with a decrease in mortality [ odds ratio ( OR ) 0.451 ; 95 % confidence interval ( CI ) : 0.22–0.924 , and , respectively , OR 0.348 ; 95 % CI : 0.140–0.863 ] . Monitoring had no significant influence on ventilation time or ICU length of stay . Conclusions A modified extended training strategy for ICU monitoring tools ( sedation , pain , delirium ) leads to higher intermediate and long-term implementation rates and is associated with improved patient outcome . However , these findings may have been biased by unmeasured confounders There has been growing interest in determining the possible immune consequences of opioid administration for the management of postoperative pain .  We studied the effects of morphine and tramadol on pain and immune function during the postoperative period in 30 patients undergoing abdominal surgery for uterine carcinoma .  Phytohemoagglutinin-induced T lymphocyte proliferation and natural killer cell activity were evaluated immediately before and after surgery , and 2 h after the acute administration of either 10 mg of morphine IM or 100 mg tramadol IM for pain . In all patients , phytohemagglutinin-induced lymphoproliferation was significantly depressed by surgical stress . However , in the morphine-treated group , proliferative values remained lower than basal levels for 2 h after treatment , whereas in tramadol-administered patients proliferative values returned to basal levels . Natural killer cell activity was not significantly affected by surgery nor by morphine administration , whereas tramadol significantly enhanced the activity of natural killer cells . Both drugs produced a comparable reduction in postoperative pain . We conclude that , as previously observed in the experimental animal , tramadol and morphine , when administered in analgesic doses , induce different immune effects . Implication s Recent studies suggest that opioids can have an adverse impact on the immune system . Because surgical stress also induces immune dysfunction , the search for analgesic drugs devoid of immunosuppressive effects is of import . This study compared the effects on immune responses of morphine and of the atypical opioid analgesic , tramadol , given for postoperative pain to gynecological cancer patients .  Tramadol and morphine showed comparable analgesic activity ; however , tramadol , in contrast to morphine , induced an improvement of postoperative immunosuppression and , therefore , may be preferred to morphine for the treatment of postoperative pain Objective To establish the validity and reliability of a new  behavioral pain scale ( BPS ) for critically ill se date d adult patients . Design Prospect i ve evaluation . Setting Ten-bed trauma and surgical intensive care unit in a university teaching hospital . Patients Thirty mechanically ventilated patients who were receiving analgesia and sedation .  Intervention Assessment s with the BPS were completed consecutively at st and ardized times ( morning , afternoon , night ) by pairs of evaluators ( nurse and nurse ’s aide ) . They collected physiologic parameters and BPS results before and during care procedures : nonnociceptive ( group 1 , compression stockings application and central venous catheter dressing change ) , nociceptive ( group 2 , endotracheal suctioning and mobilization ) , and retested nociceptive ( group 3 ) . The BPS score was the sum of three items that had a range score of 1–4 : facial expression , movements of upper limbs , and compliance with mechanical ventilation . Measurements and Main Results Two hundred and sixty nine assessment s were completed , including 104 , 134 , and 31 measurements in groups 1 , 2 and 3 , respectively . There was no difference in Ramsay scale scores between the three groups ( Ramsay 4–6 ) . Nociceptive stimulations ( group 2 ) result ed in significantly higher BPS values than nonnociceptive ones ( group 1 , 4.9 vs. 3.5 , p < .01 ) , whereas the two groups had comparable BPS values before stimulation ( 3.1 vs. 3.0 ) . A trend was found in group 2 between the dosage of sedation/analgesia and BPS : the higher the dosage , the lower BPS values and BPS changes to nociceptive stimulation . Group 3 had BPS values similar to group 2 at rest ( 3.2 vs. 3.2 ) and during the procedure ( 4.4 vs. 4.5 ) , with good interrater correlations ( r2 = .71 and .50 , respectively ) . Conclusions These results indicate that the expression of pain can be scored validly and reliably by