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Wang H, Wang Q, He Q, Li S, Zhao Y, Zuo Y. Current perioperative nociception monitoring and potential directions. Asian J Surg 2024; 47:2558-2565. [PMID: 38548545 DOI: 10.1016/j.asjsur.2024.03.090] [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: 12/08/2023] [Revised: 03/04/2024] [Accepted: 03/06/2024] [Indexed: 06/05/2024] Open
Abstract
Perioperative nociception-antinociception balance is essential for the prevention of adverse postoperative events. Estimating the nociception level helps optimize intraoperative management. In the past two decades, various nociception monitoring devices have been developed for the identification of intraoperative nociception. However, each type of nociception monitoring device has advantages and disadvantages, limiting their clinical application in particular patients and settings. Therefore, this review aimed to summarize the information on nociceptor monitoring in current clinical settings, explore each technique's particularities, and possible future directions to provide a reference for clinicians and researchers.
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Affiliation(s)
- Haiyan Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, China
| | - Qifeng Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, China
| | - Qinqin He
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, China
| | - Shikuo Li
- Department of Anesthesiology, Yan'an Hospital of Kunming City, Kunming Medical University, Kunming, Yunnan, China
| | - Yuyi Zhao
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yunxia Zuo
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, China.
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Liu J, Wang Z, Huang W, Cheng N, Chen W, Wu W, Li S. Analgesia nociception index is an indicator of laparoscopic trocar insertion-induced transient nociceptive stimuli. Open Med (Wars) 2024; 19:20240933. [PMID: 38681026 PMCID: PMC11048736 DOI: 10.1515/med-2024-0933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/15/2024] [Accepted: 02/20/2024] [Indexed: 05/01/2024] Open
Abstract
Objective This study aimed to investigate whether analgesia nociception index (ANI) could be an indicator of perioperative pain during laparoscopic trocar insertion. Methods A total of 280 participants of anesthesia receiving laparoscopic surgery were enrolled. Anesthesia induction and maintenance were performed using the Marsh model for target propofol and the Minto model for remifentanil. Systolic blood pressure (SBP), heart rate (HR), and ANI were recorded at skin incision, the first-, second, the last-trocar insertion, and 5 min after the last trocar insertion. Results ANI was significantly different among the five groups in the last four time points (all P < 0.05). Pearson's correlation showed that ANI was negatively correlated with SBP (r = -0.114, P = 0.077) and HR (r = -0.247, P < 0.001). The area under the curve of ANI was positively correlated with those of SBP (r = 0.493, P < 0.001) and HR (r = -0.420, P < 0.001). Multivariate logistic regression showed that the ANI was an independent factor associated with intraoperative hemodynamic adverse events only at 5 min after the last trocar insertion. Conclusions Under general anesthesia, the change in ANI was consistent with changes in the balance between analgesia and nociceptive stimuli. The ANI can reflect the extent of transient pain but had a poor predictive performance for hemodynamic adverse events.
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Affiliation(s)
- Jun Liu
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangdong Province, 510630, China
| | - Zhuodan Wang
- Department of Anesthesiology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou City, Guangdong Province, 510260, China
| | - Wan Huang
- Department of Anesthesiology, Sun Yat-sen University Cancer Center, Guangzhou City, Guangdong Province, 510060, China
| | - Nan Cheng
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangdong Province, 510630, China
| | - Weiqiang Chen
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangdong Province, 510630, China
| | - Weijun Wu
- Shenzhen Mindray Bio-Medical Electronics Co., Ltd., Shenzhen City, Guangdong Province, 518000, China
| | - Shangrong Li
- Department of Anesthesiology, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou City, Guangdong Province, 510630, China
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Teng WN, Lin YS, Sung CS, Tseng LM, Chang WK, Ting CK. Analgesia-nociception index accurately predicts inadequate pectoralis muscle fascia block (PECS) in patients undergoing breast surgery: A prospective observational study. J Formos Med Assoc 2024:S0929-6646(24)00145-1. [PMID: 38448346 DOI: 10.1016/j.jfma.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 02/15/2024] [Accepted: 02/29/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Postoperative opioid administration has been largely replaced by regional anesthesia techniques. We aimed to determine whether intraoperative Analgesia-Nociception Index (ANI) can aid in early evaluation of the effectiveness of regional blocks such as the pectoralis muscle fascia block (PECS, pectoserratus and interpectoral plane blocks) and predicting the need for analgesics postoperatively. METHODS This prospective observational study enrolled 30 women (age: 20-80 years) undergoing unilateral, non-intubated, breast tumor excision alone or in conjunction with sentinel lymph node biopsy. PECS block was performed following sedation. ANI readings were obtained at 1-min intervals, and polar coordinates were assigned to the distance from the nipple (0.5-cm intervals) and o'clock position (15-min intervals) for each reading. Pain scores were assessed using a numeric rating scale from 0 to 10, and analgesics were administered depending on pain score post-operatively. RESULTS 8 (27%), 19 (63%), and 3 (10%) patients received morphine, tramadol, and no analgesics, respectively. In total, 954 ANI measurements were obtained. At the proposed cut-off of 50, the sensitivity and specificity of the ANI nadir for need of post-operative opioids were 0.875 and 0.932, respectively. Block effectiveness was most satisfactory in the upper lateral quadrant of the breast with nipple-areolar complex (NAC) sparing effect. Most average ANI measurements for the NAC were <50. No patient experienced postoperative nausea/vomiting, although one reported dizziness. CONCLUSIONS The intraoperative ANI nadir <50 was strongly correlated with need for postoperative opioids. The ANI may aid in objectively evaluating the effectiveness of pectoralis muscle fascial blocks and predicting postoperative need for analgesics.
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Affiliation(s)
- Wei-Nung Teng
- Department of Anesthesiology, Taipei Veterans General Hospital, School of Medicine, National Yang Ming Chiao Tung University, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, Taiwan 11217, China
| | - Yen-Shu Lin
- Department of Surgery, Taipei Veterans General Hospital, School of Medicine, National Yang Ming Chiao Tung University, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, Taiwan 11217, China
| | - Chun-Sung Sung
- Department of Anesthesiology, Taipei Veterans General Hospital, School of Medicine, National Yang Ming Chiao Tung University, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, Taiwan 11217, China
| | - Ling-Ming Tseng
- Department of Surgery, Taipei Veterans General Hospital, School of Medicine, National Yang Ming Chiao Tung University, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, Taiwan 11217, China
| | - Wen-Kuei Chang
- Department of Anesthesiology, Taipei Veterans General Hospital, School of Medicine, National Yang Ming Chiao Tung University, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, Taiwan 11217, China
| | - Chien-Kun Ting
- Department of Anesthesiology, Taipei Veterans General Hospital, School of Medicine, National Yang Ming Chiao Tung University, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, Taiwan 11217, China; Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Beitou District, Taipei City, Taiwan 11230, China.
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Bihani P, Pandey A, Jha M, Paliwal N, Jaju R, Solanki R. Comparing Perfusion Index and Visual Analogue Scores for Postoperative Pain Assessment Following Upper Limb Surgeries Under Supraclavicular Brachial Plexus Block: An Observational Study. Cureus 2024; 16:e55529. [PMID: 38576659 PMCID: PMC10993003 DOI: 10.7759/cureus.55529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Effective pain assessment is crucial to tailor the analgesic regimen post-operatively. Perfusion index (PI) has been reported to be a useful objective assessment tool for monitoring pain. This study aimed to explore the utility of PI in assessing postoperative pain in upper limb surgeries under supraclavicular block and its correlation with visual analogue scale (VAS) scores. METHODS This prospective, observational study included 140 patients scheduled for elective upper limb surgeries. PI, VAS scores, heart rate (HR), mean arterial pressure (MAP) and physiological parameters were recorded at baseline and postoperatively. Inj. tramadol was administered when the VAS score exceeded ≥ 4 and the VAS score, PI, HR and MAP were recorded at 5, 10, 15 and 20 minutes after administration. Comparison of normally and non-normally distributed data was done using t-statistics and Mann-Whitney U-test respectively. Pearson correlation was used to establish a correlation between variables and the receiver operating characteristic (ROC) curve was used to calculate the cut-off value of PI to determine the onset of pain. RESULTS There was a significant and moderate correlation between pre-analgesic and post-analgesic PI and VAS score (r = -0.425 and -0.448 respectively, p<0.001), while PI and MAP or PI and HR showed only a weak correlation. A cut-off value of 14.7 for PI showed 76.3% sensitivity and 100% specificity in predicting rescue analgesia requirements. CONCLUSION The study supports the use of PI as an objective measure for postoperative pain assessment, with a notable correlation with VAS scores. The identified cut-off value for PI adds to its clinical utility in predicting the need for rescue analgesia.
