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      An observational study: The utility of perfusion index as a discharge criterion for pain assessment in the postanesthesia care unit

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          Abstract

          Acute post-operative pain can remain untreated if patients cannot express themselves. The perfusion index (PI) may decrease when pain activates sympathetic tone and may increase after analgesics are administered. We evaluated if the perfusion index is a feasible indicator for objectively assessing pain relief in the postanesthesia care unit (PACU) and calculated the changes in PI measurements at the time of discharge from the PACU relative to baseline PI measurements to examine if the PI is a useful criterion for discharging patients from the postanesthesia care unit. This retrospective observational study enrolled female patients who were admitted for gynecological or general surgery. The patients received general anesthesia and were admitted to the postanesthesia care unit. The PI, visual analogue scale (VAS) score, heart rate, and blood pressure were recorded before and after administration of intravenous morphine. Changes in these parameters before and after analgesics were administered and the difference of these parameters between age and BMI subgroups were compared. The correlation between the PI and VAS score, ΔPI and ΔVAS, and %ΔPI and %ΔVAS were also evaluated. The percentage change in ΔPI (P9-T0/T0) of the patients at the time of discharge from the postanesthesia care unit relative to baseline PI measurements was calculated. Eighty patients were enrolled, and there were 123 instances during which analgesia was required. Heart rate, PI, and VAS score were significantly different before and after analgesics were administered (p < 0.0001). The difference of parameters between age and BMI subgroups were not significant. The correlation between the PI and VAS score, ΔPI and ΔVAS, and the percentage change in ΔPI and ΔVAS showed weak correlations in age, BMI subgroups, and all measurements. The baseline PI and the PI when arriving at and when being discharged from the postanesthesia care unit were significantly different (p < 0.01). The mean percentage change in Δ PI at the time of discharge from the PACU was 66.2%, and the 99% confidence interval was 12.2%~120.3%. The perfusion index was increased, and the VAS score was decreased significantly after analgesics were administered, but the correlation was weak in each subgroup. The VAS score is a subjective and psychometric parameter. The PI increased when partial pain relief was achieved after morphine was administered but did not reflect pain intensity or changes in the VAS score regardless of age or BMI. A percentage change in ΔPI at the time of discharge from the PACU relative to baseline PI measurements of greater than 12% can be used as a supplemental objective discharge criterion for pain assessment in the postanesthesia care unit.

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          Most cited references14

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          Postoperative intravenous morphine titration.

          Relief of acute pain during the immediate postoperative period is an important task for anaesthetists. Morphine is widely used to control moderate-to-severe postoperative pain and the use of small i.v. boluses of morphine in the post-anaesthesia care unit allows a rapid titration of the dose needed for adequate pain relief. The essential principle of a titration regimen must be to adapt the morphine dose to the pain level. Although morphine would not appear to be the most appropriate choice for achieving rapid pain relief, this is the sole opioid assessed in many studies of immediate postoperative pain management using titration. More than 90% of the patients have pain relief using a protocol of morphine titration and the mean dose required to obtain pain relief is 12 (7) mg, after a median of four boluses. Sedation is frequent during i.v. morphine titration and should be considered as a morphine-related adverse event and not evidence of pain relief. The incidence of ventilatory depression is very low when the criteria to limit the dose of i.v. morphine are enforced. Morphine titration can be used with caution in elderly patients, in children, or in obese patients. In practice, i.v. morphine titration allows the physician to meet the needs of individual patients rapidly and limits the risk of overdose making this method the first step in postoperative pain management.
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            Masimo signal extraction pulse oximetry.

