Fratino Sara, Peluso Lorenzo, Talamonti Marta, Menozzi Marco, Costa Hirai Lucas Akira, Lobo Francisco A, Prezioso Chiara, Creteur Jacques, Payen Jean-François, Taccone Fabio Silvio
Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium.
Department of Anesthesiology, CHTMAD-Hospital de S. Pedro, 5000 Vila Real, Portugal.
Brain Sci. 2021 Jan 15;11(1):109. doi: 10.3390/brainsci11010109.
Pain assessment is a challenge in critically ill patients, in particular those who are unable to express movements in reaction to noxious stimuli. The purpose of the study was to compare the pupillary response and skin conductance to pain stimulation in critically ill unconscious patients.
This observational study included adult patients admitted to the intensive care unit (ICU) with acute brain injury (Glasgow Coma Scale < 9 with a motor response < 5) and/or requirements for deep level of sedation. Automated pupillometry (Algiscan, ID-MED, Marseille, France) was used to determine pupillary reflex dilation during tetanic stimulation. The maximum intensity of the stimulation value allowed the determination of a pupillary pain index score ranging from 1 (no nociception) to 9 (high nociception): a pupillary pain index (PPI) score of ≤4 was used to reflect adequate pain control. For skin conductance (SC), the number of SC peaks per second (NSCF) was collected concomitantly to tetanic stimulation. An NSCF of ≤0.07 peak/second was used to reflect adequate pain control.
Of the 51 included patients, there were 32 with brain injury and 19 receiving deep sedation. Mean PPI score was 5 (Interquartile Range= 2-7); a total of 28 (55%) patients showed inadequate control of the nociceptive stimulation according to the PPI assessment. Only 15 (29%) patients showed a detectable skin conductance, with NSCF values from 0.07 to 0.47/s. No correlation was found between skin conductance algesimeter (SCA)-derived variables and PPI score or pupillary dilation to pain.
Detection of inadequate pain control might vary according to the method used to assess nociception in ICU patients. A poor agreement between quantitative pupillometry and skin conductance was observed.
疼痛评估对重症患者而言是一项挑战，尤其是那些无法对有害刺激做出反应性动作的患者。本研究的目的是比较重症昏迷患者对疼痛刺激的瞳孔反应和皮肤电传导。
这项观察性研究纳入了入住重症监护病房（ICU）的成年患者，这些患者患有急性脑损伤（格拉斯哥昏迷量表评分<9且运动反应<5）和/或需要深度镇静。使用自动瞳孔测量仪（Algiscan，ID-MED，法国马赛）来确定强直刺激期间的瞳孔反射性扩张。刺激值的最大强度可确定瞳孔疼痛指数评分，范围从1（无伤害感受）到9（高伤害感受）：瞳孔疼痛指数（PPI）评分≤4用于反映疼痛得到充分控制。对于皮肤电传导（SC），在强直刺激的同时收集每秒的SC峰值数量（NSCF）。NSCF≤0.07个峰值/秒用于反映疼痛得到充分控制。
在纳入的51例患者中，有32例患有脑损伤，19例接受深度镇静。平均PPI评分为5（四分位间距=2-7）；根据PPI评估，共有28例（55%）患者对伤害性刺激的控制不充分。只有15例（29%）患者表现出可检测到的皮肤电传导，NSCF值为0.07至0.47/秒。未发现皮肤电传导痛觉计（SCA）衍生变量与PPI评分或对疼痛的瞳孔扩张之间存在相关性。
ICU患者疼痛控制不充分的检测可能因用于评估伤害感受的方法而异。观察到定量瞳孔测量和皮肤电传导之间的一致性较差。