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Affiliation(s)
- Pooja Bihani
- Anesthesiology, Dr. Sampurnanand Medical College, Jodhpur, IND
| | - Akanksha Pandey
- Anesthesiology, Pacific Medical College and Hospital, Udaipur, IND
| | - Manish Jha
- Anesthesiology, Dr. Sampurnanand Medical College, Jodhpur, IND
| | - Naveen Paliwal
- Anesthesiology, Dr. Sampurnanand Medical College, Jodhpur, IND
| | - Rishabh Jaju
- Anesthesiology, All India Institute of Medical Sciences, Deoghar, Deoghar, IND
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Laferrière-Langlois P, Morisson L, Jeffries S, Duclos C, Espitalier F, Richebé P. Depth of Anesthesia and Nociception Monitoring: Current State and Vision For 2050. Anesth Analg 2024; 138:295-307. [PMID: 38215709 DOI: 10.1213/ane.0000000000006860] [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: 01/14/2024]
Abstract
Anesthesia objectives have evolved into combining hypnosis, amnesia, analgesia, paralysis, and suppression of the sympathetic autonomic nervous system. Technological improvements have led to new monitoring strategies, aimed at translating a qualitative physiological state into quantitative metrics, but the optimal strategies for depth of anesthesia (DoA) and analgesia monitoring continue to stimulate debate. Historically, DoA monitoring used patient's movement as a surrogate of awareness. Pharmacokinetic models and metrics, including minimum alveolar concentration for inhaled anesthetics and target-controlled infusion models for intravenous anesthesia, provided further insights to clinicians, but electroencephalography and its derivatives (processed EEG; pEEG) offer the potential for personalization of anesthesia care. Current studies appear to affirm that pEEG monitoring decreases the quantity of anesthetics administered, diminishes postanesthesia care unit duration, and may reduce the occurrence of postoperative delirium (notwithstanding the difficulties of defining this condition). Major trials are underway to further elucidate the impact on postoperative cognitive dysfunction. In this manuscript, we discuss the Bispectral (BIS) index, Narcotrend monitor, Patient State Index, entropy-based monitoring, and Neurosense monitor, as well as middle latency evoked auditory potential, before exploring how these technologies could evolve in the upcoming years. In contrast to developments in pEEG monitors, nociception monitors remain by comparison underdeveloped and underutilized. Just as with anesthetic agents, excessive analgesia can lead to harmful side effects, whereas inadequate analgesia is associated with increased stress response, poorer hemodynamic conditions and coagulation, metabolic, and immune system dysregulation. Broadly, 3 distinct monitoring strategies have emerged: motor reflex, central nervous system, and autonomic nervous system monitoring. Generally, nociceptive monitors outperform basic clinical vital sign monitoring in reducing perioperative opioid use. This manuscript describes pupillometry, surgical pleth index, analgesia nociception index, and nociception level index, and suggest how future developments could impact their use. The final section of this review explores the profound implications of future monitoring technologies on anesthesiology practice and envisages 3 transformative scenarios: helping in creation of an optimal analgesic drug, the advent of bidirectional neuron-microelectronic interfaces, and the synergistic combination of hypnosis and virtual reality.
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Affiliation(s)
- Pascal Laferrière-Langlois
- From the Maisonneuve-Rosemont Research Center, CIUSSS de l'Est de L'Ile de Montréal, Montreal, Quebec, Canada
- Department of Anesthesiology and Pain Medicine, Montreal University, Montreal, Quebec, Canada
| | - Louis Morisson
- Department of Anesthesiology and Pain Medicine, Montreal University, Montreal, Quebec, Canada
| | - Sean Jeffries
- Department of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Catherine Duclos
- Department of Anesthesiology and Pain Medicine, Montreal University, Montreal, Quebec, Canada
| | - Fabien Espitalier
- Department of Anesthesia and Intensive Care, University Hospitals of Tours, Tours, France
| | - Philippe Richebé
- From the Maisonneuve-Rosemont Research Center, CIUSSS de l'Est de L'Ile de Montréal, Montreal, Quebec, Canada
- Department of Anesthesiology and Pain Medicine, Montreal University, Montreal, Quebec, Canada
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Wegeberg AM, Sejersgaard-Jacobsen TH, Brock C, Drewes AM. Prediction of pain using electrocardiographic-derived autonomic measures: A systematic review. Eur J Pain 2024; 28:199-213. [PMID: 37655709 DOI: 10.1002/ejp.2175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/08/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND AND OBJECTIVE Pain is a major clinical challenge, and understanding the pathophysiology is critical for optimal management. The autonomic nervous system reacts to pain stimuli, and autonomic dysfunction may predict pain sensation. The most used assessment of autonomic function is based on electrocardiographic measures, and the ability of such measures to predict pain was investigated. DATABASES AND DATA TREATMENT English articles indexed in PubMed and EMBASE were reviewed for eligibility and included when they reported electrocardiographic-derived measures' ability to predict pain response. The quality in prognostic studies (QUIPS) tool was used to assess the quality of the included articles. RESULTS The search revealed 15 publications, five on experimental pain, five on postoperative pain, and five on longitudinal clinical pain changes, investigating a total of 1069 patients. All studies used electrocardiographically derived parameters to predict pain assessed with pain thresholds using quantitative sensory testing or different scales. Across all study modalities, electrocardiographic measures were able to predict pain. Higher parasympathetic activity predicted decreased experimental, postoperative, and long-term pain in most cases while changes in sympathetic activity did not consistently predict pain. CONCLUSIONS Most studies demonstrated that parasympathetic activity could predict acute and chronic pain intensity. In the clinic, this may be used to identify which patients need more intensive care to prevent, for example postoperative pain and develop personalized chronic pain management. SIGNIFICANCE Pain is a debilitating problem, and the ability to predict occurrence and severity would be a useful clinical tool. Basal autonomic tone has been suggested to influence pain perception. This systematic review investigated electrocardiographic-derived autonomic tone and found that increased parasympathetic tone could predict pain reduction in different types of pain.
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Affiliation(s)
- Anne-Marie Wegeberg
- Thisted Research Unit, Aalborg University Hospital Thisted, Thisted, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Christina Brock
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Denmark, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Thisted Research Unit, Aalborg University Hospital Thisted, Thisted, Denmark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Denmark, Aalborg, Denmark
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Ho CN, Fu PH, Hung KC, Wang LK, Lin YT, Yang AC, Ho CH, Chang JH, Chen JY. Prediction of early postoperative pain using sleep quality and heart rate variability. Pain Pract 2024; 24:82-90. [PMID: 37615236 DOI: 10.1111/papr.13288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
PURPOSE Accurate predictions of postoperative pain intensity are necessary for customizing analgesia plans. Insomnia is a risk factor for severe postoperative pain. Moreover, heart rate variability (HRV) can provide information on the sympathetic-parasympathetic balance in response to noxious stimuli. We developed a prediction model that uses the insomnia severity index (ISI), HRV, and other demographic factors to predict the odds of higher postoperative pain. METHODS We recruited gynecological surgery patients classified as American Society of Anesthesiologists class 1-3. An ISI questionnaire was completed 1 day before surgery. HRV was calculated offline using intraoperative electrocardiogram data. Pain severity at the postanesthesia care unit (PACU) was assessed with the 0-10 numerical rating scale (NRS). The primary outcome was the model's predictive ability for moderate-to-severe postoperative pain. The secondary outcome was the relationship between individual risk factors and opioid consumption in the PACU. RESULTS Our study enrolled 169 women. Higher ISI scores (p = 0.001), higher parasympathetic activity (rMSSD, pNN50, HF; p < 0.001, p < 0.001, p < 0.001), loss of fractal dynamics (SD2, alpha 1; p = 0.012, p = 0.039) in HRV analysis before the end of surgery were associated with higher NRS scores, while laparoscopic surgery (p = 0.031) was associated with lower NRS scores. We constructed a multiple logistic model (area under the curve = 0.852) to predict higher NRS scores at PACU arrival. The five selected predictors were age (OR: 0.94; p = 0.020), ISI score (OR: 1.14; p = 0.002), surgery type (laparoscopic or open; OR: 0.12; p < 0.001), total power (OR: 2.02; p < 0.001), and alpha 1 (OR: 0.03; p < 0.001). CONCLUSION We employed a multiple logistic regression model to determine the likelihood of moderate-to-severe postoperative pain upon arrival at the PACU. Physicians could personalize analgesic regimens based on a deeper comprehension of the factors that contribute to postoperative pain.
