国际麻醉学与复苏杂志   2019, Issue (3): 0-0
    
全身麻醉下瞳孔直径变化率对伤害性刺激的评估价值
李艳, 谢海1()
1.海南医学院附属医院
Assessment of pupillary diameter variation rate in determining noxious stimulation during general anesthesia
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摘要：

目的　通过观察瞳孔直径（pupillary diameter， PD）变化对手术切皮后心率或SBP变化的反应性，探讨PD变化率对伤害性刺激的评估价值。　方法　选择择期手术患者150例，均经静脉全身麻醉诱导气管插管，手术开始前5 min给予芬太尼1 μg/kg。记录手术切皮前5 min（T0）、手术切皮后即刻（T1）和切皮后1 min内每5 s［5 s（T2）、10 s（T3）、15 s（T4）、20 s（T5）、25 s（T6）、30 s（T7）、35 s（T8）、40 s（T9）、45 s（T10）、50 s（T11）、55 s（T12）、60 s（T13）］的心率、SBP和PD，计算各个时点心率、SBP对T0时点的变化率和PD对T0时点的最大变化率，分别记为△HR、△SBP和△PD。以△HR或△SBP为15%分别作为评判伤害性刺激/抗伤害性刺激标准，受试者工作特征曲线（receiver operating characteristic curve， ROC）分析△PD对△SBP、△HR反应的敏感度和特异性，寻找诊断临界值（cutoff值）；Pearson相关分析△PD与△SBP、△HR的相关性；比较心率、SBP和PD对伤害性刺激的反应时间。　结果　△PD对△SBP、△HR反应的ROC曲线下面积（area under the receiver operating characteristic curve， AUC）分别为0.936（95%CI 0.894~0.997）和0.921（95%CI 0.884~0.971）；△PD对△HR反应的cutoff值为44.5%，敏感度89.7%，特异性92.5%；△PD对△SBP反应的cutoff值为46.5%，敏感度88.6%，特异性89.1%；△PD和△HR的Pearson相关系数r=0.721（95%CI 0.617，0.786）；△PD和△SBP的Pearson相关系数r=0.679（95%CI 0.605~0.758）；PD、心率和SBP对伤害性刺激的反应时间分别为（5.5±2.7）、（28.3±9.9）、（32.7±7.2） s，△PD比△HR、△SBP的反应时间均短（P<0.05）。　结论　PD对术中伤害性刺激/抗伤害性刺激平衡的评价具有很高的准确性，其反应时间更短，是评估术中伤害性刺激/抗伤害性刺激平衡的有价值指标。
关键词： 瞳孔直径；　伤害性刺激；　疼痛；　心率；　收缩压
Abstract:

Ｏｂｊｅｃｔｉｖｅ　To observe the reactivity of pupillary diameter (PD) variation responding to the variation of heart rate (HR) or systole blood pressure (SBP) after operative incision, and evaluate pupillary diameter for noxious stimulation.　Methods　One hundred and fifty patients underwent surgery were selected, after endotracheal intubation under intravenous induction, 1 μg/kg fentanyl was administered before operation. The HR, SBP, PD were measured and recorded subsequently before surgical incision (T0), after surgical incision (T1), each 5 s in 1 min after incision［5 s (T2), 10 s (T3), 15 s (T4), 20 s (T5), 25 s (T6), 30 s (T7), 35 s (T8), 40 s (T9), 45 s (T10), 50 s (T11), 55 s (T12), 60 s (T13)］. The variation rate of HR or SBP responding to the value at T0 and the maximum variation rate of PD responding to the value in T0 were calculated, marked with name of △HR, △SBP and △PD. With the 15% variation rate of HR or SBP as a criteria for noxious stimulation/anti-noxious stimulation, the reactivity of △PD responding to △HR or △SBP were assessed respectively by analysis the receiver operating characteristic curve (ROC) for the result of sensitivity and specificity and the area under the receiver operating characteristic curve (AUC), and Pearson rank correlation were analyzed. The time of HR, SBP and PD responding to noxious stimulation were compared.　Results　The AUC value of △PD responding to △HR and △SBP were 0.936 (95%CI 0.894-0.997) and 0.921 (95%CI 0.884-0.971) respectively. Importantly, their ROC analysis displayed that the diagnostic cutoff value of △PD responding to △HR was 44.5% with a sensitivity of 89.7% and a specificity of 92.5%, and △PD responding to △SBP was 46.5% with a sensitivity of 88.6% and a specificity of 89.1%. The value of Pearson′s correlation coefficient between △PD and △HR was r△PD-△HR =0.721(95%CI 0.617-0.786), between △PD and △SBP was r△PD-△SBP =0.679 (95%CI 0.605-0.758). The time of HR, SBP and PD responding to noxious stimulation were (5.5±2.7), (28.3±9.9) s and (32.7±7.2) s respectively.　Conclusions　This study demonstrated that high accuracy in PD variation rate responding to noxious stimulation/anti-noxious stimulation during operation with shorter responding time. PD is a valuable parameter for determining noxious stimulation.
Key words: Pupillary diameter;　Noxious stimulation;　Pain;　Heart rate;　Systolic blood pressure