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Cruzat F, Ibacache M, González A, Pedemonte JC, Contreras V, Giordano A, Cortínez I. Assessment of the antinociceptive effect of a single fentanyl bolus dose in children: A pharmacokinetic and pharmacodynamic analysis based on the nociception level index during sevoflurane general anesthesia. Paediatr Anaesth 2024. [PMID: 39365289 DOI: 10.1111/pan.15013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Revised: 09/13/2024] [Accepted: 09/22/2024] [Indexed: 10/05/2024]
Abstract
BACKGROUND The Nociception Level Index has shown benefits in estimating the nociception/antinociception balance in adults, but there is limited evidence in the pediatric population. Evaluating the index performance in children might provide valuable insights to guide opioid administration. AIMS To evaluate the Nociception Level Index ability to identify a standardized nociceptive stimulus and the analgesic effect of a fentanyl bolus. Additionally, to characterize the pharmacokinetic/pharmacodynamic relationship of fentanyl with the Nociception Level Index response during sevoflurane anesthesia. METHODS Nineteen children, 5.3 (4.1-6.7) years, scheduled for lower abdominal or urological surgery, were studied. After sevoflurane anesthesia and caudal block, a tetanic stimulus (50 Hz, 60 mA, 5 s) was performed in the forearm. Following the administration of fentanyl 2 μg/kg intravenous bolus, three similar consecutive tetanic stimuli were performed at 5-, 15-, and 30-min post-fentanyl administration. Changes in the Nociception Level Index, heart rate, mean arterial pressure, and bispectral index were compared in response to the tetanic stimuli. Fentanyl plasma concentrations and the Nociception Level Index data were used to elaborate a pharmacokinetic/pharmacodynamic model using a sequential modeling approach in NONMEM®. RESULTS After the first tetanic stimulus, both the Nociception Level Index and the heart rate increased compared to baseline (8 ± 7 vs. 19 ± 10; mean difference (CI95) -12(-18--6) and 100 ± 10 vs. 102 ± 10; -2(-4--0.1)) and decrease following fentanyl administration (19 ± 10 vs. 8 ± 8; 12 (5-18) and 102 ± 10 vs. 91 ± 11; 11 (7-16)). In subsequent tetanic stimuli, heart rate remained unchanged, while the Nociception Level Index progressively increased within 15 min to values similar to those before fentanyl. An allometric weight-scaled, 3-compartment model best characterized the pharmacokinetic profile of fentanyl. The pharmacokinetic/pharmacodynamic modeling analysis revealed hysteresis between fentanyl plasma concentrations and the Nociception Level Index response, characterized by plasma effect-site equilibration half-time of 1.69 (0.4-2.9) min. The estimated fentanyl C50 was 1.93 (0.73-4.2) ng/mL. CONCLUSION The Nociception Level Index showed superior capability compared to traditional hemodynamic variables in discriminating different nociception-antinociception levels during varying fentanyl concentrations in children under sevoflurane anesthesia.
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Affiliation(s)
- Francisco Cruzat
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Red de Salud UC-Christus, Santiago, Chile
| | - Mauricio Ibacache
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Red de Salud UC-Christus, Santiago, Chile
- Programa de Farmacología y Toxicología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alejandro González
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Red de Salud UC-Christus, Santiago, Chile
| | - Juan Cristóbal Pedemonte
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Red de Salud UC-Christus, Santiago, Chile
- Programa de Farmacología y Toxicología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Víctor Contreras
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Red de Salud UC-Christus, Santiago, Chile
- Departamento del Adulto, Escuela de Enfermería, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ady Giordano
- Departamento de Química Inorgánica, Escuela de Química y Farmacia, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ignacio Cortínez
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Red de Salud UC-Christus, Santiago, Chile
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Van Santvliet H, Vereecke HEM. Progress in the validation of nociception monitoring in guiding intraoperative analgesic therapy. Curr Opin Anaesthesiol 2024; 37:352-361. [PMID: 38841919 DOI: 10.1097/aco.0000000000001390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW This article summarizes the current level of validation for several nociception monitors using a categorized validation process to facilitate the comparison of performance. RECENT FINDINGS Nociception monitors improve the detection of a shift in the nociception and antinociception balance during anesthesia, guiding perioperative analgesic therapy. A clear overview and comparison of the validation process for these monitors is missing. RESULTS Within a 2-year time-frame, we identified validation studies for four monitors [analgesia nociception index (ANI), nociception level monitor (NOL), surgical pleth index (SPI), and pupillometry]. We categorized these studies in one out of six mandatory validation steps: developmental studies, clinical validation studies, pharmacological validation studies, clinical utility studies, outcome improvement studies and economical evaluation studies. The current level of validation for most monitors is mainly focused on the first three categories, whereas ANI, NOL, and SPI advanced most in the availability of clinical utility studies and provide confirmation of a clinical outcome improvement. Analysis of economical value for public health effects is not yet publicly available for the studied monitors. SUMMARY This review proposes a stepwise structure for validation of new monitoring technology, which facilitates comparison between the level of validation of different devices and identifies the need for future research questions.
