危重患者疼痛观察工具对开颅术后患者疼痛的评价效果

The value of a tool for evaluation of pain in patients undergone craniotomy

目的观察应用危重患者疼痛观察工具（CPOT）对神经外科开颅术后患者疼痛评价的准确性。方法采用前瞻性观察性研究方法，选择2014年8月至2015年8月首都医科大学附属北京天坛医院神经外科开颅术后收住综合重症加强治疗病房（ICU）的患者118例，在拔除深静脉导管前、拔除即刻及拔除后20min分别使用CPOT和视觉模拟评分（VAS）进行疼痛评价，记录其评分值，比较3个时间点两种评分值的差异。绘制受试者工作特征曲线（ROC），以患者主观感觉疼痛为“金标准”，计算ROC曲线下面积（AUC）并确定两种评分判断疼痛的敏感度和特异度的最高截断值（cut—off值）。结果评价神经外科开颅手术患者拔除深静脉导管前、中、后疼痛的COPT评分分别为0（0～3）、0（0～6）、0（0～2）分，VAS分别为4（1，6）、3（1，6），4（1，6）分，拔管中COPT评分明显高于拔管前和拔管后（均P〈0．01）。COPT最佳eut—off值为1时，评价拔管前、中、后的疼痛具有最大的约登指数（分别为1．183、1．515和1．438）；COPT在拔管前和拔管后评价疼痛具有较高特异度，均为100％，但敏感度不佳，分别为18．3％和43．8％；在拔管中的敏感度和特异度均较好，分别为69．4％和82．1％。VAS最佳eut—off值在拔管前和拔管中取2、在拔管后取4时具有最大的约登指数，分别为1．568、1．452和1．509，VAS在拔管前、中、后均具有较好的敏感度和特异度，敏感度分别为97．2％、95．2％和75．0％，特异度分别为59．6％、50．0％和75．9％。COPT在拔管前、中、后的AUC分别为0．592（95％可信区间（95％CI）=0．490～0．693]、0．778（95％CI=0．693～0．863）和0．719（95％CI=0．627～0．811）；VAS在拔管前、中、后的AUC分别为0．846（95％CI=0．771—0．920）、0．767（95％CI=0．681—0．854）和0．838（95％CI=0．767—0．909）；拔管前、后VAS的AUC均明显大于CPOT（P〈0．001和P=0．006），但拔管中两者的AUC差异无统计学意义（P=0．826）。结论CPOT可以用于神经外科术后患者拔除深静脉导管疼痛的评估，并具有较好的准确性；但对静息痛的评价效果欠佳。

Objective To determine the optimal cut-off value of critical-care pain observation tool （CPOT） in assessing degree of pain in patients undergone craniotomy, and to determine the sensitivity and specificity of CPOT with this cut-off value. Methods A prospective observational study was conducted in Beijing Tiantan Hospital. A total of 118 patients admitted to intensive care unit （ICU） after craniotomy was consecutively enrolled during August 2014 to August 2015. CPOT and visual analogue scale （VAS） were used to assess the pain before, during and 20 minutes after the removal of central venous catheters, and the difference was compared between two scores at three time points. Receiver operating characteristic （ROC） curve was used to determine the optimal cut-off values for evaluation of the sensitivity and specificity of CPOT. Patients＇ complaint of pain was considered the ＂gold-standard＂. Results CPOT values （inter-quartile range） before, during and after the procedure were 0 （0-3）, 0 （0-6） and 0 （0-2）, respectively; while VAS values were 4 （1, 6）, 3 （1, 6） and 4 （1, 6）, respectively. CPOT value during the procedure was significantly higher than CPOT values before and after the procedure （both P 〈 0.01）. When the optimal cut-off value of CPOT was 1, CPOT showed the highest Youden index before, during and after the procedure （1.183, 1.515, and 1.438, respectively）, and showed high specificity （all 100%） and low sensitivity （18.3% and 43.8%, respectively） when assessing the pain before and after the removal of the catheter. The sensitivity and the specificity were high when assessing the pain during the procedure, the sensitivity was 69.4%, and the specificity was 82.1%. When the optimal cut-off value of VAS was 2 before and during the procedure, and was 4 after the procedure, VAS showed the highest Youden index, 1.568, 1.452, and 1.509, respectively. VAS demonstrated high sensitivity and specificity before, during and after the procedure （sensitivity was 97.2%, 95.2% and 75.0%, respectively; specificity was 59.6%, 50.0% and 75.9%, respectively）. The area under ROC curve （AUC） of CPOT before, during and after the procedure were 0.592 [95% confidence interval （95%CI） = 0.490- 0.693], 0.778 （95%CI = 0.693-0.863） and 0.719 （95%CI = 0.627-0.811）, respectively; the AUC of VAS before, during and after the procedure were 0.846 （95%CI = 0.771-0.920）, 0.767 （95%CI = 0.681-0.854） and 0.838 （95%CI = 0.767- 0.909）, respectively. The AUC of VAS before and after the procedure was significantly higher than the AUC of CPOT （P 〈 0.001 and P = 0.006）, while there was no significant difference between the AUC of VAS and CPOT during the procedure （P = 0.826）. Conclusion CPOT can be used to assess the pain during painful procedure, and it shows high accuracy, but with poor evaluation effect on pain in rest.