危重患者疼痛观察工具在颅脑肿瘤开颅术后疼痛评估中的应用

Application of the critical-care pain observation tool for pain assessment in intracranial tumor patients after craniotomy

目的评价危重患者疼痛观察工具(critical-care pain observation tool,CPOT)用于颅脑肿瘤开颅术后患者疼痛评估的信度和效度。方法纳入收治于重症加强医疗病房(intensive care unit,ICU)的颅脑肿瘤开颅术后进行机械通气支持的患者,随机先后进行致痛性操作(气管内吸引)和非致痛性操作(右肩轻贴电极),操作前后由两名研究者各自完成CPOT评价,另一名研究者在操作后进行主观疼痛评价。根据能否表达疼痛分为能表达组和不能表达组。应用组内相关系数(intraclass correlation coefficient,ICC)比较两名研究者之间的CPOT评价信度。能表达疼痛组以疼痛主诉为标准,绘制CPOT和生命体征(包括平均动脉压、心率和呼吸频率)的受试者工作特征(receiver operating characteristic,ROC)曲线,并计算曲线下面积(area under the curve,AUC)和95%可信区间(confidence interval,CI)。不能表达疼痛组比较操作前后CPOT和生命体征(包括平均动脉压、心率和呼吸频率)的变化。结果纳入患者243例,能表达疼痛者171例(70.4%),致痛性操作后感觉疼痛者151例(88.3%),非致痛性操作后感觉疼痛者34例(19.9%)。两组患者在不同操作前后的ICC范围在0.790~0.945。CPOT在能表达疼痛组的AUC和95%CI为0.805(0.759~0.852),在不能表达疼痛组进行致痛性操作前后以及不同操作后差异均有统计学意义。结论对于颅脑肿瘤开颅术后机械通气的患者,应用CPOT进行疼痛评估具有较好的信度和效度,特别是存在表达障碍的患者中区辩效度良好,可以用于此类患者操作痛的评估。

Objective To evaluate the reliability and validity of the critical-care pain observation tool(CPOT)for pain assessment in intracranial tumor patients after craniotomy.Methods This prospective study was enrolled intracranial tumor patients after craniotomy undergoing mechanical ventilation in the intensive care unit(ICU).Nociceptive and non-nociceptive operations were performed in a random crossover manner.Two researchers completed CPOT evaluation before and after the operation,and another researcher performed pain evaluation after the operation.Patients were divided into two groups according to whether they could self-report pain.The intraclass correlation coefficient(ICC)was used to compare the reliability of CPOT between the two researchers.By using self-reported pain as the reference,the receiver operating characteristic(ROC)curve of CPOT and vital signs was drawn,and the area under the curve(AUC)and 95%confidence intervals(CI)were calculated.Changes in CPOT and vital signs before and after different operations were compared in patients without self-reported pain.Results A total of 243 patients were enrolled,171(70.4%)were able to complain self-report pain.It was maintained in 151(88.3%)and 34(19.9%)patients complained pain during nociceptive and non-nociceptive operations,respectively.The ICC range of patients with self-reported pain or not before and after different operations was between 0.790 and 0.945.For patients with self-reported pain,the AUC and 95%CI for CPOT were 0.805(0.759-0.852)(P<0.001).For patients without self-reported pain,CPOT was increased significantly after nociceptive operation.Conclusion CPOT has good reliability and validity for pain assessment in intracranial tumor patients after craniocerebral craniotomy.It could also distinguish the differences between nociceptive and non-nociceptive operations in patients without self-report pain.