Spanish Translation and Cultural Adaptation of the Intensive Care Unit Delirium Playbook.

Background: A lack of high-quality provider education hinders the delivery of standard-of-care delirium detection and prevention practices in the intensive care unit (ICU). To fill this gap, we developed and validated an e-learning ICU Delirium Playbook consisting of eight videos and a 44-question knowledge assessment quiz. Given the increasing Spanish-speaking population worldwide, we translated and cross-culturally adapted the playbook from English into Spanish. Objective: To translate and culturally adapt the ICU Delirium Playbook into Spanish, the second most common native language worldwide. Methods: The translation and cross-cultural adaptation process included double forward and back translations and harmonization by a 14-person interdisciplinary team of ICU nurses and physicians, delirium experts, methodologists, medical interpreters, and bilingual professionals representing many Spanish-speaking global regions. After a preeducation quiz, a nurse focus group completed the playbook videos and posteducation quiz, followed by a semistructured interview. Results: The ICU Delirium Playbook: Spanish Version maintained conceptual equivalence to the English version. Focus group participants posted mean (standard deviation) pre- and post-playbook scores of 63% (10%) and 78% (12%), with a 15% (11%) pre-post improvement (P = 0.01). Participants reported improved perceived competency in performing the Confusion Assessment Method for the ICU and provided positive feedback regarding the playbook. Conclusion: After translation and cultural adaptation, the ICU Delirium Playbook: Spanish Version yielded significant knowledge assessment improvements and positive feedback. The Spanish playbook is now available for public dissemination.

Development and Validation of an ICU Delirium Playbook for Provider Education.

Although delirium detection and prevention practices are recommended in critical care guidelines, there remains a persistent lack of effective delirium education for ICU providers. To address this knowledge-practice gap, we developed an "ICU Delirium Playbook" to educate providers on delirium detection (using the Confusion Assessment Method for the ICU) and prevention. DESIGN: Building on our previous ICU Delirium Video Series, our interdisciplinary team developed a corresponding quiz to form a digital "ICU Delirium Playbook." Playbook content validity was evaluated by delirium experts, and face validity by an ICU nurse focus group. Additionally, focus group participants completed the quiz before and after video viewing. Remaining focus group concerns were evaluated in semi-structured follow-up interviews. SETTING: Online validation survey, virtual focus group, and virtual interviews. SUBJECTS: The validation group included six delirium experts in the fields of critical care, geriatrics, nursing, and ICU education. The face validation group included nine ICU nurses, three of whom participated in the semi-structured feedback interviews. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The 44-question quiz had excellent content validity (average scale-level content validity index [S-CVI] of individual items = 0.99, universal agreement S-CVI = 0.93, agreement κ ≥ 0.75, and clarity p ≥ 0.8). The focus group participants completed the Playbook in an average (sd) time of 53 (14) minutes, demonstrating significant improvements in pre-post quiz scores (74% vs 86%; p = 0.0009). Verbal feedback highlighted the conciseness, utility, and relevance of the Playbook, with all participants agreeing to deploy the digital education module in their ICUs. CONCLUSIONS: The ICU Delirium Playbook is a novel, first-of-its-kind asynchronous digital education tool aimed to standardize delirium detection and prevention practices. After a rigorous content and face validation process, the Playbook is now available for widespread use.

Pain, Anxiety, and the Continuous Use of Opioids and Benzodiazepines in Trauma Intensive Care Unit Survivors: An Exploratory Study.

OBJECTIVE: To evaluate at-home opioid and benzodiazepine use, the degrees of pain and anxiety, and the incidence of probable withdrawal in post-discharge Trauma Intensive Care Unit (TICU) survivors. METHODS: This was an exploratory study of post-TICU survivors who had participated in a previous study of opioid and benzodiazepine withdrawal. We surveyed survivors by telephone asking for retrospective information (during their first 4-months postdischarge- Time 1) and current information (around 2-years post-discharge- Time 2). RESULTS: A mostly male (82%), young (median 38 years [IQR, 28-52]) sample of 27 TICU survivors reported using opioids (56%) at Time 1 for a median of 30 (IQR,14-90) days. Twelve percent of 26 survivors were still using opioids at Time 2. Sixty percent of the survivors had pain during Time 1, a median pain score of 6 (IQR, 5-8) on a 0-10 numeric rating scale (NRS).; 57% had pain at Time 2, median NRS score=6 (IQR, 4-7). Sixty-five percent of survivors had anxiety during Time 1, NRS median=7 (IQR, 5-9); 50% had anxiety at Time 2, NRS median= 6 (IQR, 3-7). At Time 1, 26% used prescribed benzodiazepines, and 12% used benzodiazepines at Time 2. Five and one of the 27 patients reported symptoms of opioid or benzodiazepine withdrawal, respectively, upon discontinuation or weaning. CONCLUSION: Many TICU survivors had discontinued opioid/benzodiazepine prescriptions by 4-months post discharge while half reporting pain/anxiety for up to 2-years. Investigating the effects of acute-to-chronic pain in ICU survivors and gaining a better understanding of the mechanisms of prolonged opioid use are warranted.