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Affiliation(s)
- Chun-Ning Ho
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
- Department of Hospital and Health Care Administration, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
- Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Pei-Han Fu
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Kuo-Chuan Hung
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
- Department of Hospital and Health Care Administration, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Li-Kai Wang
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
- Department of Hospital and Health Care Administration, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Yao-Tsung Lin
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
- Department of Hospital and Health Care Administration, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Albert C Yang
- Institute of Brain Science/Digital Medicine Center, National Yang Ming Chial Tung University, Taipei, Taiwan
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Han Ho
- Department of Medicine Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Jia-Hui Chang
- Department of Medicine Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Jen-Yin Chen
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
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Kim J, Kim JA, Jang JN, Yang M, Ahn HJ, Choi J, Jo S. The arousal effect of sugammadex reversal of neuromuscular blockade differs with anesthetic depth in propofol-remifentanil anesthesia: a randomized controlled trial. Sci Rep 2023; 13:20776. [PMID: 38012277 PMCID: PMC10682451 DOI: 10.1038/s41598-023-48031-6] [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: 09/06/2023] [Accepted: 11/21/2023] [Indexed: 11/29/2023] Open
Abstract
Sugammadex reverses neuromuscular blockade by encapsulating steroidal neuromuscular blockers; therefore, it does not pharmacologically affect sedation levels. However, some clinicians avoid using it because of sudden unwanted acting out or patient arousal. Previous studies suggested sugammadex-induced awakening, but frontal muscle contraction after sugammadex administration compromised reliability of results obtained from EEG-based anesthesia depth monitoring tools like bispectral index (BIS). We hypothesized that sugammadex would affect patients' arousal depending on their baseline levels of sedation. We evaluated arousal signs after sugammadex administration with BIS between 25 - 35 and 45 - 55 under steady-state propofol-remifentanil anesthesia at the end of a surgery (n = 33 in each group). After sugammadex administration, twelve patients with a BIS of 45 - 55 showed clinical signs of awakening but none with a BIS of 25 - 35 (36.4% vs. 0%, P = 0.001). The distribution of the modified observer's assessment of alertness/sedation scale scores was also significantly different between the two groups (P < 0.001). Changes in the BIS were significantly greater in the BIS 45 - 55 than in the 25 - 35 group (median difference, 7; 95% CI 2 - 19, P = 0.002). Arousal after sugammadex was affected by patient sedation levels, and clinical signs of awakening appeared only in those with BIS 45 - 55. Unwanted arousal of the patient should be considered when using sugammadex under shallow anesthesia.Clinical trial registry number: Clinical Trial Registry of Korea ( https://cris.nih.go.kr ; Principal investigator: Jieae Kim; Registration number: KCT0006248; Date of first registration: 11/06/2021).
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Affiliation(s)
- Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon‑Ro, Gangnam‑Gu, Seoul, 06351, Korea
| | - Jie Ae Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon‑Ro, Gangnam‑Gu, Seoul, 06351, Korea.
| | - Jae Ni Jang
- Department of Anesthesiology and Pain Medicine, International St. Mary's Hospital, Catholic Kwandong University School of Medicine, Incheon, Korea
| | - Mikyung Yang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon‑Ro, Gangnam‑Gu, Seoul, 06351, Korea
| | - Hyun Joo Ahn
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon‑Ro, Gangnam‑Gu, Seoul, 06351, Korea
| | - Jiwon Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon‑Ro, Gangnam‑Gu, Seoul, 06351, Korea
| | - Sungwoo Jo
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon‑Ro, Gangnam‑Gu, Seoul, 06351, Korea
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Kim MK, Choi GJ, Oh KS, Lee SP, Kang H. Pain Assessment Using the Analgesia Nociception Index (ANI) in Patients Undergoing General Anesthesia: A Systematic Review and Meta-Analysis. J Pers Med 2023; 13:1461. [PMID: 37888072 PMCID: PMC10608238 DOI: 10.3390/jpm13101461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/18/2023] [Accepted: 09/23/2023] [Indexed: 10/28/2023] Open
Abstract
The analgesia nociception index (ANI) has emerged as a potential measurement for objective pain assessment during general anesthesia. This systematic review and meta-analysis aimed to evaluate the accuracy and effectiveness of ANI in assessing intra- and post-operative pain in patients undergoing general anesthesia. We conducted a comprehensive search of Ovid-MEDLINE, Ovid-EMBASE, Cochrane Central Register of Controlled Trials, Google Scholar, public clinical trial databases (ClinicalTrials and Clinical Research Information Service), and OpenSIGLE to identify relevant studies published prior to May 2023 and included studies that evaluated the accuracy and effectiveness of ANI for intra- or post-operative pain assessment during general anesthesia. Among the 962 studies identified, 30 met the eligibility criteria and were included in the systematic review, and 17 were included in the meta-analysis. For predicting intra-operative pain, pooled sensitivity, specificity, diagnostic odds ratio (DOR), and area under curve of ANI were 0.81 (95% confidence interval [CI] = 0.79-0.83; I2 = 68.2%), 0.93 (95% CI = 0.92-0.93; I2 = 99.8%), 2.32 (95% CI = 1.33-3.30; I2 = 61.7%), and 0.77 (95% CI = 0.76-0.78; I2 = 87.4%), respectively. ANI values and changes in intra-operative hemodynamic variables showed statistically significant correlations. For predicting post-operative pain, pooled sensitivity, specificity, and DOR of ANI were 0.90 (95% CI = 0.87-0.93; I2 = 58.7%), 0.51 (95% CI = 0.49-0.52; I2 = 99.9%), and 3.38 (95% CI = 2.87-3.88; I2 = 81.2%), respectively. ANI monitoring in patients undergoing surgery under general anesthesia is a valuable measurement for predicting intra- and post-operative pain. It reduces the use of intra-operative opioids and aids in pain management throughout the perioperative period.
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Affiliation(s)
- Min Kyoung Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul 06974, Republic of Korea; (M.K.K.); (G.J.C.); (K.S.O.)
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong-si 14353, Republic of Korea
| | - Geun Joo Choi
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul 06974, Republic of Korea; (M.K.K.); (G.J.C.); (K.S.O.)
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, Seoul 06973, Republic of Korea
| | - Kyung Seo Oh
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul 06974, Republic of Korea; (M.K.K.); (G.J.C.); (K.S.O.)
| | - Sang Phil Lee
- Department of Biomedical Engineering Graduate School, Chungbuk National University, Cheongju-si 28644, Republic of Korea;
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul 06974, Republic of Korea; (M.K.K.); (G.J.C.); (K.S.O.)
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, Seoul 06973, Republic of Korea
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Singh A, Akhileshwar, Kumar N, De RR, Bahadur R, Shekhar S. The Role of Pupillometry in the Assessment of Pain in Children Under General Anesthesia: A Prospective Single-Blinded Observational Study. Cureus 2023; 15:e43894. [PMID: 37753025 PMCID: PMC10518524 DOI: 10.7759/cureus.43894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 09/28/2023] Open
Abstract
Background and objective The management and treatment of nociception remain one of the major challenges in anesthesiology, and hemodynamic variations may occur due to inadequate analgesia, which at times can be injurious. Pupillometry is a new noninvasive tool to assess nociception during anesthesia. The amount of pupillary reflex dilation (PRD) is directly proportional to the intensity of nociceptive stimuli and inversely proportional to the opioid dosage. This study aimed to assess the use of pupillometry as reflex pupillary dilatation in response to surgical stimulus in children under general anesthesia and to guide intraoperative opioid consumption. Materials and methods After obtaining approval from the institutional ethics committee and written consent from parents, children with an American Society of Anesthesiology (ASA) classification of I and II and aged 2-12 years who were undergoing surgery under general anesthesia were enrolled in this prospective randomized observational study. General anesthesia was standardized with propofol, sevoflurane, and O2 and N2O (50:50%), and fentanyl administration was guided by pupil diameter changes. The primary outcome was to measure pupillary dilatation in response to pain and fentanyl administration guided by it. Results A total of 72 patients were included in the study. The mean pupil diameter significantly increased after surgical stimulus from 1.37 ±0.87 to 2.40 ±1.95 mm (p<0.001). The heart rate (116.2 ±12.25 to 118.50 ±8.20 beats/minute, p=0.18) and systolic BP (114.60 ±17.73 to 118.50 ±12.25 mmHg, p=0.12) did not change significantly on stimulus. The mean fentanyl consumption was 2.4 ug/kg and the side effects were not remarkable. Conclusion Based on our findings, pain has a significant influence on the pupil dilatation reflex in anesthetized children, and opioid administration based on pupil diameter can be valuable in clinical settings. We recommend the use of pupillometry as a pain index in children undergoing surgery under general anesthesia, and it can be a beneficial tool for assessing intraoperative pain. Newer techniques and developments are required in this field.
