手术体积描计指数、瞳孔直径和镇痛指数预测腹腔镜阑尾切除术中疼痛的有效性

Efficiency of predicting intraoperative pain with surgical pleth index,pupillary dilatation and pain threshold index during laparoscopic appendectomy

目的探讨手术体积描计指数(SPI)、瞳孔直径(PD)和镇痛指数(PTi)在不同手术操作刺激下预测疼痛反应的有效性。方法选择全身麻醉下行腹腔镜阑尾切除术患者38例,男女各18例,年龄18~65岁,ASAⅠ或Ⅱ级。记录术中SPI、PD、PTi、BIS、MAP、HR的变化,并将气管插管、切皮、气腹建立、气腹撤退这四项操作前1 min和操作即刻的差值定义为基础波动值,并将操作即刻后2 min内的最大值与操作即刻的差值定义为波动幅度(Δ)。采用受试者工作特征(ROC)曲线分析Δ的预测效能。结果所有指标在4个手术时间点间的基础波动值差异无统计学意义。所有指标的Δ值在气管插管时均明显大于气腹建立时(P<0.001);SPI、PTi、MAP、HR的Δ值在气腹建立时明显大于切皮时(P<0.001);SPI、PD、PTi、MAP、HR的Δ值在切皮时明显大于气腹撤退时(P<0.001)。SPI的Δ值/基础波动值在气管插管、气腹建立、切皮时明显大于PD、PTi、BIS、MAP和HR(P<0.001),但在气腹撤退时差异无统计学意义。SPI和PTi的Δ值诊断手术操作刺激始终具有高度准确性,且高于BIS、MAP和HR,而BIS仅有低度准确性。结论 SPI、PD、PTi均为良好的疼痛监测指标,而SPI诊断准确性极高,可能是最佳的疼痛监测指标。

Objective To explore the changes of surgical pleth index(SPI), pupillary dilatation(PD) and pain threshold index(PTi) during different operative stimulation. Methods Thirty-eight patients, 18 males and females, aged 18-65 years, ASA physical status Ⅰ or Ⅱ, undergoing laparoscopic appendectomy under general anesthesia were included. Values of SPI, PD, PTi, BIS, MAP, HR and their differences between 1 minutes before and instantly at endotracheal intubation, skin incision, pneumoperitoneum establishment and pneumoperitoneum retreat were recorded. The amplitude changes(Δ=maximum value within 2 min after operation-minimum value within 2 min after operation) of these parameters were recorded. The ROC analysis was used to determine the value with the performance at predicting the pain response. The area under the curve was calculated to provide predictive accuracy. Results No significant difference was found in 6 indexes of basic fluctuation among 4 surgical timing. The Δ values at endotracheal intubation of all 6 indexes were larger than those at pneumoperitoneum establishment(P < 0.001). The Δ values of SPI, PTi, MAP and HR at pneumoperitoneum establishment were larger than those at skin incision(P < 0.001). The Δ values of SPI, PD, PTi, MAP and HR at skin incision were larger than those at pneumoperitoneum retreatment(P < 0.001). The Δ value/basic fluctuation of SPI at endotracheal intubation, pneumoperitoneum establishment, skin incision were larger than PD, PTi, BIS, MAP and HR respectively(P < 0.001), but no significant difference was found at pneumoperitoneum retreatment(P = 0.10). The diagnostic accuracy of SPI and PTi were higher than BIS, MAP and HR, but low with BIS. Conclusion SPI, PD, PTi are all favorable pain monitor index, while SPI is the best pain monitor index for the small basic fluctuation, with a large increased amplitude after operation and highly diagnostic accuracy.