using the BPS in se date d , mechanically ventilated patients . Further studies are warranted regarding the utility of the BPS in making clinical decisions about the use of analgesic drugs in the intensive care unit Objective : To measure the impact of implementation of the systematic evaluation of pain and agitation by nurses  using the Behavioral Pain Scale ( BPS ) , the Numerical Rating Scale ( NRS ) for pain , and the Richmond Agitation Sedation Scale ( RASS ) associated with medical staff education in analgesia and sedation management in intensive care unit ( ICU ) patients . Design : Two-phase , prospect i ve , controlled study . Setting : Twelve-bed medical-surgical ICU in a university hospital . Patients : Consecutive patients staying > 24 hrs in ICU . Interventions :  BPS , NRS , and RASS were measured twice daily , at rest , by independent observers during 21 wks ( control group ) and after 4 wks of training , by nurses during 29 wks ( intervention group ) . In the intervention group , the treating physician was alerted in case of pain defined by BPS > 5 or NRS > 3 or in case of agitation defined by RASS > 1 . Measurements and Main Results : A total of 230 patients were included ( control group , n = 100 ; intervention group , n = 130 ) . Baseline characteristics were not significantly different . The incidence of pain and agitation decreased significantly in the intervention group : 63 % vs. 42 % ( p = .002 ) and 29 % vs. 12 % ( p = .002 ) , respectively . Rate of severe pain and agitation events defined by NRS > 6 and RASS > 2 , respectively , also decreased significantly . There were significantly more therapeutic changes in the intervention group in the way of an escalation but also in the way of a de-escalation for analgesic and psychoactive drugs . Compared with the control group , there was a marked decrease in the duration of mechanical ventilation ( 120 [ interquartile range 48–312 ] vs. 65 ( 24–192 ) hrs , p = .01 ) and nosocomial infections rate ( 17 % vs. 8 % , p < .05 ) in the intervention group . There was no significant difference in median length of stay ( 9 [ 4 , 15 ] vs. 7 [ 4 , 13 ] days ) and mortality in ICU ( 12 vs. 15 % ) . Conclusions : Systematic evaluation of pain and agitation , and analgesics and sedatives need was associated with a decrease in incidence of pain and agitation , duration of mechanical ventilation and nosocomial infections Background : Critically ill patients frequently experience pain , but assessment rates remain below 40 % in mechanically ventilated patients . Whether pain assessment affects patient outcomes is largely unknown . Methods : As part of a prospect i ve cohort study of mechanically ventilated patients who received analgesia on day 2 of their stay in the intensive care unit ( ICU ) , the investigators performed propensity-adjusted score analysis to compare the duration of ventilator support and duration of ICU stay between 513 patients who were assessed for pain and 631 patients who were not assessed for pain . Results : Patients assessed for pain on day 2 were more likely to receive sedation level assessment , nonopioids , and dedicated analgesia during painful procedures than patients whose pain was not assessed . They also received fewer hypnotics and lower daily doses of midazolam . Patients with pain assessment had a shorter duration of mechanical ventilation ( 8 vs. 11 days ; P < 0.01 ) and a reduced duration of stay in the ICU ( 13 vs. 18 days ; P < 0.01 ) . In propensity-adjusted score analysis , pain assessment was associated with increased odds of weaning from the ventilator ( odds ratio , 1.40 ; 95 % confidence interval , 1.00–1.98 ) and of discharge from the ICU ( odds ratio , 1.43 ; 95 % confidence interval , 1.02–2.00 ) . Conclusions : Pain assessment in mechanically ventilated patients is independently associated with a reduction in the duration of ventilator support and of duration of ICU stay . This might be related to higher concomitant rates of sedation assessment s and a restricted use of hypnotic drugs when pain is assessed BACKGROUND Pain can adversely affect a patient 's physiological and psychological recovery , yet little is known about the pain experience of cardiac surgical patients . OBJECTIVES To examine nursing practice regarding analgesic administration and measure pain intensity and patient satisfaction with pain management practice s. METHODS To establish baseline nursing practice regarding