The V-ATPase complex regulates non-canonical Atg8-family protein lipidation through ATG16L1 recruitment.

Conjugation of the Atg8 (autophagy related 8) family of ubiquitin-like proteins to phospholipids of the phagophore is a hallmark of macroautophagy/autophagy. Consequently, Atg8 family members, especially LC3B, are commonly used as a marker of autophagosomes. However, the Atg8 family of proteins are not found solely attached to double-membrane autophagosomes. In non-canonical Atg8-family protein lipidation they become conjugated to single membranes. We have shown that this process is triggered by recruitment of ATG16L1 by the vacuolar-type H+-translocating ATPase (V-ATPase) proton pump, suggesting a role for pH sensing in recruitment of Atg8-family proteins to single membranes.

Translation into Spanish and Cultural Adaptation of the Critical-Care Pain Observation Tool.

BACKGROUND: The Critical-Care Pain Observation Tool (CPOT) is recommended for evaluating pain behaviors in patients in the intensive care unit who are unable to report pain. The source of the only published Spanish version of the CPOT does not verify that it underwent a formal translation process. OBJECTIVE: To describe the translation into Spanish and cultural adaptation of the original French version of the CPOT. METHODS: Key persons in the translation process included one with a master's degree in translation, a critical care physician, nurse faculty members with vast experience in intensive care units, and the instrument's developer. This team followed the Principles of Good Practice for the Translation and Cultural Adaptation Process for Patient-Reported Outcomes Measures as a guide to translate and culturally adapt the CPOT. RESULTS: The first Spanish-language version was back translated to French and was also compared with the English version. Revisions necessitated a second version, which was submitted to experts in critical care. Their modifications required a third version, which was back translated to French and discussed with the CPOT developer, after which a fourth version was created. Finally, a linguistic expert proofread the tool, and the translation leaders incorporated the recommendations, thereby obtaining a final Spanish version. CONCLUSION: The Spanish version is ready to undergo validation with patients in the intensive care unit, which is the next step toward its use in assessing pain behaviors among patients in intensive care units where Spanish is spoken.

Opioid and Benzodiazepine Withdrawal Syndromes in Trauma ICU Patients: A Prospective Exploratory Study.

Trauma ICU patients may require high and/or prolonged doses of opioids and/or benzodiazepines as part of their treatment. These medications may contribute to drug physical dependence, a response manifested by withdrawal syndrome. We aimed to identify risk factors, symptoms, and clinical variables associated with probable withdrawal syndrome. DESIGN: Prospective exploratory observational study. SETTING: Trauma ICU in large medical center in Puerto Rico. PARTICIPANTS: Fifty patients who received opioids and/or benzodiazepines for greater than or equal to 5 days. MEASUREMENTS AND MAIN RESULTS: Using an opioid/benzodiazepine withdrawal syndrome checklist developed from research in adult ICU patients, the Diagnostic and Statistical Manual of Mental Disorders-5, and the International Classification of Diseases, 10th Edition, we evaluated patients at baseline and for 72 hours after drug weaning was initiated. Patients received opioid/benzodiazepine (88%), opioid (10%), or benzodiazepine (2%). Probable withdrawal syndrome occurred in 44%, questionable withdrawal syndrome in 20%, and no withdrawal syndrome in 18 (36%). Signs that were more frequent in the probable withdrawal syndrome group were agitation, diarrhea, fever, tachypnea, lacrimation, and hyperactive delirium. Patients who developed probable withdrawal syndrome spent almost double the amount of time receiving mechanical ventilation, and length of stay was higher in both ICU and hospital when compared with patients in the other two groups. Age, cumulative opioid dose amounts, and previous drug (opioid/benzodiazepine, cannabis, cocaine, or heroin) use were associated with odds of developing withdrawal syndrome. With the addition of Richmond Agitation-Sedation Scale and delirium to the multilevel analysis, older age no longer had its protective effect, whereas increase in Richmond Agitation-Sedation Scale scores, delirium presence, and increased duration of mechanical ventilation were associated with higher odds of withdrawal syndrome. CONCLUSIONS: We identified probable withdrawal syndrome in a sample of trauma ICU patients through observation of several associated symptoms. Significant factors associated with withdrawal syndrome found in this study should be considered when caring for patients being weaned from opioids and/or benzodiazepines. Further validation of the opioid/benzodiazepine withdrawal syndrome checklist is recommended.

