Yes. Propofol suppresses motor responses and may mask pain even at light sedation levels. A patient at RASS -2 on propofol may have significant underlying pain that is not behaviorally expressed due to sedation. Perform CPOT at rest and — importantly — during nursing procedures. Consider reducing propofol briefly before CPOT assessment during procedures when clinically safe, to allow a more accurate behavioral pain response.

Not necessarily. Agitation can be caused by delirium (positive CAM-ICU), anxiety, environmental disturbances, ventilator dyssynchrony, or discomfort that doesn't manifest as CPOT-scored behaviors. A CPOT of 0 in an agitated patient does not definitively exclude pain, but suggests other causes are more likely. Assess CAM-ICU for delirium, check ventilator settings, and address environmental factors before attributing agitation to pain.

Facial burns, edema, or trauma may prevent facial expression assessment. In these cases, weight the available CPOT domains more heavily — body movements, muscle tension, and ventilator compliance/vocalization can still be assessed. Document 'facial expression unassessable — burns/trauma' and proceed with the remaining 3 domains. Adjust institutional CPOT thresholds for management decisions when a domain is unassessable.

Patients with Parkinson's disease, other movement disorders, or decerebrate/decorticate posturing may have baseline muscle rigidity that inflates the muscle tension domain. Assess muscle tension relative to the patient's known baseline — if they always have rigid arms, score as 0 (relaxed for them) unless you detect an acute change from baseline. Document this modification in the nursing notes.