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Affiliation(s)
| | - Hugo E M Vereecke
- Department of Anesthesia and Reanimation, AZ Sint-Jan Brugge AV, Brugge, Belgium
- University Medical Center Groningen and University of Groningen, Groningen, The Netherlands
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Chisling S, Jette E, Engelhardt T, Ingelmo P, Poulin-Harnois C, Garbin M, Wasserman S, Bertolizio G. Does heart rate variability using the Newborn Infant Parasympathetic Evaluation index identify postsurgical pain levels and emergence delirium in toddlers? A prospective observational study. Can J Anaesth 2024; 71:1117-1125. [PMID: 38720113 DOI: 10.1007/s12630-024-02764-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 02/29/2024] [Accepted: 03/02/2024] [Indexed: 07/26/2024] Open
Abstract
PURPOSE Children recovering from anesthesia commonly experience early postoperative negative behaviour, caused by pain and emergence delirium. Differentiating the two is challenging in young children. Perioperative pain influences the heart rate variability-derived Newborn Infant Parasympathetic Evaluation (NIPE) index and may also affect emergence delirium. We sought to investigate whether the perioperative NIPE index can discriminate between mild, moderate, or severe pain levels and can detect emergence delirium. METHODS This prospective observational study enrolled children aged three years or younger undergoing elective adenotonsillectomy, tonsillectomy, or adenoidectomy. The NIPE index, the Faces, Legs, Activity, Cry, Consolability (FLACC) score, and the Pediatric Anesthesia Emergence Delirium (PAED) score were recorded in the postanesthesia care unit (PACU). The primary aim was to investigate the relationship between the postoperative NIPE index and postoperative pain severity. The secondary aims were to evaluate the association between the NIPE index and emergence delirium (PAED ≥ 10) and its delirium-specific (ED-I) and pain-specific (ED-II) components. RESULTS Sixty-nine children were recruited. In the PACU, the mean (standard deviation [SD]) NIPE values in children experiencing moderate and severe pain were 50 (12) and 49 (14), respectively. These values were significantly lower than the mean (SD) value of 64 (13) observed in children with mild pain (mean difference moderate vs no/mild pain, -14; 95% confidence interval [CI], -17 to -11; P < 0.001, and mean difference severe vs no/mild pain, -17; 95% CI, -20 to -14; P < 0.001, respectively). The NIPE index was significantly lower in children experiencing pain-specific ED-II (mean [SD] NIPE instantaneous [NIPEi] for ED-II 49 [10] vs no ED-II 55 [13]; mean difference, -6; 95% CI, -11 to -2; P = 0.009). The NIPE index was unable to detect emergence delirium (mean [SD] NIPEi for ED, 54 [15] vs no ED, 51 [10]; mean difference, 3; 95% CI, -2 to 8; P = 0.23) or the delirium-specific component ED-I (mean [SD] NIPEi for ED-I, 55 [15] vs no ED-I, 51 [11]; mean difference, 4; 95% CI, 0 to 8; P = 0.06). CONCLUSION The NIPE index can identify moderate and severe postoperative pain after adenotonsillectomy but not emergence delirium in children aged three years and younger. This discrimination can be valuable in the early postoperative phase when the differentiation between pain and emergence delirium is difficult. STUDY REGISTRATION ClinicalTrials.gov ( NCT04909060 ); first submitted 26 May 2021.