CHC22 clathrin mediates traffic from early secretory compartments for human GLUT4 pathway biogenesis.

Glucose transporter 4 (GLUT4) is sequestered inside muscle and fat and then released by vesicle traffic to the cell surface in response to postprandial insulin for blood glucose clearance. Here, we map the biogenesis of this GLUT4 traffic pathway in humans, which involves clathrin isoform CHC22. We observe that GLUT4 transits through the early secretory pathway more slowly than the constitutively secreted GLUT1 transporter and localize CHC22 to the ER-to-Golgi intermediate compartment (ERGIC). CHC22 functions in transport from the ERGIC, as demonstrated by an essential role in forming the replication vacuole of Legionella pneumophila bacteria, which requires ERGIC-derived membrane. CHC22 complexes with ERGIC tether p115, GLUT4, and sortilin, and downregulation of either p115 or CHC22, but not GM130 or sortilin, abrogates insulin-responsive GLUT4 release. This indicates that CHC22 traffic initiates human GLUT4 sequestration from the ERGIC and defines a role for CHC22 in addition to retrograde sorting of GLUT4 after endocytic recapture, enhancing pathways for GLUT4 sequestration in humans relative to mice, which lack CHC22.

Occurrence and Practices for Pain, Agitation, and Delirium in Intensive Care Unit Patients.

OBJECTIVE: Our study described the occurrence, assessment, prevention, and management practices of pain, agitation, and delirium (PAD) in four intensive care units (ICUs) from the Puerto Rico Medical Center and compared findings with the 2013 PAD guidelines. METHODS: A descriptive study, with repeated bedside measures (two times a day/two times a week) of PAD and review of patient clinical records. RESULTS: Eighty ICU patients (20 per ICU) were evaluated, (median 3 times [IQR, 2-7]). At least once during the assessment period, 57% percent of patients had significant pain and 34% had delirium. Moreover, 46% were deeply sedated, 17.5% had agitation, and 52.5% of patients were within the recommended Richmond Agitation-Sedation Scale (RASS) scores. The Numeric Rating Scale and RASS were the most common tools used by clinicians to evaluate pain and agitation/sedation levels, respectively. Clinicians did not assess pain in patients unable to self-report with any guideline-recommended tools, as was the case for delirium. Fentanyl and morphine were the most commonly used analgesics, while benzodiazepines were used for sedation. CONCLUSION: Although pain, agitation, and delirium occurrence were similar to other studies, patients continue to suffer. A gap exists between clinical practices in these ICUs and current guidelines. Strategies that contribute to integrating guidelines into these ICUs should be developed, studied, and implemented.

Opioid and Benzodiazepine Iatrogenic Withdrawal Syndrome in Patients in the Intensive Care Unit.

Iatrogenic withdrawal syndrome is an increasingly recognized issue among adult patients in the intensive care unit. The prolonged use of opioids and benzodiazepines during the intensive care unit stay and preexisting disorders associated with their use put patients at risk of developing iatrogenic withdrawal syndrome. Although research to date is scant regarding iatrogenic withdrawal syndrome in adult patients in the intensive care unit, it is important to recognize and adequately manage iatrogenic withdrawal syndrome in order to prevent possible negative outcomes during and after a patient's intensive care unit stay. This article discusses in depth 8 studies of iatrogenic withdrawal syndrome among adult patients in the intensive care unit. It also addresses important aspects of opioid and benzodiazepine iatrogenic withdrawal syndrome, including prevalence, risk factors, and assessment and considers its prevention and management.

