程控硬膜外脉冲式注射分娩镇痛后爆发痛列线图预测模型的构建及验证

Construction and validation of a nomogram prediction model for breakthrough pain after labor analgesia with programmed intermittent epidural bolustechnique

目的探讨基于程控硬膜外脉冲式注射(programmed intermittent epidural bolustechnique,PIEB)分娩镇痛后爆发痛危险因素的列线图预测模型构建及临床应用价值。方法选取2021年1月至2023年4月在沧州市人民医院接受PIEB分娩镇痛的242例产妇为研究对象,采用完全随机法按7:3比例将产妇分为训练集(n=169)和验证集(n=73)。在训练集中,采用多因素Logistic回归分析分娩爆发痛的危险因素并构建列线图预测模型,绘制ROC曲线及校准曲线对列线图模型的预测效能进行评估,并在验证集中进行验证。同时应用决策曲线分析(DCA)分娩爆发痛列线图模型的临床应用价值。结果训练集中出现爆发痛者33例(19.53%),验证集中出现16例(21.92%),训练集和验证集爆发痛发生率及临床特征差异均无统计学意义(P>0.05)。训练集中,有神经根受累的慢性背痛、胎儿偏大、穿刺后15 min NRS评分较高、脉冲给药间隔时间为60 min、第一产程时间较长是接受PIEB分娩镇痛孕妇出现爆发痛的独立危险因素(P<0.05),并进一步构建列线图预测模型。列线图模型在训练集和验证集中在预测和实际间均具有较好的校准和拟合度(C-index指数分别为0.836和0.847,预测值与真实值符合度的平均绝对误差分别为0.024和0.048,Hosmer-Lemeshow检验P值分别为0.718和0.901)。ROC曲线显示训练集和验证集中列线图模型预测接受PIEB分娩镇痛孕妇出现爆发痛的AUC分别为0.852(95%CI:0.777-0.927)和0.899(95%CI:0.822-0.976),灵敏度、特异度分别为0.818、0.750和0.875、0.754。结论基于PIEB分娩镇痛后爆发痛危险因素构建的列线图预测模型有助于早期预测分娩爆发痛,并指导临床制定适宜的临床决策,从而最大限度地降低分娩爆发痛风险,保障母婴安全。

Objective To explore the construction and clinical application value of a nomogram prediction model based on the risk factors of breakthrough pain after labor analgesia with programmed intermittent epidural bolustechnique(PIEB).Methods A total of 242 patients who received labor analgesia with PIEB in Cangzhou People's Hospital from January 2021 to April 2023 were selected as the research objects.The patients were divided into training set(n=169)and validation set(n=73)according to the ratio of 7∶3 by the completely random method.In the training set,multivariate Logistic regression was used to analyze the risk factors of labor breakthrough pain and a nomogram prediction model was constructed,ROC curve and calibration curve were drawn to evaluate the predictive efficacy of the nomogram model,and the validation set was used to verify the nomogram model.At the same time,using decision curve analysis(DCA)nomogram model of labor breakthrough pain to evaluate the clinical application value.Results Breakthrough pain occurred in 33 cases(19.53%)in the training set and 16 cases(21.92%)in the validation set.There was no significant difference in the incidence of breakthrough pain and clinical characteristics between the two sets(P>0.05).In the training set,chronic back pain with nerve root involvement,bigger fetal size,higher NRS score at 15 min after puncture,60 min interval of pulse administration and longer duration of the first stage of labor were independent risk factors for breakthrough pain in pregnant women receiving PIEB of labor analgesia(P<0.05),and a nomogram prediction model was further constructed.The nomogram model had good calibration and fit between prediction and actual values in the training set and validation set(C-index were 0.836 and 0.847,respectively;mean absolute error of coincidence between predicted value and actual value were 0.024 and 0.048,respectively;Hosmer-Lemeshow test P=0.718,0.901,respectively).The ROC curve showed that the AUC of the nomogram model for predicting breakthrough pain in pregnant women receiving PIEB of labor analgesia was 0.852(95%CI:0.777-0.927)in the training set and 0.899(95%CI:0.822-0.976)in the validation set,the sensitivity and specificity were 0.818,0.750 and 0.875,0.754,respectively.Conclusion The nomogram prediction model based on the risk factors of breakthrough pain after labor analgesia with PIEB is helpful for early prediction of labor breakthrough pain and guiding clinical decision-making,so as to minimize the risk of labor breakthrough pain and ensure the safety of mother and child.