Assessment of Thoracic Epidural Analgesia During General Anesthesia Using Pupillary Reflex Dilation: A Preliminary Study

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.Design: Prospective study.Setting: University hospital.Participants: Thirteen patients undergoing thoracotomy.Interventions: 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 ≥ 0.5 mm was predictive of incomplete block (sensitivity 76%, specificity 79%, and positive predictive value 86%). PRD ≥ 1 mm was highly predictive of inadequate block (sensitivity 73%, specificity 91%, and positive predictive value 94%).Conclusion: PRD-guided continuous thoracic epidural analgesia under low-dose remifentanil/propofol anesthesia is feasible and ensures good postoperative analgesia.