Acute Pain Assessment in Sedated Patients in the Postanesthesia Care Unit.

CONTEXT: Acute postoperative pain remains inadequately assessed and managed. A valid instrument that assesses acute pain in sedated postanesthesia care unit (PACU) patients is needed. OBJECTIVES: Two behavioral pain assessment instruments, the NonVerbal Pain Scale Revised (NVPS-R) and Critical-care Pain Observation Tool (CPOT), were used to determine whether these instruments adequately assess acute pain in the PACU. METHODS: A crossover study design was used. The study was conducted in the Medical Services Administration at the Puerto Rico Medical Center. Upon PACU arrival, patient sedation levels were evaluated using the Richmond Agitation Sedation Scale. Acute pain was assessed using the CPOT (scored, 0 to 8) and the NVPS-R (scored, 0 to 10) at timepoints 0, 15, 30, 45, 60, 90, and 120 minutes. Descriptive statistics and mixed model regression analysis were used to compare pain score assessment between instruments. RESULTS: Clinically significant increases in vital signs and respiratory indicators using the NVPS-R were not seen in patients with significant pain at time 0, 15, and 120 minutes. The CPOT vocalization indicator was more frequent in patients with significant pain. CONCLUSIONS: Findings suggest that NVPS-R and CPOT can assess acute pain in sedated PACU patients. In patients with significant pain, the CPOT vocalization indicator was more consistent than physiological and respiratory indicators in detecting acute pain. Thus, our data do not support the exclusive use of vital sign indicators to assess acute pain, suggesting the superiority of the CPOT for the assessment of acute pain in sedated PACU patients.

Introduction of a prediction model to assigning periodontal prognosis based on survival time.

AIMS: To develop a prediction model for tooth loss due to periodontal disease (TLPD) in patients following periodontal maintenance (PM), and assess its performance using a multicentre approach. MATERIAL AND METHODS: A multilevel analysis of eleven predictors of TLPD in 500 patients following PM was carried out to calculate the probability of TLPD. This algorithm was applied to three different TLPD samples (369 teeth) gathered retrospectively by nine periodontist, associating several intervals of probability with the corresponding survival time, based on significant differences in the mean survival time. The reproducibility of these associations was assessed in each sample (One-way ANOVA and pairwise comparison with Bonferroni corrections). RESULTS: The model presented high specificity and moderate sensitivity, with optimal calibration and discrimination measurements. Seven intervals of probability were associated with seven survival time and these associations contained close to 80% of the cases: the probability predicted the survival time at this percentage. The model performed well in the three samples, as the mean survival time of each association were significantly different within each sample, while no significant differences between the samples were found in pairwise comparisons of means. CONCLUSIONS: This model might be useful for predicting survival time in different TLPD samples.

Five-year outcomes of a randomized clinical trial comparing bone-level implants with either submerged or transmucosal healing.

AIM: To evaluate the long-term hard and soft tissue peri-implant tissue stability of bone-level implants using a different implant placement protocol (submerged versus transmucosal). MATERIALS AND METHODS: This study was partly a subset analysis of a multicentre study where in 40 patients, a single bone-level implant with platform switching and a conical implant-abutment interface was placed either submerged or transmucosal in non-molar sites. Changes in the peri-implant tissues between implant placement and 5 years were assessed clinically and radiologically. Patient-related outcomes were also recorded. RESULTS: Thirty patients completed the 5-year follow-up. Implant survival rate was 100%. The mean radiographic changes in crestal bone levels between baseline and 5 years were 0.59 (0.92) mm and 0.78 (1.03) mm for the submerged and the transmucosal groups, respectively. No statistical significant differences were found between the groups for any of the investigated variables. Peri-implantitis, defined as changes in the level of crestal bone of ≥2 mm together with bleeding on probing, was only diagnosed in one patient. Patients in both groups were highly satisfied with the treatment received. CONCLUSIONS: Bone-level implants with submerged or transmucosal healing protocols demonstrated similar outcomes after 5 years. Both protocols yielded optimal clinical and radiographic results when bone-level implants were placed in non-molar positions for single tooth replacement.