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Affiliation(s)
- Sara Chisling
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Evan Jette
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Thomas Engelhardt
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Pablo Ingelmo
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Christelle Poulin-Harnois
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Marta Garbin
- Department of Clinical Sciences, Université de Montréal, St-Hyacinthe, QC, Canada
| | - Samuel Wasserman
- Research Institute, McGill University Health Center, Montreal, QC, Canada
| | - Gianluca Bertolizio
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
- Department of Anesthesia, Montreal Children's Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
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Liang Z, Xie Y, Chen S, Liu J, Lv H, Muhoza BG, Xing F, Mao Y, Wei X, Xing N, Yang J, Wang Z, Yuan J. Predicting postoperative pain in children: an observational study using the pain threshold Index. Front Pediatr 2024; 12:1398182. [PMID: 39091987 PMCID: PMC11291306 DOI: 10.3389/fped.2024.1398182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 07/03/2024] [Indexed: 08/04/2024] Open
Abstract
Objective While the pain threshold index (PTI) holds potential as a tool for monitoring analgesia-pain equilibrium, its precision in forecasting postoperative pain in children remains unconfirmed. This study's primary aim was to assess the PTI's predictive precision for postoperative pain. Methods Children (aged 2-16 years) undergoing general surgery under general anesthesia were included. Within 5 min prior to the patient's emergence from surgery, data including PTI, wavelet index (WLI), heart rates (HR) and mean arterial pressure (MAP) were collected. Subsequently, a 15-min pain assessment was conducted following the patient's awakening. The accuracy of these indicators in discerning between mild and moderate to severe postoperative pain was evaluated through receiver operating characteristic (ROC) analysis. Results The analysis encompassed data from 90 children. ROC analysis showed that PTI was slightly better than HR, MAP and WLI in predicting postoperative pain, but its predictive value was limited. The area under the curve (AUC) was 0.659 [0.537∼0.780] and the optimal threshold was 65[64-67]. Sensitivity and specificity were determined at 0.90 and 0.50, respectively. In a multivariable logistic regression model, a higher predictive accuracy was found for a multivariable predictor combining PTI values with gender, BMI, HR and MAP (AUC, 0.768; 95%CI, 0.669-0.866). Upon further scrutinizing the age groups, PTI's AUC was 0.796 for children aged 9-16, 0.656 for those aged 4-8, and 0.601 for younger individuals. Conclusions PTI, when used alone, lacks acceptable accuracy in predicting postoperative pain in children aged 2 to 16 years. However, when combined with other factors, it shows improved predictive accuracy. Notably, PTI appears to be more accurate in older children.
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Affiliation(s)
- Zenghui Liang
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yanle Xie
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Cognition and Emotion, Henan Province International Joint Laboratory of Pain, Zhengzhou, Henan, China
| | - Shuhan Chen
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Cognition and Emotion, Henan Province International Joint Laboratory of Pain, Zhengzhou, Henan, China
| | - Jing Liu
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Huimin Lv
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Cognition and Emotion, Henan Province International Joint Laboratory of Pain, Zhengzhou, Henan, China
| | - Bertrand-Geoffrey Muhoza
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Fei Xing
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Cognition and Emotion, Henan Province International Joint Laboratory of Pain, Zhengzhou, Henan, China
| | - Yuanyuan Mao
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Cognition and Emotion, Henan Province International Joint Laboratory of Pain, Zhengzhou, Henan, China
| | - Xin Wei
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Cognition and Emotion, Henan Province International Joint Laboratory of Pain, Zhengzhou, Henan, China
| | - Na Xing
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Cognition and Emotion, Henan Province International Joint Laboratory of Pain, Zhengzhou, Henan, China
| | - Jianjun Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Cognition and Emotion, Henan Province International Joint Laboratory of Pain, Zhengzhou, Henan, China
| | - Zhongyu Wang
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Cognition and Emotion, Henan Province International Joint Laboratory of Pain, Zhengzhou, Henan, China
| | - Jingjing Yuan
- Department of Anesthesiology, Pain and Perioperative Medicine, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Cognition and Emotion, Henan Province International Joint Laboratory of Pain, Zhengzhou, Henan, China
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Ledowski T. [New Approaches in Perioperative Algesimetry]. Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:640-653. [PMID: 38056443 DOI: 10.1055/a-2006-9923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
The measurement of anaesthetic depth and muscle relaxation have been routine procedures during general anaesthesia for years. Quantification of intraoperative nociception, on the other hand, is still largely impossible. Various methods have been tested and commercialised for more than 10 years. However, a real breakthrough has not yet been achieved and the routine application of all methods available so far is not without problems. This article explains methodological similarities, but also points to specific aspects of various commercial solutions for perioperative algesimetry.
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Bertolizio G, Molliex S, Richebé P. Evaluation of nociception: if one parameter can do so little, can multiple parameters do so much? Anaesth Crit Care Pain Med 2023; 42:101236. [PMID: 37116863 DOI: 10.1016/j.accpm.2023.101236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 04/30/2023]
Affiliation(s)
- Gianluca Bertolizio
- Department of Pediatric Anesthesiology, Montreal Children's Hospital, Montreal, QC H4A 3J1, Canada; Research Institute, McGill University Health Centre, Montreal, QC H4A 3J1, Canada; Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H4A 3J1, Canada.
| | - Serge Molliex
- Université Saint Etienne, Département d'Anesthésie-Réanimation CHU Saint Etienne, Inserm Sainbiose U1059, F-42023, Saint Etienne, France
| | - Philippe Richebé
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montreal, Montreal, QC, H1T 2M4, Canada; Research Center of Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montreal, Montreal, QC, H1T 2M4, Canada; Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, H3T 1J4
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