Impact of chronic treatment by β1-adrenergic antagonists on Nociceptive-Level (NOL) index variation after a standardized noxious stimulus under general anesthesia: a cohort study
Impact of chronic treatment by β1-adrenergic antagonists on Nociceptive-Level (NOL) index variation after a standardized noxious stimulus under general anesthesia: a cohort study
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DOI：
10.1007/s10877-020-00626-4
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发表时间：
2021-01-04
影响因子：
2.2
通讯作者：
Richebe, Philippe
中科院分区：
文献类型：
--
作者：
Bergeron, Catherine;Brulotte, Veronique;Richebe, Philippe
在围手术期，痛觉控制无疑是麻醉师在照顾病人时的主要目标之一。有一些文献表明，手术过程中经历的伤害性刺激负责外周和中枢致敏现象，这可能导致持续的术后疼痛。个体化的评估和治疗围手术期伤害感觉的方法是有益的，以避免致敏现象，导致术后疼痛延长，并尽量减少阿片类药物的消耗及其不良反应。最近的文献表明，与心率（HR）和平均动脉压（MAP）相比，在敏感性、特异性和阳性/阴性预测值方面，NOL变化（Delta NOL）是区分有害刺激和非有害刺激的最佳指标。使用β 1-肾上腺素能拮抗剂进行慢性治疗可能会限制NOL指数的使用。β 1-肾上腺素能拮抗剂对心率产生抑制作用，导致在有害刺激后心率变异性受到限制。由于心率和心率变异性是纳入NOL指数的两个参数，因此NOL指数在接受β 1-肾上腺素能拮抗剂治疗的患者群体中的有效性尚未确定。我们的研究旨在探讨一组在全身麻醉下接受标准化有害刺激的β 1-肾上腺素能拮抗剂慢性治疗的患者的NOL指数、BIS和心率变化。然后，我们将这些结果与我们之前研究的对照组（CJA组）患者进行比较，对照组患者未接受β 1-肾上腺素能拮抗剂慢性治疗。在这项研究中，患者接受了标准化的麻醉方案，从诱导到3分钟后，标准化的尺神经刺激频率为100赫兹，电流为70毫安，持续时间为30秒。电子记录数据，以获得NOL、BIS和心率值，每5 s在协议期间。在我们的两个队列(CJA: 30（14）与BETANOL: 36（14) (p = 0.12)）之间，在有害刺激后达到的NOL最大平均值没有差异。我们的队列在NOL AUC方面没有统计学上的显著差异，代表NOL在180 s期间的变化(CJA: 595（356）与BETANOL: 634（301) (p = 0.30)）。然而，重复测量ANCOVA发现我们的队列之间在有害刺激后20和65 s的NOL指数变化峰值有轻微的统计学意义，β -阻断患者的NOL指数高于CJA患者。此外，达到最大值的时间也没有差异(CJA: 73（37）与BETANOL: 63（41) (p = 0.35)）。在全身麻醉下，NOL检测有害刺激的敏感性和特异性与未服用β受体阻滞剂的患者相似，且优于心率和双谱指数(AUC NOL 0.97， CI（0.92-1), AUC BIS 0.78， CI（0.64-0.89）和AUC HR 0.66， CI(0.5-0.8)）。总之，NOL指数是评估慢性受体阻滞剂治疗患者群体伤害感受的可靠监测指标。接受这种治疗的患者在标准化的有害刺激后180 s内获得了相似的最大NOL值，并且NOL随时间的变化（以AUC为代表）与非β -阻断患者的队列没有显著差异。无论患者是否服用β受体阻滞剂，NOL指数在全麻下检测实验性有害刺激时的敏感性大于BIS指数或心率。
During the perioperative period, nociception control is certainly one of the anesthesiologist's main objectives when assuming care of a patient. There exists some literature demonstrating that the nociceptive stimuli experienced during surgery are responsible for peripheral and central sensitization phenomena, which can in turn lead to persistent postsurgical pain. An individualized approach to the evaluation and treatment of perioperative nociception is beneficial in order to avoid the sensitization phenomena that leads to prolonged postoperative pain and to minimize the consumption of opiates and their adverse effects. In terms of sensitivity, specificity, and positive/negative predictive values when compared to heart rate (HR) and mean arterial pressure (MAP), recent literature has shown that the NOL variation (Delta NOL) is the best index to distinguish noxious from non-noxious stimuli. Chronic treatment with beta 1-adrenergic antagonists may constitute a limitation to the use of the NOL index. beta 1-adrenergic antagonists induce a depressive action on the heart rate, which results in a limitation of its variability after a noxious stimulus. Since heart rate and heart rate variability are two parameters integrated into the NOL index, the validity of the NOL index in a population of patients receiving beta 1-adrenergic antagonists has not yet been determined. Our study sought to explore the NOL index, the BIS, and the heart rate variation in a group of patients under chronic treatment with beta 1-adrenergic antagonists submitted to standardized noxious stimulus under general anesthesia. We then compared those results to a control group of patients from our previous study (CJA group) that received no beta 1-adrenergic antagonist chronic treatment. The patients in this study were subjected to a standardized anesthetic protocol from induction up to 3 min after a standardized tetanic stimulus to the ulnar nerve at a frequency of 100 Hz and an amperage of 70 mA, for a duration of 30 s. Data were electronically recorded to obtain NOL, BIS, and heart rate values every 5 s for the duration of the protocol. The NOL maximal mean value reached after noxious stimulation was not different between our two cohorts (CJA: 30(14) versus BETANOL: 36(14) (p = 0.12)). There was no statistically significant difference between our cohorts in regards of the NOL AUC representing the variation of the NOL over a 180 s period (CJA: 595(356) versus BETANOL: 634(301) (p = 0.30)). However, a repeated measurement ANCOVA identified slight statistically significant differences between our cohorts in the peak of variation of the NOL index between 20 and 65 s after noxious stimulation, the NOL index of the cohort of beta-blocked patients being higher than the CJA patients. Moreover, the time to reach the maximum value was not different (CJA: 73(37) versus BETANOL: 63(41) (p = 0.35)). NOL sensitivity and specificity to detect a noxious stimulus under general anesthesia were similar in patients taking beta-blockers or not, and were better than those of heart rate and Bispectral index (AUC NOL 0.97, CI(0.92-1), versus AUC BIS 0.78, CI(0.64-0.89) and AUC HR 0.66, CI(0.5-0.8)). In conclusion, the NOL index is a reliable monitor to assess nociception in a population of patients under chronic beta-blocker therapy.Patients under such therapy achieve similar maximal NOL values over a 180 s period after a standardized noxious stimulus and the NOL variation over time, represented by the AUC is not significantly different from a cohort of non-beta-blocked patients. Whether the patient takes beta-blockers or not, sensitivity of the NOL index is greater than that seen for BIS index or heart rate to detect an experimental noxious stimulus under general anesthesia.