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Affiliation(s)
- Akrity Singh
- Department of Trauma and Emergency Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Akhileshwar
- Department of Trauma and Emergency Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Nitin Kumar
- Department of Trauma and Emergency Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Ranjeet Rana De
- Department of Trauma and Emergency Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Raj Bahadur
- Department of Trauma and Emergency Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Saurav Shekhar
- Department of Trauma and Emergency Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
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11
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Sharma P, Shwethashri KR, Chakrabarti D, Sadashiva N, Shah K, Gopalakrishna KN. Analgesia Nociception Index (ANI) as a monitor of peri-operative nociception-antinociception balance in paediatric craniotomies: a prospective observational study. Childs Nerv Syst 2023; 39:2169-2176. [PMID: 36869908 DOI: 10.1007/s00381-023-05905-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 02/25/2023] [Indexed: 03/05/2023]
Abstract
INTRODUCTION Analgesia Nociception Index (ANI) as a monitor of peri-operative nociception-anti-nociception balance has not been studied in paediatric neurosurgery. The objectives were to study the correlation between ANI (Mdoloris Education system) and revised FLACC (r-FLACC) score for the prediction of acute postoperative pain in paediatric population undergoing elective craniotomies and to compare the changes in ANI values with heart rate (HR), mean arterial pressure (MAP) and surgical plethysmographic index (SPI) during various time points of intraoperative noxious stimulation and before and after opioid administration. METHODS This prospective observational pilot study included 14 patients between 2 and 12 years of age undergoing elective craniotomies. HR, MAP, SPI, ANI instantaneous (ANIi) and ANI mean (ANIm) values were recorded intraoperatively and before and after opioid administration. Postoperatively HR, MAP, ANIi and ANIm, and pain scores (r-FLACC scale) were recorded. RESULTS There was a statistically significant negative correlation between ANIi and ANIm with r-FLACC during the time course of PACU stay (r = - 0.89, p < 0.001 and r = - 0.88 and p < 0.001 respectively). Intraoperatively, in patients with ANIi values < 50, with additional fentanyl administration, there was an increasing trend in values beyond 50, which was statistically significant (p < 0.05) at 3, 4, 5 and 10 min. The trend in changes of SPI after opioid administration was not found to be significant for patients irrespective of the baseline SPI values. CONCLUSION The ANI is a reliable tool for objective assessment of acute postoperative pain as assessed by r-FLACC in children undergoing craniotomies for intracranial lesions. It may be used as a guide to nociception-antinociception balance during the peri-operative period in this population.
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Affiliation(s)
- Prachi Sharma
- Department of Neuroanaesthesia and Neurocritical care, National Institute of Mental Health & Neurosciences (NIMHANS), 3rd floor Faculty Block, Hosur Road, Bangalore, 560029, India
| | - Kondavagilu Ramaprasannakumar Shwethashri
- Department of Neuroanaesthesia and Neurocritical care, National Institute of Mental Health & Neurosciences (NIMHANS), 3rd floor Faculty Block, Hosur Road, Bangalore, 560029, India
| | - Dhritiman Chakrabarti
- Department of Neuroanaesthesia and Neurocritical care, National Institute of Mental Health & Neurosciences (NIMHANS), 3rd floor Faculty Block, Hosur Road, Bangalore, 560029, India
| | - Nishanth Sadashiva
- Department of Neurosurgery, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Keyur Shah
- Department of Neurosurgery, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Kadarapura Nanjundaiah Gopalakrishna
- Department of Neuroanaesthesia and Neurocritical care, National Institute of Mental Health & Neurosciences (NIMHANS), 3rd floor Faculty Block, Hosur Road, Bangalore, 560029, India.
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12
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Aulenkamp JL, Mosch L, Meyer-Frießem CH, Malewicz-Oeck NM. [Application possibilities of digital tools in postoperative pain therapy]. Schmerz 2023:10.1007/s00482-023-00732-7. [PMID: 37430071 PMCID: PMC10368541 DOI: 10.1007/s00482-023-00732-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 04/15/2023] [Accepted: 05/11/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Recently, digital tools, such as smartphone-based applications and the use of artificial intelligence have increasingly found their way into pain medicine. This could enable new treatment approaches in postoperative pain management. Therefore, this article provides an overview of various digital tools and their potential application options in postoperative pain management. MATERIAL AND METHODS An orienting literature search was carried out in the MEDLINE and Web of Science databases, and a targeted selection of essential key publications was made in order to provide a structured presentation of different current possible applications and a discussion based on the most recent knowledge. RESULTS Today, possible applications of digital tools, even if they mostly have only a model character, include pain documentation and assessment, patient self-management and education, pain prediction, decision support for medical staff, and supportive pain therapy, for example in the form of virtual reality and videos. These tools offer advantages such as individualized treatment concepts, addressing specific patient groups, reduction of pain and analgesics, and the potential for early warning or detection of postoperative pain. Furthermore, the challenges of the technical implementation and appropriate user training are highlighted. CONCLUSION The use of digital tools, although so far integrated in clinical routine in a relatively selective and exemplary manner, promises to be an innovative approach for personalized postoperative pain therapy in the future. Future studies and projects should help to integrate the promising research approaches into everyday clinical practice.
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Affiliation(s)
- Jana L Aulenkamp
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45122, Essen, Deutschland.
| | - Lina Mosch
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Deutschland
- Institut für Medizinische Informatik, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Deutschland
| | - Christine H Meyer-Frießem
- Klinik für Anästhesiologie, Intensiv- und Schmerzmedizin, Universitätsklinikum Bergmannsheil Bochum gGmbH, Bochum, Deutschland
- Klinik für Anästhesiologie, Intensiv- und Schmerzmedizin, St. Marien Hospital, Lünen, Deutschland
| | - Nathalie M Malewicz-Oeck
- Klinik für Anästhesiologie, Intensiv- und Schmerzmedizin, Universitätsklinikum Bergmannsheil Bochum gGmbH, Bochum, Deutschland
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13
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Fratino S, Garré A, Garufi A, Hafidi S, Migliorino E, Stropeni S, Bogossian EG, Ndieugnou Djangang N, Albano G, Creteur J, Peluso L, Taccone FS. Evaluation of nociception in unconscious critically ill patients using a multimodal approach. Anaesth Crit Care Pain Med 2023; 42:101175. [PMID: 36396073 DOI: 10.1016/j.accpm.2022.101175] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/05/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022]
Abstract
This prospective observational study included 80 adults (>18 years) patients admitted to the intensive care unit who were unconscious (Glasgow Coma Scale [GCS] score <9 with a motor response <5) and receiving mechanical ventilation. A tetanic stimulation was used to assess nociception; automated pupillometry (Algiscan, ID-MED, France) was used to compute the pupillary pain index score (PPI), with a PPI > 4 considered as nociception. Concomitantly, the number of skin conductance fluctuations (NSCF) per second, measured using a Skin Conductance Algesimeter (SCA, MEDSTORM Innovation AS, Norway; > 0.27 fluctuations/sec indicating nociception), and the instantaneous Analgesia Nociception Index (iANI, MDoloris Medical Systems, France; <50 indicating nociception) were collected. Tetanic stimulation resulted in a median pupillary dilation of 16 [6-25]% and a PPI of 5 [2-7]. According to the PPI assessment, 44 patients (55%) had nociception, whereas 23 (29%) and 18 (23%) showed nociception according to the algesimeter and iANI assessment, respectively. No significant changes in measured physiologic variables were observed after the tetanic stimulation. There were no correlations between PPI, post-stimulation iANI, and SCA-derived variables. There were no differences in PPI, iANI, and SCA variables in patients with low and normal baseline EEG power at baseline. PERSPECTIVES: Detection of nociception varies across different devices in unconscious critically ill patients. Further studies are required to understand which method to implement for analgesic administration in this patient population.
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Affiliation(s)
- Sara Fratino
- Department of Intensive Care, Erasme University Hospital - Université Libre de Bruxelles, Brussels, Belgium.
| | - Annalisa Garré
- Department of Intensive Care, Erasme University Hospital - Université Libre de Bruxelles, Brussels, Belgium
| | - Alessandra Garufi
- Department of Intensive Care, Erasme University Hospital - Université Libre de Bruxelles, Brussels, Belgium
| | - Sofia Hafidi
- Department of Intensive Care, Erasme University Hospital - Université Libre de Bruxelles, Brussels, Belgium
| | - Ernesto Migliorino
- Department of Intensive Care, Erasme University Hospital - Université Libre de Bruxelles, Brussels, Belgium
| | - Serena Stropeni
- Department of Intensive Care, Erasme University Hospital - Université Libre de Bruxelles, Brussels, Belgium
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Erasme University Hospital - Université Libre de Bruxelles, Brussels, Belgium
| | | | - Giovanni Albano
- Department of Anesthesiology and Intensive Care, Humanitas Gavazzeni, Bergamo, Italy
| | - Jacques Creteur
- Department of Intensive Care, Erasme University Hospital - Université Libre de Bruxelles, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme University Hospital - Université Libre de Bruxelles, Brussels, Belgium; Department of Anesthesiology and Intensive Care, Humanitas Gavazzeni, Bergamo, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme University Hospital - Université Libre de Bruxelles, Brussels, Belgium
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14
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Tiryaki Ö, Doğu Ö, Okumuş GY, Tuna AT, Bayar F. Analgesia Nociception Index Monitoring in the Evaluation of Postoperative Pain in Children: A Prospective Observational Pilot Study. J Perianesth Nurs 2023; 38:213-218. [PMID: 36241538 DOI: 10.1016/j.jopan.2022.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 02/14/2022] [Accepted: 04/02/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE In this study, we aimed to evaluate the relationship between the analgesia nociception index (ANI) device and pain scales used in the postoperative pain assessment of pediatric patients who underwent laparoscopic appendectomy. DESIGN The study was designed as a correlation observational pilot study. METHODS Postoperative pain was evaluated using pediatric pain scales (face, legs, arms, cry, consolability scale; numerical rating scale; Wong-Baker scale) and ANI device in school-aged children and adolescents. RESULTS The mean age of the children was 14.00 ± 1.63 years, and the mean BMI was 22.52. We found a statistically significant positive correlation between the pain scale scores and a statistically significant negative relationship between the pain scale score and the ANI. CONCLUSIONS The ANI device can be used safely and constantly for the objective assessment of postoperative pain in pediatric patients.
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Affiliation(s)
- Öznur Tiryaki
- Sakarya Education and Research Hospital, Sakarya, Turkey.
| | - Özlem Doğu
- Department of Fundamentals, Sakarya University, Sakarya, Turkey
| | - Gamze Yılmaz Okumuş
- Department of Anaesthesiology and Reanimation, Sakarya University, Sakarya, Turkey
| | - Ayça Taş Tuna
- Department of Anaesthesiology and Reanimation, Sakarya University, Sakarya, Turkey
| | - Fikret Bayar
- Department of Anaesthesiology and Reanimation, Sakarya Education and Research Hospital, Sakarya, Turkey
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15
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Goff J, Hina M, Malik N, McLardy H, Reilly F, Robertson M, Ruddy L, Willox F, Forget P. Can Opioid-Free Anaesthesia Be Personalised? A Narrative Review. J Pers Med 2023; 13:jpm13030500. [PMID: 36983682 PMCID: PMC10056629 DOI: 10.3390/jpm13030500] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/04/2023] [Accepted: 03/08/2023] [Indexed: 03/12/2023] Open
Abstract
Background: A significant amount of evidence suggests that Opioid-Free Anaesthesia (OFA) may provide better outcomes for patients undergoing surgery, sparing patients who are particularly vulnerable to adverse side effects of opioids. However, to what extent personalizing OFA is feasible and beneficial has not been adequately described. Methods: We conducted a narrative literature review aiming to provide a comprehensive understanding of nociception and pain and its context within the field of OFA. Physiological (including monitoring), pharmacological, procedural (type of surgery), genetical and phenotypical (including patients’ conditions) were considered. Results: We did not find any monitoring robustly associated with improved outcomes. However, we found evidence supporting particular OFA indications, such as bariatric and cancer surgery. We found that vulnerable patients may benefit more from OFA, with an interesting field of research in patients suffering from vascular disease. We found a variety of techniques and medications making it impossible to consider OFA as a single technique. Our findings suggest that a vast field of research remains unexplored. In particular, a deeper understanding of nociception with an interest in its genetic and acquired contributors would be an excellent starting point paving the way for personalised OFA. Conclusion: Recent developments in OFA may present a more holistic approach, challenging the use of opioids. Understanding better nociception, given the variety of OFA techniques, may help to maximize their potential in different contexts and potential indications.
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Affiliation(s)
- Jenna Goff
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Morgan Hina
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Nayaab Malik
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Hannah McLardy
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Finley Reilly
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Matthew Robertson
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
- Correspondence:
| | - Louis Ruddy
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Faith Willox
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Patrice Forget
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
- Department of Anaesthesia, NHS Grampian, Aberdeen AB25 2ZD, UK
- Pain AND Opioids after Surgery (PANDOS) European Society of Anaesthesia and Intensive Care (ESAIC) Research Group, 1000 Brussels, Belgium
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16
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Yoshida K, Obara S, Inoue S. Analgesia nociception index and high frequency variability index: promising indicators of relative parasympathetic tone. J Anesth 2023; 37:130-137. [PMID: 36272031 PMCID: PMC9589736 DOI: 10.1007/s00540-022-03126-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/11/2022] [Indexed: 01/26/2023]
Abstract
At present, there is no objective and absolute measure of nociception, although various monitoring techniques have been developed. One such technique is the Analgesia Nociception Index (ANI), which is calculated from heart rate variability that reflects the relative parasympathetic tone. ANI is expressed on a non-unit scale of 0-100 (100 indicates maximal relative parasympathetic tone). Several studies indicated that ANI-guided anesthesia may help reduce intraoperative opioid use. The usefulness of ANI in the intensive care unit (ICU) and during surgery has also been reported. However, some limitations of ANI have also been reported; for example, ANI is affected by emotions and some drugs. In 2022, a high frequency variability index (HFVI), which was renamed from ANI and uses the same algorithm as ANI, was commercialized; therefore, ANI/HFVI are currently in the spotlight. Unlike ANI, HFVI can be displayed along with other biometric information on the Root® monitor. ANI/HFVI monitoring may affect the prognosis of not only patients in the perioperative period but those in ICU, those who receive home medical care, or outpatients. In this article, we present an updated review on ANI that has been published in the last decade, introduce HFVI, and discuss the outlooks of ANI/HFVI.
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Affiliation(s)
- Keisuke Yoshida
- Department of Anesthesiology, Fukushima Medical University, 1 Hikariga-Oka, Fukushima City, Fukushima, 960-1297, Japan.
| | - Shinju Obara
- Department of Anesthesiology, Fukushima Medical University, 1 Hikariga-Oka, Fukushima City, Fukushima, 960-1297, Japan
| | - Satoki Inoue
- Department of Anesthesiology, Fukushima Medical University, 1 Hikariga-Oka, Fukushima City, Fukushima, 960-1297, Japan
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17
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Morisson L, Nadeau-Vallée M, Espitalier F, Laferrière-Langlois P, Idrissi M, Lahrichi N, Gélinas C, Verdonck O, Richebé P. Prediction of acute postoperative pain based on intraoperative nociception level (NOL) index values: the impact of machine learning-based analysis. J Clin Monit Comput 2023; 37:337-344. [PMID: 35925430 DOI: 10.1007/s10877-022-00897-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 07/07/2022] [Indexed: 01/24/2023]
Abstract
The relationship between intraoperative nociception and acute postoperative pain is still not well established. The nociception level (NOL) Index (Medasense, Ramat Gan, Israel) uses a multiparametric approach to provide a 0-100 nociception score. The objective of the ancillary analysis of the NOLGYN study was to evaluate the ability of a machine-learning aglorithm to predict moderate to severe acute postoperative pain based on intraoperative NOL values. Our study uses the data from the NOLGYN study, a randomized controlled trial that evaluated the impact of NOL-guided intraoperative administration of fentanyl on overall fentanyl consumption compared to standard of care. Seventy patients (ASA class I-III, aged 18-75 years) scheduled for gynecological laparoscopic surgery were enrolled. Variables included baseline demographics, NOL reaction to incision or intubation, median NOL during surgery, NOL time-weighted average (TWA) above or under manufacturers' recommended thresholds (10-25), and percentage of surgical time spent with NOL > 25 or < 10. We evaluated different machine learning algorithms to predict postoperative pain. Performance was assessed using cross-validated area under the ROC curve (CV-AUC). Of the 66 patients analyzed, 42 (63.6%) experienced moderate to severe pain. NOL post-intubation (42.8 (31.8-50.6) vs. 34.8 (25.6-41.3), p = 0.05), median NOL during surgery (13 (11-15) vs. 11 (8-13), p = 0.027), percentage of surgical time spent with NOL > 25 (23% (18-18) vs. 20% (15-24), p = 0.036), NOL TWA < 10 (2.54 (2.1-3.0) vs. 2.86 (2.48-3.62), p = 0.044) and percentage of surgical time spent with NOL < 10 (41% (36-47) vs. 47% (40-55), p = 0.022) were associated with moderate to severe PACU pain. Corresponding ROC AUC for the prediction of moderate to severe PACU pain were 0.65 [0.51-0.79], 0.66 [0.52-0.81], 0.66 [0.52-0.79], 0.65 [0.51-0.79] and 0.67 [0.53-0.81]. Penalized logistic regression achieved the best performance with a 0.753 (0.718-0.788) CV-AUC. Our results, even if limited by the small number of patients, suggest that acute postoperative pain is better predicted by a multivariate machine-learning algorithm rather than individual intraoperative nociception variables. Further larger multicentric trials are highly recommended to better understand the relationship between intraoperative nociception and acute postoperative pain.Trial registration Registered on ClinicalTrials.gov in October 2018 (NCT03776838).
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Affiliation(s)
- Louis Morisson
- Department of Anesthesiology and Pain Medicine, CIUSSS de l'Est de l'Ile de Montréal, Maisonneuve-Rosemont Hospital, Montréal, Québec, Canada.
- Department of Anesthesiology and Pain Medicine, University of Montréal, Montréal, Québec, Canada.
| | - Mathieu Nadeau-Vallée
- Department of Anesthesiology and Pain Medicine, CIUSSS de l'Est de l'Ile de Montréal, Maisonneuve-Rosemont Hospital, Montréal, Québec, Canada
- Department of Anesthesiology and Pain Medicine, University of Montréal, Montréal, Québec, Canada
| | - Fabien Espitalier
- Department of Anesthesiology and Intensive Care, University Hospitals of Tours, Tours, France
| | - Pascal Laferrière-Langlois
- Department of Anesthesiology and Pain Medicine, CIUSSS de l'Est de l'Ile de Montréal, Maisonneuve-Rosemont Hospital, Montréal, Québec, Canada
- Department of Anesthesiology and Pain Medicine, University of Montréal, Montréal, Québec, Canada
| | - Moulay Idrissi
- Department of Anesthesiology and Pain Medicine, CIUSSS de l'Est de l'Ile de Montréal, Maisonneuve-Rosemont Hospital, Montréal, Québec, Canada
| | - Nadia Lahrichi
- Department of Mathematical and Industrial Engineering, Polytechnique Montréal, Montréal, Québec, Canada
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montréal, Québec, Canada
| | - Olivier Verdonck
- Department of Anesthesiology and Pain Medicine, CIUSSS de l'Est de l'Ile de Montréal, Maisonneuve-Rosemont Hospital, Montréal, Québec, Canada
- Department of Anesthesiology and Pain Medicine, University of Montréal, Montréal, Québec, Canada
| | - Philippe Richebé
- Department of Anesthesiology and Pain Medicine, CIUSSS de l'Est de l'Ile de Montréal, Maisonneuve-Rosemont Hospital, Montréal, Québec, Canada
- Department of Anesthesiology and Pain Medicine, University of Montréal, Montréal, Québec, Canada
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18
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Bertolizio G, Garbin M, Ingelmo PM. Evaluation of Nociception during Pediatric Surgery: A Topical Review. J Pers Med 2023; 13:260. [PMID: 36836492 PMCID: PMC9964458 DOI: 10.3390/jpm13020260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/26/2023] [Accepted: 01/26/2023] [Indexed: 02/03/2023] Open
Abstract
The association between intraoperative nociception and increased patient's morbidity is well established. However, hemodynamic parameters, such as heart rate and blood pressure, may result in an inadequate monitor of nociception during surgery. Over the last two decades, different devices have been marketed to "reliably" detect intraoperative nociception. Since the direct measure of nociception is impractical during surgery, these monitors measures nociception surrogates such as sympathetic and parasympathetic nervous systems responses (heart rate variability, pupillometry, skin conductance), electroencephalographic changes, and muscular reflex arc. Each monitor carries its own advantages and disadvantages. The manuscript aims to give an overview of the most up-to-date information available in the literature on current nociceptor monitors available in clinical practice, with particular focus on their applications in pediatrics.
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Affiliation(s)
- Gianluca Bertolizio
- Department of Pediatric Anesthesiology, Montreal Children’s Hospital, Montreal, QC H4A 3J1, Canada
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H4A 3J1, Canada
- Research Institute, McGill University Health Center, Montreal, QC H4A 3J1, Canada
| | - Marta Garbin
- Department of Clinical Sciences, Université de Montréal, St-Hyacinthe, QC J2S 2M2, Canada
| | - Pablo M. Ingelmo
- Department of Pediatric Anesthesiology, Montreal Children’s Hospital, Montreal, QC H4A 3J1, Canada
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H4A 3J1, Canada
- Research Institute, McGill University Health Center, Montreal, QC H4A 3J1, Canada
- Edwards Family Interdisciplinary Center for Complex Pain, Montreal Children’s Hospital, Montreal, QC H4A 3J1, Canada
- Alan Edwards Center for Research on Pain, McGill University, Montreal, QC H3A 2B4, Canada
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19
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Hung KC, Chang PC, Hsu CW, Lan KM, Liao SW, Lin YT, Huang PW, Sun CK. Usefulness of Analgesia Nociception Index for guiding intraoperative opioid administration: a systematic review and meta-analysis. Minerva Anestesiol 2023; 89:74-84. [PMID: 36282226 DOI: 10.23736/s0375-9393.22.16697-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION This study primarily aimed at investigating the efficacy of Analgesia Nociception Index (ANI) for guiding intraoperative opioid administration in patients receiving surgery under general anesthesia. EVIDENCE ACQUISITION The Medline, Embase, Google scholar, and the Cochrane Library databases were searched from inception to April 2022 for randomized controlled trials. The primary outcome was intraoperative opioid administration, while the secondary outcomes included postoperative opioid consumption, pain score, emergency time, risk of nausea/vomiting (PONV), and Postanesthesia Care Unit (PACU) stay. EVIDENCE SYNTHESIS Six studies including 399 participants (published from 2015 to 2022) focused on non-cardiac surgery, including spine surgery (two trials), breast surgery (two trials), gynecologic surgery (one trial), and laparoscopic cholecystectomy (one trial) were included. Meta-analysis revealed no difference in intraoperative opioid administration with the use of ANI-guided analgesia compared to the control group that used conventional clinical measurements (e.g., heart rate) to guide opioid use [standardized mean difference (SMD)=-0.17, 95% CI: -0.56 to 0.22, P=0.39, I2=72%, six trials, 399 participants]. Gender-based subgroup analysis showed effectiveness of ANI for reducing opioid administration in female patients (SMD=-0.53, P=0.02). There were no differences in postoperative recovery characteristics including pain score [Mean difference (MD): -0.03, P=0.79], opioid consumption (SMD: -0.34, P=0.08), emergence time (MD=1.12, P=0.47), length of stay in the PACU (MD: -0.56, P=0.83), and risk of PONV [risk ratio(RR): 0.75, P=0.46] between the two groups. CONCLUSIONS Analgesia nociception index-guided analgesia was unable to reduce intraoperative opioid administration compared to monitoring using conventional clinical parameters. Further studies are required to support our findings.
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Affiliation(s)
- Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Po-Chih Chang
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Medical University Hospital/Kaohsiung Medical University, Kaohsiung, Taiwan.,Weight Management Center, Kaohsiung Medical University Hospital/Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Sports Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Program in Biomedical Engineering, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kuo-Mao Lan
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Shu-Wei Liao
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Yao-Tsung Lin
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Ping-Wen Huang
- Department of Emergency Medicine, Show Chwan Memorial Hospital, Changhua City, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, Kaohsiung, Taiwan - .,College of Medicine, I-Shou University, Kaohsiung, Taiwan
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Orzabal M, Naidu R, Amirdelfan K, Akhbardeh A. A Forehead Wearable Sensor for the Objective Measurement of Chronic Pain. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:17041. [PMID: 36554922 PMCID: PMC9778873 DOI: 10.3390/ijerph192417041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/11/2022] [Accepted: 12/15/2022] [Indexed: 06/17/2023]
Abstract
Chronic pain impacts one in five Americans and is difficult to manage, costing ~USD 600 billion annually. The subjective experience of pain is a complex processing of central nervous system input. Recent advances in magnetic resonance imaging revealed the prefrontal cortex as vital to the perception of pain and that changes in the cerebral hemodynamics can be used to detect painful sensations. Current pain monitoring is dependent on the subjective rating provided by patients and is limited to a single time point. We have developed a biomarker for the objective, real-time and continuous chronic pain assessment using proprietary algorithms termed ROPA and cerebral optical spectrometry. Using a forehead sensor, the cerebral optical spectrometry data were collected in two clinical sites from 41 patients (19 and 22, respectively, from sites 1 and 2), who elected to receive an epidural steroid injection for the treatment of chronic pain. Patients rated their pain on a numeric rating scale, ranging from 0-10, which were used to validate the ROPA objective pain scoring. Multiple time points, including pre- and post-procedure were recorded. The steroid injection was performed per standard medical practice. There was a significant correlation between the patient's reported numeric rating scale and ROPA, for both clinical sites (Overall ~0.81). Holding the subjective pain ratings on a numeric rating scale as ground truth, we determined that the area under the receiver operator curves for both sites revealed at least good (AUC: 64%) to excellent (AUC > 98%) distinctions between clinically meaningful pain severity differentiations (no/mild/moderate/severe). The objective measure of chronic pain (ROPA) determined using cerebral optical spectrometry significantly correlated with the subjective pain scores reported by the subjects. This technology may provide a useful method of detection for the objective and continuous monitoring and treatment of patients with chronic pain, particularly in clinical circumstances where direct assessment is not available, or to complement the patient-reported pain scores.
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Affiliation(s)
- Marcus Orzabal
- CereVu Medical Inc., 688 Missouri Street, San Francisco, CA 94107, USA
| | - Ramo Naidu
- California Orthopedics & Spine, 2 Bon Air Road, Larkspur, CA 94939, USA
| | - Kasra Amirdelfan
- IPM Medical Group, 450 N Wiget Lane, Walnut Creek, CA 94598, USA
| | - Alireza Akhbardeh
- CereVu Medical Inc., 688 Missouri Street, San Francisco, CA 94107, USA
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Evrard B, Lefebvre C, Spiry P, Hodler C, Chapellas C, Youssef B, Gauthier F, Marais L, Labrunie A, Douchez M, Senges P, Cros J, Nathan-Denizot N. Evaluation of the Analgesia Nociception Index and videopupillometry to predict post-tonsillectomy morphine requirements in children : a single-centre, prospective interventional study. BJA OPEN 2022; 3:100024. [PMID: 37588574 PMCID: PMC10430817 DOI: 10.1016/j.bjao.2022.100024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 08/18/2023]
Abstract
Background Tonsil surgery causes significant and challenging postoperative pain. The Analgesia Nociception Index (ANI) and videopupillometry are two techniques of interest to monitor nociception in adults and may predict postoperative morphine requirements. We hypothesised that these techniques could predict the need for morphine after tonsillectomy in children. The main objective was to assess the prognostic significance of ANI and videopupillometry, measured at the end of surgery, on morphine consumption determined by a Face, Legs, Activity, Cry, Consolability (FLACC) scale score >3 in the Post Anesthesia Care Unit (PACU). Methods A single-centre, prospective, interventional study evaluating children between 2 and 7 yr old undergoing tonsil surgery was performed. ANI and videopupillometry with tetanic stimulation were measured under general anaesthesia 4 min after the end of the surgical procedure. Each child was evaluated every 10 min by a nurse using the FLACC scale in the PACU and blinded to the measurements performed in the operating theatre. Results Eighty-nine children were analysed and 39 (44%) received morphine in the PACU. Neither ANI values nor videopupillometry values were predictive of postoperative morphine consumption (areas under the receiver operating characteristic curve 0.54, 95% confidence interval [CI; 0.42-0.65], and P=0.57; and 0.52, 95% CI [0.41-0.63], and P=0.69, respectively). Neither ANI values nor videopupillometry values were correlated to the maximum FLACC scale score in the PACU with ρ=0.04 (P=0.71) and ρ=0.06 (P=0.57), respectively. Conclusions Neither ANI nor videopupillometry performed at the end of surgery can predict morphine consumption in the PACU in children undergoing tonsillectomy.
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Affiliation(s)
- Bruno Evrard
- Medical-surgical ICU, Dupuytren Teaching Hospital, Limoges, France
- Inserm CIC, 1435, Dupuytren Teaching Hospital, Limoges, France
- Department of Anaesthesiology and Intensive Care, Dupuytren Teaching Hospital, Limoges, France
| | - Cyrielle Lefebvre
- Department of Anaesthesiology and Intensive Care, Dupuytren Teaching Hospital, Limoges, France
| | - Paul Spiry
- Department of Anaesthesiology and Intensive Care, Dupuytren Teaching Hospital, Limoges, France
| | - Charles Hodler
- Department of Anaesthesiology and Intensive Care, Dupuytren Teaching Hospital, Limoges, France
| | - Catherine Chapellas
- Department of Anaesthesiology and Intensive Care, Dupuytren Teaching Hospital, Limoges, France
| | - Baher Youssef
- Department of Anaesthesiology and Intensive Care, Dupuytren Teaching Hospital, Limoges, France
| | - François Gauthier
- Department of Anaesthesiology and Intensive Care, Dupuytren Teaching Hospital, Limoges, France
| | - Loïc Marais
- Research and Innovation Department, Dupuytren Teaching Hospital, Limoges, France
| | - Anaïs Labrunie
- Department of Epidemiology, Biostatistics and Research Methodology, Dupuytren Teaching Hospital, Limoges, France
| | - Marie Douchez
- Department of Anaesthesiology and Intensive Care, Dupuytren Teaching Hospital, Limoges, France
| | - Patrick Senges
- Department of Anaesthesiology and Intensive Care, Dupuytren Teaching Hospital, Limoges, France
| | - Jérôme Cros
- Department of Anaesthesiology and Intensive Care, Dupuytren Teaching Hospital, Limoges, France
| | - Nathalie Nathan-Denizot
- Department of Anaesthesiology and Intensive Care, Dupuytren Teaching Hospital, Limoges, France
- Medicine Faculty, University of Limoges, Limoges, France
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22
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Ma D, Ma J, Chen H, Mu D, Kong H, Yu L. Nociception monitors vs. standard practice for titration of opioid administration in general anesthesia: A meta-analysis of randomized controlled trials. Front Med (Lausanne) 2022; 9:963185. [PMID: 36091708 PMCID: PMC9454957 DOI: 10.3389/fmed.2022.963185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/21/2022] [Indexed: 11/18/2022] Open
Abstract
Background Nociception monitors are being increasingly used during surgery, but their effectiveness in guiding intraoperative opioid administration is still uncertain. This meta-analysis of randomized controlled trials (RCTs) aimed to compare the effectiveness of nociception monitors vs. standard practice for opioid administration titration during general anesthesia. Methods We searched the electronic databases of PubMed, EMBASE, Cochrane Library, Clinical Trial, and Web of Science from inception up to August 1, 2021, to identify relevant articles, and extracted the relevant data. Intraoperative opioid administration, extubation time, postoperative pain score, postoperative opioid consumption and postoperative nausea and vomiting (PONV) were compared between patients receiving nociception monitoring guidance and patients receiving standard management. The standardized mean difference (SMD), with 95% confidence interval (CI), was used to assess the significance of differences. The risk ratio (RR), with 95% CI, was used to assess the difference in incidence of PONV. Heterogeneity among the included trials was evaluated by the I2 test. RevMan 5.3 software was used for statistical analysis. Results A total of 21 RCTs (with 1957 patients) were included in the meta-analysis. Intraoperative opioid administration was significantly lower in patients receiving nociception monitor-guided analgesia than in patients receiving standard management (SMD, −0.71; 95% CI, −1.07 to −0.36; P < 0.001). However, pain scores and postoperative opioid consumption were not significantly higher in the former group. Considerable heterogeneity was found among the studies (92%). Extubation time was significantly shorter (SMD, −0.22; 95% CI, −0.41 to −0.03; P = 0.02) and the incidence of PONV significantly lower (RR, 0.78; 95% CI, 0.61 to 1.00; P = 0.05) in patients receiving nociception monitoring guidance. Conclusions Intraoperative nociception monitoring guidance may reduce intraoperative opioid administration and appears to be a viable strategy for intraoperative titration of opioids. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=273619, identifier: CRD42019129776.
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Affiliation(s)
- Dandan Ma
- Department of Pain Management, Jinan Central Hospital, Shandong University, Jinan, China
- Department of Anesthesiology, Yidu Central Hospital Affiliated to Weifang Medical University, Weifang, China
| | - Jiahui Ma
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Huayong Chen
- Department of Anesthesiology, Yidu Central Hospital Affiliated to Weifang Medical University, Weifang, China
| | - Dongliang Mu
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Hao Kong
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Lingzhi Yu
- Department of Pain Management, Jinan Central Hospital, Shandong University, Jinan, China
- *Correspondence: Lingzhi Yu
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Michalot A, Bazin JÉ, Richebé P, Allaouchiche B, Boselli E. Effect of GOAL-Directed ANalgesia using ANI (Analgesia/Nociception Index) during general anesthesia on immediate postoperative pain and intraoperative hemodynamics in adult patients (GOALDAN study): a study protocol for randomized, controlled, multicenter trial. Trials 2022; 23:353. [PMID: 35468803 PMCID: PMC9040325 DOI: 10.1186/s13063-022-06273-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 04/02/2022] [Indexed: 12/24/2022] Open
Abstract
Background Severe postoperative pain remains a major problem that is seen in 20 to 40% of patients. The Analgesia/Nociception Index (ANI) is a 0–100 index reflecting the relative parasympathetic activity allowing for intraoperative analgesia monitoring. We have previously shown that an ANI value < 50 immediately before extubation may predict the occurrence of immediate postoperative pain with good performance. We hypothesized that GOAL-Directed ANalgesia may provide reduced immediate postoperative pain and optimized intraoperative remifentanil administration (GOLDAN study). Methods The GOALDAN study is an international, multicenter, simple-blind, parallel, prospective, randomized, controlled, two-armed trial. Patients are randomly assigned in a 1:1 ratio in the control group or in the experimental group. Patients will be randomly allocated to either the intervention group (ANI) or the control group (standard care only). In the ANI group, the administration of remifentanil will be goal-directed targeting a 50–80 ANI range, with a prophylactic injection of morphine immediately after extubation if the case of ANI < 50. Our primary objective was to determine whether the prophylactic administration of morphine at the end of the procedure in patients at risk of immediate postoperative pain (ANI < 50 immediately before extubation) could reduce the incidence of the latter by 50% in the post-anesthetic care unit. Our secondary objective was to determine whether the intraoperative use of goal-directed analgesia with an ANI target of 50 to 80 could improve intraoperative hemodynamics and postoperative outcome. Discussion Because of the paucity of well-conducted trials, the authors believe that a randomized-controlled trial will improve the evidence for using analgesia monitoring during general anesthesia and strengthen current recommendations for intraoperative analgesia management. Trial registration ClinicalTrials.gov NCT03618082. Registered on 7 August 2018
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Affiliation(s)
- Adrien Michalot
- Department of Anesthesiology and Intensive Care, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Étienne Bazin
- Department of Anesthesiology and Intensive Care, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Philippe Richebé
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital - CIUSSS de L'Est de l'Ile de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Bernard Allaouchiche
- APCSe VetAgro Sup UPSP 2016.A101, Claude Bernard Lyon 1 University, Université de Lyon, Marcy-l'Étoile, France
| | - Emmanuel Boselli
- APCSe VetAgro Sup UPSP 2016.A101, Claude Bernard Lyon 1 University, Université de Lyon, Marcy-l'Étoile, France. .,Groupement Hospitalier Nord Dauphiné, Pierre Oudot Hospital Centre, Department of Anesthesiology, Bourgoin-Jallieu, France.
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Baroni DA, Abreu LG, Paiva SM, Costa LR. Comparison between Analgesia Nociception Index (ANI) and self-reported measures for diagnosing pain in conscious individuals: a systematic review and meta-analysis. Sci Rep 2022; 12:2862. [PMID: 35190644 PMCID: PMC8860998 DOI: 10.1038/s41598-022-06993-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 01/12/2022] [Indexed: 12/30/2022] Open
Abstract
The Analgesia Nociception Index (ANI), an objective measure of pain based on heart rate variability (HRV), has its usefulness in awake patients still unclear. This systematic review and meta-analysis aimed to assess ANI's accuracy compared to self-reported pain measures in conscious individuals undergoing medical procedures or painful stimuli. PubMed, Ovid, Web of Science, Scopus, Embase, and grey literature were searched until March 2021. Of the 832 identified citations, 16 studies complied with the eligibility criteria. A meta-analysis including nine studies demonstrated a weak negative correlation between ANI and NRS for pain assessment in individuals in the post-anesthetic recovery room (r = − 0.0984, 95% CI = − 0.397 to 0.220, I2 = 95.82%), or in those submitted to electrical stimulus (r = − 0.089; 95% CI = − 0.390 to 0.228, I2 = 0%). The evidence to use ANI in conscious individuals is weak compared to self-report measures of pain, yet ANI explains a part of self-report. Therefore, some individuals may be benefited from the use of ANI during procedures or in the immediate postoperative period.
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Affiliation(s)
- Daniela Abrão Baroni
- Dentistry Graduate Program, Faculty of Dentistry, Universidade Federal de Goiás (UFG), Goiânia, Goiás, Brazil
| | - Lucas Guimarães Abreu
- Department of Paediatric Dentistry, Faculty of Dentistry, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
| | - Saul Martins Paiva
- Department of Paediatric Dentistry, Faculty of Dentistry, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
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25
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Vazquez PM, Jensen EW. Different perspectives for monitoring nociception during general anesthesia. Korean J Anesthesiol 2022; 75:112-123. [PMID: 35172074 PMCID: PMC8980281 DOI: 10.4097/kja.22002] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 02/15/2022] [Indexed: 11/30/2022] Open
Abstract
Safe anesthesia is achieved using objective methods that estimate the patient’s state during different phases of surgery. A patient’s state under anesthesia is characterized by three major aspects, which are linked to the main effects produced by each of the families of anesthetic agents administered: hypnosis, analgesia, and muscular relaxation. While quantification techniques designed to assess muscular relaxation under neuromuscular blocking agents have a relatively long history with a high degree of standardization and understanding (e.g., the train-of-four), the knowledge and techniques used to the depth of hypnosis assessment suffer from a lesser degree in both standardization and interpretation due to brain complexity. The problem of standardization and interpretation in the analgesia and nociception assessment increases since it involves more systems, the central nervous system, and the autonomic nervous system. This helps to explain why there are multiple a priori valid approaches to develop nociception monitoring from different interpretations and physiological bases of noxious stimuli processing. Thus, in this review, the current monitoring technologies clinically available for estimating a patient’s nociception under general anesthesia are described.
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Affiliation(s)
- Pablo Martinez Vazquez
- Deutsches Primaten Zentrum (DPZ), 37077 Goettingen, Germany.,R&D of Quantium Medical/Fresenius Kabi. Barcelona, Spain
| | - Erik Weber Jensen
- R&D of Quantium Medical/Fresenius Kabi. Barcelona, Spain.,Automatic Control and Information (ESAII) Department, CREB. UPC-Barcelonatech, Barcelona, Spain
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Exploring Alterations in Electrocardiogram During the Postoperative Pain. PATTERN RECOGNITION AND IMAGE ANALYSIS 2022. [DOI: 10.1007/978-3-031-04881-4_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Ogata H, Matsuki Y, Okamoto T, Ueki R, Kariya N, