Indian Journal of Pain

: 2019  |  Volume : 33  |  Issue : 1  |  Page : 11--14

Combination of critical care pain observation tool and face, legs, activity, cry, consolability scale in assessment of postoperative pain severity in postanesthesia care unit: A prospective cross-sectional analytical study

Debanjali Ray1, Sudesna Gupta1, Subrata Ray2,  
1 Department of Anaesthesiology, North Bengal Medical College and Hospital, Siliguri, West Bengal, India
2 Department of Anaesthesiology, KPC Medical College and Hospital, Kolkata, West Bengal, India

Correspondence Address:
Dr. Subrata Ray
Department of Anaesthesiology, KPC Medical College and Hospital, 1F, Raja S.C.Mullick Road, Kolkata - 700 032, West Bengal


Context: Effective post-operative pain assessment is mandatory to exclude overdose of analgesics and avoid adverse effects. Patients in PACU have impaired ability to communicate making pain assessment challenging. This study aims to establish agreement between two pain scales, CPOT (Criticalcare Pain Observation Tool) and FLACC (Face, Legs, Activity, Cry, Consolability) and to find out specificity of combination of scales. Methods: Taking sample size of 50 patients of either sex, aged 18-80 years, ASA-PS I-III, undergoing elective surgeries were chosen, study period being June-September 2017. Adequately reversed, extubated patients not receiving sedatives, analgesics and local anaesthetics within 15 minutes before end of operation were included while patients with ASA-PS more than III or on ventilator were excluded. Assessment was done upto 2 hours at 30 minutes interval using CPOT tool and FLACC scale simultaneously by two observers, both being blinded about study. Results: Combination of two scales show high odds ratio (41%) and kappa coefficient (0.78) suggesting excellent agreement. Specificity of combination of scales is very high (95.2%) than individual test. Conclusion: CPOT and FLACC scale together has excellent agreement and their combination are more specific to assess the severity of post-operative pain than when used individually.

How to cite this article:
Ray D, Gupta S, Ray S. Combination of critical care pain observation tool and face, legs, activity, cry, consolability scale in assessment of postoperative pain severity in postanesthesia care unit: A prospective cross-sectional analytical study.Indian J Pain 2019;33:11-14

How to cite this URL:
Ray D, Gupta S, Ray S. Combination of critical care pain observation tool and face, legs, activity, cry, consolability scale in assessment of postoperative pain severity in postanesthesia care unit: A prospective cross-sectional analytical study. Indian J Pain [serial online] 2019 [cited 2020 Jul 15 ];33:11-14
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Full Text


Pain, as defined by the International Association for Study of Pain (IASP), is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”[1] A complex combination of factors is known to affect the experience of pain, making it quite difficult to either prejudge or identify benchmarks for the likely amount of pain any individual will experience, following any surgical procedure. Thus, pain is one of the most challenging clinical phenomena encountered by clinicians. Effective postoperative pain assessment is therefore extremely mandatory to exclude misuse, abuse, over use, or underuse of analgesics and prevent unnecessary adverse effects. Moreover, it attributes to additional economic benefits for rapid recovery and early discharge. Patients in the postanesthesia care unit (PACU) have impaired ability to communicate making pain assessment quite difficult. Systemic pain assessment with valid tools is thus extremely essential lest a possibility of under treatment may occur, the patients being critically ill, under sedation, or too agonized to comprehend. Pain severity assessment as required by The Joint Commission, on accreditation of healthcare organization, is intended to improve the quality of postoperative pain management.[2] Multiple instruments currently exist to measure and assess postoperative pain. The sensitivity and specificity of these instruments have been widely debated and have resulted in a plethora of studies to establish their reliability and validity. The Critical Care Pain Observation Tool (CPOT) is the highest in both, while Face, Legs, Activity, Cry, Consolability Scale (FLACC) is the most commonly used scale to assess pain in the clinical setup.[2] The aim of the present study was:

To compare the agreement between two different scales, namely CPOT and FLACC, when used in combination in diagnosing severity of postoperative pain among the study populationTo establish the specificity of combination of these two scales.


The study was carried out in the PACU of a teaching institute in West Bengal from June to September 2017. After obtaining Institutional Ethics Committee's approval, 50 patients of either sex attending our PAC clinic with informed consent to participate in the survey were taken for this study. The sample size was determined based on a previous study; the mean difference and the pooled standard deviation were calculated with the power of study being 80% and confidence interval being 95%. The inclusion criteria were patients of either sex, aged 18–80 years, having American Society of Anesthesiologists (ASA) Physical Status I–III, undergoing major elective surgeries under balanced general anesthesia with endotracheal intubation and controlled positive pressure ventilation, adequately reversed and extubated, and not receiving any sedative, analgesics, or any local anesthetics within 15 min before end of operation. The exclusion criteria were patients with ASA-Physical Status >III, patient on ventilator support, receiving sedative, analgesics, or local anesthetics within 15 min before end of the operation.

Intravenous (IV) line was established and all patients were premedicated with injection ranitidine (50 mg), injection fentanyl (2 μgm/kg), injection glycopyrrolate 0.01 mg/kg all IV. After standard multichannel monitoring and preoxygenation, induction was done either by injection propofol (2 mg/kg) or injection etomidate (0.3 mg/kg) and intubation was done with 0.5 mg/kg injection atracurium IV. Maintenance was done with injection atracurium 0.1 mg/kg according to response, sevoflurane, O2:N2O (1:2), infusion paracetamol, injection ondansetron 4–8 mg IV. After adequate reversal with appropriate dose of injection neostigmine and glycopyrrolate, patients were sent to the PACU. They were attended for2 h after surgery at 30-min interval to assess the severity of postoperative pain on both CPOT and FLACC scale by two different observers. First observer explained the CPOT scale before anesthesia or during PAC and recorded the data after assessment in the PACU. Along with the CPOT, all the patients were assessed on FLACC scale by the second observer at the same time, both being blinded about the study. The CPOT is a four-parameter bound scale to assess the postoperative pain in the most analytical and descriptive way with facial expressions, body movements, vocalization (for extubated patients) or compliance with the ventilator (for intubated patients), and muscle tension, each parameter rated on a scale of 0–2. The total score may range from 0 to 8 with lesser scores, indicating less pain [Table 1]. On the other hand, the FLACC is a five-item pain assessment tool assessing severity of postoperative pain on the basis of parameters as depicted by the name itself on a scale of 0–2. Scores may range from 0 to 10, with lower scores indicating less pain [Table 2]. Face, legs, activity, cry, and consolability are to be observed for 1–5 min or longer, with legs and body uncovered. Patients are to be repositioned and activities to be observed. Consoling interventions may be initiated whenever required. The recorded data by two observers were submitted to analyzer who computed the data on severity scale which is a combination of the above-mentioned scales based on study of Garra et al., already prepared prior to the study [Table 3].[3] Score “0” was considered as no pain, Scores 1–4 were considered as mild pain, Scores 5–8 were considered as moderate pain, and Scores 9 and 10 were considered as severe pain. Patients having score ≥5 were taken into account and designated positive as they required rescue analgesic. Score <5 was considered negative as counseling, adequate sedation, and proper positioning were sufficient for relief of pain [CPOT and FLACC scale were downloaded from the website of IASP, no permission is required to use these scales, and any modification is subjected to permission by IASP].{Table 1}{Table 2}{Table 3}

Statistical analysis

Data of 50 patients were compiled on Microsoft Excel worksheets (Microsoft, Redwoods, WA, USA) and analyzed using SPSS (IBM Corporation) software version 22.0. Validity of the tests was expressed by sensitivity and specificity by judging severity of pain as gold standard. Cohen's Kappa coefficient (κ) was computed to see what extent the reading of two different methods agreed beyond which we would expect by chance alone. Kappa value was computed as 0.78, that is, the two scales have excellent percentage agreement according to the Fleiss's guideline.


[Table 4] shows the demographic data of 50 patients in the form of men-women ratio, mean and standard deviation of age, and duration of surgery. They were comparable in respect to demographic profile. Of 50 patients, 28 had moderate-to-severe pain (56.7%) according to CPOT and 22 had moderate-to-severe pain (43.3%) according to the FLACC scale. Two different tools were assessed on every patient and compared with severity scale. For each of the measured parameters, odds ratio (OR), κ, and confidence interval were calculated and are summarized in [Table 5] and [Figure 1]. Sensitivity and specificity of individual scale and combination of scales are shown in [Table 6] and [Figure 2]. Individually, CPOT has higher OR (17.2%) and κ (0.6) than FLACC scale (OR: 2.82%, Kappa: 0.4%), but combination of these two scales show high OR (41%) and κ (0.78). Sensitivity of CPOT and FLACC is 45.40% and 52.66%, respectively, but combination of these has sensitivity of 67.55%. Specificity of combination of these tools is very high (95.2%) than individual test (CPOT: 18.21%, FLACC: 3.4%).{Figure 1}{Figure 2}{Table 4}{Table 5}{Table 6}


The purpose of our study was to determine the agreement of scales when used in combination which was found to be excellent as per the high OR (41%) and Kappa value (0.78) thus obtained. Combination of scales has high specificity (95.2), thereby excluding the true negatives and more efficiently curbing down the undue need of analgesics.

The CPOT was originally developed in France for assessing pain in hospitalized critically ill ventilated patients. Gélinas and Johnston evaluated the English version of the CPOT in conscious (with varying levels of ability to self-report) and unconscious critically ill ventilated patients, focusing on reliability and validity and also examining physiologic indicators thought to be associated with pain (mean arterial pressure, heart rate, respiratory rate, and transcutaneous oxygen saturation).[4] Results demonstrated that the CPOT was reliable and valid and physiologic indicators were not correlated with self-report of pain, leading to a suggestion that they are used as a cue to perform a behavioral pain assessment. This suggestion was subsequently echoed by Chen and Chen when trying to validate physiologic indicators (vital signs) for pain assessment [5] and is consistent with the American Society for Pain Management Nursing Practice Guidelines. On the other hand, although the FLACC was developed and tested in children, a paucity of evidence exists for its use in adults. Voepel-Lewis et al. conducted a subsequent study in a small sample of critically ill adults (n = 29) and children (n = 8) who could not self-report. Using the checklist for non-verbal pain scale (for adults) or the comfort scale (for children) as the gold standard, they found acceptable and significant correlations with the FLACC.[6]

Two studies by Marmo and Fowler comparing the FLACC to the CPOT and Nonverbal Pain Scale [7] and Buttes et al. comparing the FLACC to the CPOT [8] were lacking data on the FLACC and focused almost exclusively on the CPOT. There outcomes also matching with our study.

In our study, 56.7% had moderate-to-severe pain in CPOT which corroborates with the study of Keane.[9] Moreover, 43.3% had moderate-to-severe pain on FLACC scale which approximately matches with the study of Voepel-Lewis et al.[6] Moreover, in our study, we got excellent correlation between CPOT and FLACC (κ: 0.78) which corroborates with the study of Buttes et al.[8] We aimed to find out the specificity or true negative rather than sensitivity to exclude misuse or abuse of analgesics and to avoid unnecessary adverse effects of analgesic medication in the study population.

This study has following limitations as well; assumption was made that patient's ranking of the painful events is a valid estimate of their perception of pain because there is no way of proving that pain exists other than believing the person in pain. Moreover, research units limited to a single center and only extubated patients undergoing major surgery were studied; therefore, our findings are generalized to these patients. Some behaviors such as stress were considered as pain by the evaluation tool. Further analysis is thus needed to define discrete behavior descriptors that are reliable and useful in measuring pain response.


CPOT and FLACC scale have excellent agreement when used together to assess the severity of post-operative pain than each of the scale individually, in patients in PACU. Combination of these two tests is more specific to assess the severity of postoperative pain than each of the test in the study population.

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Conflicts of interest

There are no conflicts of interest.


1International Association for the Study of Pain. IASP Taxonomy; 1994. Available from: [Last accessed on 2016 Jan 04].
2Gélinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Validation of the critical-care pain observation tool in adult patients. Am J Crit Care 2006;15:420-7.
3Garra G, Singer AJ, Taira BR, Chohan J, Cardoz H, Chisena E, et al. Validation of the Wong-Baker FACES pain rating scale in pediatric emergency department patients. Acad Emerg Med 2010;17:50-4.
4Gélinas 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;23:497-505.
5Chen HJ, Chen YM. Pain assessment: Validation of the physiologic indicators in the ventilated adult patient. Pain Manag Nurs 2015;16:105-11.
6Voepel-Lewis T, Zanotti J, Dammeyer JA, Merkel S. Reliability and validity of the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients. Am J Crit Care 2010;19:55-61.
7Marmo L, Fowler S. Pain assessment tool in the critically ill post-open heart surgery patient population. Pain Manag Nurs 2010;11:134-40.
8Buttes 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;33:78-81.
9Keane KM. Validity and reliability of the critical care pain observation tool: A replication study. Pain Manag Nurs 2013;14:e216-25.