analgesic administration , charts were review ed retrospectively in 50 adult cardiac surgical patients , and the same information was collected concurrently for a prospect i ve sample of 51 patients . The subjects completed  visual analogue scales as a  measure of  pain intensity twice daily while in the cardiothoracic intensive care unit and  Pain Relief Satisfaction Question naires on the day after transfer from the unit . RESULTS Patients in the prospect i ve group received significantly more  analgesia  . Pain intensity was moderate ( 4 or greater on the Visual Analogue Scale ) . Women had higher overall visual analogue scale scores than did men , 4.57 versus 3.70 . Patients in whom an internal mammary artery had been used as a bypass graft had significantly higher scores compared with patients with vein grafts . The Pain Relief Satisfaction Question naire responses indicated that 96 % of the patients experienced effective pain management in the cardiothoracic intensive care unit . CONCLUSIONS Despite receiving analgesic doses twice those reported elsewhere for similar population s , the patients in this study reported moderate pain intensity . This finding was confounded by the fact that 96 % expressed satisfaction with their pain management in the cardiothoracic intensive care unit . Frequent assessment and documentation of both pain and pain relief from interventions are necessary if the healthcare team is to implement an individualized analgesic regimen Background : The authors conducted a patient-based survey of practice s to fully describe the assessment and the management of  pain and sedation  of a large cohort of mechanically ventilated patients during their first week of intensive care unit ( ICU ) stay . Methods : A total of 1,381 adult patients were included in a prospect i ve , observational study in 44 ICUs in France .  Pain and sedation assessment , analgesic and sedative use , and analgesic management during procedural pain were collected on days 2 , 4 , and 6 of the ICU stay . Results : The observed rates of assessment on day 2 for sedation ( 43 % ) and analgesia ( 42 % ) were significantly smaller than that of use of sedatives ( 72 % ) and opioids ( 90 % ) , also noted on days 4 and 6 . The use of protocol s/ guidelines for sedation/analgesia in the ICU reduced the proportion of patients who were treated , although not evaluated . A large proportion of assessed patients were in a deep state of sedation ( 40–50 % ) . Minor changes in the dosages of the main prescribed agents for sedation ( midazolam , propofol ) and analgesia ( sufentanil , fentanyl , morphine , remifentanil ) were found across 6 days of the patient ’s ICU stay . Procedural pain was specifically managed for less than 25 % of patients ; during those procedures , the proportion of patients with pain significantly increased from the baseline pain evaluation . Conclusions : Excessively deep states of sedation and a lack of analgesia during painful procedures must be prevented . To facilitate systematic pain and sedation assessment and to adjust daily drug dosages accordingly , it seems crucial to promote educational programs and elaboration of protocol s/ guidelines in the ICU BACKGROUND Administration of analgesics per patient request or r and om pain assessment s may provide inadequate pain management . OBJECTIVE To examine the impact of nurses ' use of a st and ardized pain flowsheet to document pain assessment and pharmacologic management on  patient-reported pain intensity .  METHODS A pre-post intervention design was used to compare 61 patients . In the preimplementation group , traditional charting of pain presence or absence was documented in the narrative notes and pharmacologic management was recorded on the medication profile . In the postimplementation group , the intensity of pain and pharmacologic management were documented on a pain flowsheet . Within 24 hours after transfer to the step-down unit , patients were interviewed 
    Output:
    
Implementation of systematic approaches to pain assessment appears to associate with more frequent documented reports of pain and more efficient decisions for pain management .
There was evidence of favorable effects on pain intensity , duration of mechanical ventilation , length of ICU stay , mortality , adverse events , and complications .
This systematic review demonstrates a link between systematic pain assessment  and outcome in critical illness .