A prospective, longitudinal, descriptive study of the effect of a customized wheelchair cushion on clinical variables, satisfaction, and functionality among patients with spinal cord injury.

The Instituto Nacional de Rehabilitación (Rehabilitation National Institute) (INR) developed a prototype wheelchair cushion (INR cushion) designed to adjust to the anthropometry of the user's ischiogluteal area and prevent pressure ulcer formation while maintaining or promoting functionality. A prospective, longitudinal, descriptive study was conducted from February 2010 to February 2011 to evaluate the effect of using the INR cushion on clinical variables, functionality, and user satisfaction. Sixteen patients were recruited (9 male, 7 female, average age 31.8 [range 22-47] years, average body mass index 25 [range 22-34], average time in a wheelchair 10.1 [range 3-26] years) who met the study protocol inclusion criteria of being pressure ulcer-free for at least 6 months and capable of propulsion and transfer without assistance, chronic spinal cord injury (>2 years), and without chronic-degenerative diseases or cognitive problems. Each participant received the cushion for a 2-month evaluation. Eight clinical variables were assessed: trunk control, posture, spasticity, transfer capacity, comfort, skin reaction, propulsion capacity, and pressure release capacity. The clinical assessment was performed using validated scales and instruments: Modified Ashworth Scale (MAS), Functional Independence Measure™ (FIM), Norton Scale, and assessment of skin reaction. Interface pressures were measured using force sensing array, and participants completed a structured interview to assess user expectation, perceived functionality, perceived quality, and likelihood of recommending the device. Two patients withdrew due to appointment conflicts; of the remaining 14, significant differences between the user's experience with other products and the INR were found with regard to pressure redistribution (P = 0.012); all participants but 1 graded the INR as good in all interview categories. No participants developed a pressure ulcer during the study. The customized cushion was especially functional among patients with incomplete thoracic and cervical injuries, high FIM scores, and moderate levels of activities of daily living. Taller patients (P = 0.01) and patients with higher degrees of spasticity (P = 0.007) were less satisfied with functionality. The results of this study contributed to the redesign process of the cushion. These findings may be useful to establish predictors, both subjective and clinical, for patient utilization of wheelchair cushion use.

Feasibility of a sedation wake-up trial and spontaneous breathing trial in critically ill trauma patients: a secondary analysis.

OBJECTIVES: To determine the feasibility of conducting a sedation wake-up trial (SWT) plus a spontaneous breathing trial (SBT) in critically ill trauma patients based on the ability to implement the combined intervention; to measure and describe patients' physiological responses; and to maintain patient safety. METHODS: A secondary analysis of the intervention group from a trial of 20 mechanically ventilated patients receiving SWT plus SBT in a trauma-intensive care unit. RESULTS: Patients passed 67% of the 39 SWTs performed; those who failed presented RASS scores of +1 and +2 (70%), tachycardia (15%) or ventilator asynchrony (15%). Eighteen patients tolerated their first SBT, and after the second SBT, more than half of the patients were discontinued from the mechanical ventilator. A significant increase from the beginning to the end of the SWT was found in heart rate (p=.021), respiratory rate (p=.043) and systolic blood pressure (p=.04). Although these measures increased significantly, their overall mean did not increase by 20%. CONCLUSION: SWT plus SBT was well tolerated and successfully implemented. Our data showed that it is not necessary to withhold continuous-infusion analgesia during the SWT.

Efficacy of small doses of ketamine with morphine to decrease procedural pain responses during open wound care.

OBJECTIVE: The purpose of this study was to evaluate differences in pain intensity, pain quality, physiological measures, and adverse effects when patients received morphine with saline (MS) compared with morphine and a small dose of ketamine (MK) before an open wound care procedure (WCP). METHODS: A randomized, cross-over design was used to determine whether the addition of a small dose of ketamine would potentiate morphine's analgesic effects and decrease WCP pain intensity. Patients were randomized to receive either 0.1 mg/kg of morphine (8 mg maximum) plus saline intravenously (IV) or 0.05 mg/kg of morphine (4 mg maximum) plus ketamine 0.25 mg/kg IV before the WCP. Patients were crossed-over to receive the alternate treatment during the next WCP. RESULTS: Eleven male patients participated in the study. Mean rank of pain intensity during WCP-MK was significantly less than during WCP-MS (P=0.005). Mean±standard error of mean pain intensity during the WCP-MK was 3.09±0.99, whereas it was 6.82±0.92 during the WCP-MS. However, 91% of the patients had adverse effects (eg, strange sensations, hallucinations, blurred vision) with MK versus 0% with MS. Diastolic blood pressure was significantly higher during the WCP-MK. DISCUSSION: Ketamine with morphine significantly reduced procedural wound pain intensity during WCP. Adverse effects and higher diastolic BP occurred with MK. Further research is warranted to determine the optimal analgesic dose of ketamine or if the addition of a benzodiazepine would mitigate the psychotomimetic effects of ketamine.

Cytogenetic, fluorescence in situ hybridization, and molecular characterization of chronic myeloid leukemia in chronic phase with four BCR/ABL1 fusion signals: a case report.

We report a case of chronic myeloid leukemia in chronic stage with 48 chromosomes and four BCR/ABL1 fusion signals on two out of three chromosomes 9 and two signals on the two Philadelphia chromosomes. These abnormalities were detected by both conventional cytogenetic analysis and metaphase and interphase fluorescence in situ hybridization studies in approximately 90% of the cells at diagnosis. Real-time-polymerase chain reaction studies on peripheral blood showed b3a2(p210) and e1a2(p190) BCR/ABL1 fusion transcripts. During treatment with imatinib, the patient was asymptomatic with hematological remission. Cytogenetic and fluorescence in situ hybridization analysis revealed that only 6.6% of cells had the initial majority line karyotype, with disappearance of the p210 but increased p190 transcript, which led to the treatment being changed. We discuss the implication of cytogenetic and molecular alterations in the patient's evolution and treatment.

Acute wound pain: gaining a better understanding.

PURPOSE: To provide the wound care practitioner with an overview of research and knowledge about the causes, mechanisms, contributing factors, and management of acute wound pain. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After reading this article and taking this test, the reader should be able to: 1. Describe the causes of acute wound pain. 2. Discuss research findings related to the physiology of wound pain. 3. Identify current concepts in the management of acute wound pain.

Sleep and delirium in ICU patients: a review of mechanisms and manifestations.

Sleep deprivation and delirium are conditions commonly encountered in intensive care unit patients. Sleep in these patients is characterized by sleep fragmentation, an increase in light sleep, and a decrease of both slow wave sleep and rapid eye movement sleep. The most common types of delirium in this population are hypoactive and mixed-type. Knowledge about the mechanisms of sleep and delirium has evolved over time, but these phenomena are not yet well understood. What is known, however, is that different areas in the brainstem transmit information to the thalamus and cortex necessary for sleep-wake regulation. Delirium is related to an imbalance in the synthesis, release, and inactivation of some neurotransmitters, particularly acetylcholine and dopamine. The relationship between sleep deprivation and delirium has been studied for many years and has been viewed as reciprocal. The link between them may be ascribed to shared mechanisms. An imbalance in neurotransmitters as well as alteration of melatonin production may contribute to the pathogenesis of both phenomena. A better understanding of the mechanisms and factors that contribute to sleep deprivation and delirium can guide the development of new methods and models for prevention and treatment of these problems and consequently improve patient outcomes.

Pain related to tracheal suctioning in awake acutely and critically ill adults: a descriptive study.

The purpose of this secondary data analysis of findings from a larger procedural pain study was to examine several factors related to pain during tracheal suctioning. In addition to tracheal suctioning, other procedures studied included turning, wound drain removal, femoral catheter removal, placement of a central venous catheter, and wound dressing change. A total of 755 patients underwent the tracheal suctioning procedure that was performed primarily in intensive care units (93%). A 0-10 numeric rating scale, a behavioural observation tool, and a modified McGill Pain Questionnaire-Short Form were used for pain assessment. Pain intensity scores were significantly greater during the tracheal suctioning procedure (M=3.96, S.D.=3.3) than prior to (M=2.14, S.D.=2.8) or after (M=1.98, S.D.=2.7) tracheal suctioning. Few patients received analgesics prior to or during the procedure. Surgical, younger, and non-white patients reported higher pain intensities. Although mean pain intensity during tracheal suctioning was mild, almost the half of the patients reported moderate-to-severe pain. Individualized pain management must be performed by healthcare providers in order to respond to patients' needs as they undergo painful procedures such as tracheal suctioning.