            To describe a new pulse oximetry technology and measurement paradigm developed by Masimo Corporation. Patient motion, poor tissue perfusion, excessive ambient light, and electrosurgical unit interference reduce conventional pulse oximeter (CPO) measurement integrity. Patient motion frequently generates erroneous pulse oximetry values for saturation and pulse rate. Motion-induced measurement error is due in part to widespread implementation of a theoretical pulse oximetry model which assumes that arterial blood is the only light-absorbing pulsatile component in the optical path. Masimo Signal Extraction Technology (SET) pulse oximetry begins with conventional red and infrared photoplethysmographic signals, and then employs a constellation of advanced techniques including radiofrequency and light-shielded optical sensors, digital signal processing, and adaptive filtration, to measure SpO2 accurately during challenging clinical conditions. In contrast to CPO which calculates O2 saturation from the ratio of transmitted pulsatile red and infrared light, Masimo SET pulse oximetry uses a new conceptual model of light absorption for pulse oximetry and employs the discrete saturation transform (DST) to isolate individual "saturation components" in the optical pathway. Typically, when the tissue under analysis is stationary, only the single saturation component produced by pulsatile arterial blood is present. In contrast, during patient motion, movement of non-arterial components (for example, venous blood) can be identified as additional saturation components (with a lower O2 saturation). When conditions of the Masimo model are met, the saturation component corresponding to the highest O2 saturation is reported by the instrument as SpO2. The technological strategies implemented in Masimo SET pulse oximetry effectively permit continuous monitoring of SpO2 during challenging clinical conditions of motion and poor tissue perfusion.
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              Perfusion index derived from a pulse oximeter can predict the incidence of hypotension during spinal anaesthesia for Caesarean delivery.

              Hypotension during spinal anaesthesia for Caesarean delivery is a result of decreased vascular resistance due to sympathetic blockade and decreased cardiac output due to blood pooling in blocked areas of the body. Change in baseline peripheral vascular tone due to pregnancy may affect the degree of such hypotension. The perfusion index (PI) derived from a pulse oximeter has been used for assessing peripheral perfusion dynamics due to changes in peripheral vascular tone. The aim of this study was to examine whether baseline PI could predict the incidence of spinal anaesthesia-induced hypotension during Caesarean delivery. Parturients undergoing elective Caesarean delivery under spinal anaesthesia with hyperbaric bupivacaine 10 mg and fentanyl 20 μg were enrolled in this prospective study. The correlation between baseline PI and the degree of hypotension during spinal anaesthesia and also the predictability of spinal anaesthesia-induced hypotension during Caesarean delivery by PI were investigated. Baseline PI correlated with the degree of decreases in systolic and mean arterial pressure (r=0.664, P 3.5 demonstrated marked decreases after spinal injection. We demonstrated that higher baseline PI was associated with profound hypotension and that baseline PI could predict the incidence of spinal anaesthesia-induced hypotension during Caesarean delivery.
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                Author and article information

                Contributors
                Role: Data curationRole: Formal analysisRole: MethodologyRole: Writing – original draft
                Role: ConceptualizationRole: SupervisionRole: Writing – review & editing
                Role: Data curationRole: Resources
                Role: ConceptualizationRole: Supervision
                Role: ConceptualizationRole: Data curationRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                16 May 2018
                2018
                : 13
                : 5
                : e0197630
                Affiliations
                [1 ] Institute of Biomedical Engineering National Taiwan University, Taipei, Taiwan
                [2 ] Department of Anesthesiology, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
                [3 ] Department of Cardiology, National Taiwan University Hospital, Taipei, Taiwan
                [4 ] Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
                National Taiwan University, School of Dentistry, TAIWAN
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0001-9122-4437
                Article
                PONE-D-18-04297
                10.1371/journal.pone.0197630
                5955537
                29768487
                30358565-416c-4dc9-8484-e7b0b1a74294
                © 2018 Chu et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 26 February 2018
                : 5 May 2018
                Page count
                Figures: 1, Tables: 3, Pages: 8
                Funding
                The authors received no specific funding for this work.
                Categories
                Research Article
                Medicine and Health Sciences
                Pharmacology
                Drugs
                Analgesics
                Medicine and Health Sciences
                Pain Management
                Analgesics
                Medicine and Health Sciences
                Surgical and Invasive Medical Procedures
                Gynecologic Surgery
                Medicine and Health Sciences
                Surgical and Invasive Medical Procedures
                Medicine and Health Sciences
                Cardiology
                Heart Rate
                Medicine and Health Sciences
                Pharmacology
                Drugs
                Analgesics
                Opioids
                Morphine
                Medicine and Health Sciences
                Pain Management
                Analgesics
                Opioids
                Morphine
                Medicine and Health Sciences
                Pharmacology
                Drugs
                Opioids
                Morphine
                Biology and Life Sciences
                Physiology
                Physiological Parameters
                Body Weight
                Body Mass Index
                Medicine and Health Sciences
                Physiology
                Physiological Parameters
                Body Weight
                Body Mass Index
                Medicine and Health Sciences
                Vascular Medicine
                Blood Pressure
                Medicine and Health Sciences
                Pain Management
                Custom metadata
                All relevant data are within the paper and its Supporting Information files.

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