title: Assessment of thoracic epidural analgesia during general anesthesia using pupillary reflex dilation: a preliminary study.
abstract: OBJECTIVE
  Pupillary reflex dilation (PRD) secondary to noxious stimulation accurately predicts sensory block during combined lumbar epidural/general anesthesia. Therefore, the adequacy of PRD-guided thoracic epidural infusion during general anesthesia for thoracotomy was studied.
  
  
  METHODS
  Prospective study.
  
  
  METHODS
  University hospital.
  
  
  METHODS
  Thirteen patients undergoing thoracotomy.
  
  
  METHODS
  An epidural catheter was placed at the T3-T4 level with initial infusion rate of 5 mL/h of ropivacaine 0.5%. Propofol/remifentanil target-controlled infusion was used for induction and maintenance of general anesthesia. Remifentanil effect site concentration was maintained constant at 0.5 ng/mL during surgery. By using a portable pupillometer, PRD secondary to tetanic stimulation of the C8, T2, and T4 segments were evaluated. Ropivacaine flow rate was adapted half hourly, according to PRD testing and a predefined algorithm. At the end of surgery, PRD was tested in the 3 investigated segments, and general anesthesia was stopped. After emergence, these zones were tested for their sensitivity to cold. Pain was evaluated by using the visual analog scale.
  
  
  RESULTS
  Pain scores were <3 of 10 in 84.6% of the patients. Mean PRD was 0.9 +/- 0.6 mm in unblocked levels versus 0.2 +/- 0.5 mm in blocked segments (p = 0.02). PRD >or= 0.5 mm was predictive of incomplete block (sensitivity 76%, specificity 79%, and positive predictive value 86%). PRD >or= 1 mm was highly predictive of inadequate block (sensitivity 73%, specificity 91%, and positive predictive value 94%).
  
  
  CONCLUSIONS
  PRD-guided continuous thoracic epidural analgesia under low-dose remifentanil/propofol anesthesia is feasible and ensures good postoperative analgesia.
authors.affiliation: Department of Anesthesiology, Erasme University Hospital, Free University of Brussels, Brussels, Belgium. isabelle.huybrechts@ulb.ac.be <isabelle.huybrechts@ulb.ac.be>
authors.forename: Isabelle
authors.initials: I
authors.lastname: Huybrechts
authors.forename: Luc
authors.initials: L
authors.lastname: Barvais
authors.forename: Anne
authors.initials: A
authors.lastname: Ducart
authors.forename: Edgard
authors.initials: E
authors.lastname: Engelman
authors.forename: Denis
authors.initials: D
authors.lastname: Schmartz
authors.forename: Marc
authors.initials: M
authors.lastname: Koch
mesh_terms: D000577:Amides / Q000008:administration & dosage; D000767:Anesthesia, Epidural / Q000379:methods*; D000768:Anesthesia, General / Q000379:methods*; D000779:Anesthetics, Local / Q000008:administration & dosage; D002404:Catheterization; D005260:Female; D006801:Humans; D007268:Injections, Epidural; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D010147:Pain Measurement; D011446:Prospective Studies; D012025:Reflex, Pupillary / Q000502:physiology*; D000077212:Ropivacaine; D013904:Thoracic Vertebrae; D013908:Thoracotomy; D016896:Treatment Outcome
chemical_list: D000577:Amides; D000779:Anesthetics, Local; D000077212:Ropivacaine