乳腺术后急性痛与光电容积脉搏波变化的关系

The Relationship between Postoperative Acute Pain after Breast Surgery and Changes in Photoplethysmographic Waveform

摘要: 目的：探讨乳腺手术患者全身麻醉苏醒后急性痛与光电容积脉搏波波幅变化的关系。方法：选择全身麻醉下行乳腺手术65例，女性患者，年龄18~65岁，ASA I或II级。麻醉诱导采用静脉注射丙泊酚1.5 mg/kg、舒芬太尼0.4 ug/kg，睫毛反射消失时静脉注射顺式阿曲库铵0.2 mg/kg；麻醉维持采用全凭静脉麻醉，丙泊酚5~6 mg•kg⁻¹•h⁻¹、瑞芬太尼0.2~0.3 ug•kg⁻¹•h⁻¹。记录患者入室后5 min (T₀)、苏醒后10 min (T₁)、苏醒后20 min (T₂)、苏醒后30 min (T₃)各时间点的心率(HR)、收缩压(SBP)、舒张压(DBP)、脉搏波收缩波波幅(PPGA)和记录静态VAS评分，计算T_x与T₀时间点PPGA比值定义为PPGA_Tx/T0。根据患者T₁时刻的VAS评分将患者分为轻度疼痛组(L组)和中度疼痛组(M组)，若发现VAS评分 ≥ 4分则给予羟考酮0.09 mg/kg。结果：与T₀时比较，T₁时L组SBP、DBP、PPGA降低，VAS增加，差异有统计学意义(P < 0.05)；M组SBP、DBP、VAS增加，PPGA降低，差异有统计学意义(P < 0.05)；T₂、T₃时两组HR、SBP、DBP、PPGA降低，VAS增加，差异有统计学意义(P < 0.05)。与前一时间点比较，L组T₂较T₁时HR降低，差异有统计学意义(P < 0.05)；M组T₂较T₁时HR、SBP、DBP、VAS降低，PPGA、PPGA_Tx/T0增加，差异有统计学意义(P < 0.05)；T₃较T₂时SBP、DBP、VAS降低，PPGA、PPGA_Tx/T0增加，差异有统计学意义(P < 0.05)。与L组比较，M组T1时VAS评分显著增高，差异有统计学意义(P < 0.05)；T₂、T₃时SBP、DBP、VAS显著降低，PPGA、PPGA_Tx/T0显著增高，差异有统计学意义(P < 0.05)。Pearson相关分析显示：VAS评分与HR、SBP、DBP无明显相关性，与PPGA (r = −0.437, P < 0.01)及PPGA_Tx/T0(r = −0.948, P < 0.01)呈负相关性。结论：全身麻醉苏醒后轻中度疼痛可以引起光电容积脉搏波波幅显著降低，对VAS疼痛评分中度患者给予镇痛药缓解疼痛至VAS疼痛评分为轻度时波幅可明显增加但不超过术前水平，伴有PPGA_Tx/T0增大且<1，PPGA_Tx/T0改变在评估全身麻醉苏醒后急性痛方面具有参考价值。

Abstract: Objective: To explore the relationship between postoperative acute pain and photoplethysmographic waveform changes in patients undergoing breast surgery after emergence from general anesthesia. Methods: Sixty-five patients, undergoing breast surgery under general anesthesia, female patients, aged 18 - 65 years, falling to ASA physical status I or II, were included in this study. Induction of anesthesia was induced by intravenous propofol 1.5 mg/kg, sufentanil 0.4 ug/kg and cisatracurium besilate 0.2 mg/kg; total intravenous anesthesia was maintained by intravenous infusion propofol 5 - 6 mg•kg⁻¹•h⁻¹ and remifentanil 0.2 - 0.3 ug•kg⁻¹•h⁻¹. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), photoplethysmographic main wave amplitude (PPGA), static VAS score were recorded at 5 min after enter the operating room (T₀), 10 min (T₁), 20 min (T₂), 30 min (T₃) after emergence from anesthesia. The ratio of PPGA at the time point of T_x and T₀ is calculated and it is defined as PPGA_Tx/T0. The patients were divided into mild pain group (L group) and moderate pain group (M group) according to the VAS score at the time of T₁. If VAS score ≥ 4, oxycodone was given at 0.09 mg/kg. Results: Compared with T0, SBP, DBP, PPGA in group L significantly decreased (P < 0.05), VAS significantly increased (P < 0.05) at T₁; SBP, DBP, VAS in group M significantly increased, PPGA significantly decreased (P < 0.05) at T₁; HR, SBP, DBP, PPGA in two groups significantly decreased, VAS significantly increased (P < 0.05) at T₂, T₃; compared with the previous time point, T₂ had lower HR than T₁ (P < 0.05) in group L; T₂ had lower HR, SBP, DBP, and VAS than T₁, and PPGA and PPGA_Tx/T0 increased(P < 0.05) in group M. Compared with T₂, SBP, DBP, VAS decreased, and PPGA, PPGA_Tx/T0 increased at T₃ (P < 0.05). Compared with the group L, the VAS score was significantly increased at T₁ (P < 0.05); SBP, DBP, and VAS were significantly decreased at T₂ and T₃, PPGA and PPGA_Tx/T0 were significantly increased in group M (P < 0.05). Pearson correlation analysis showed that there was no correlation between VAS scores and HR, SBP, and DBP, and it dislayed a significant negative relationship with PPGA (r = −0.437, P < 0.01) and PPGA_Tx/T0 (r = −0.948, P < 0.01). Conclusion: Mild to moderate pain after emergence from general anesthesia can cause significant reduction in the photoplethysmographic main wave amplitude. When patients with moderate VAS pain scores can be given analgesics to relieve pain to the VAS pain score which is mild, the amplitude can be significantly increased but not exceed the preoperative level, and PPGA_Tx/T0 increases but less than 1, PPGA_Tx/T0 maybe has reference value in assessing the pain degree after general anesthesia.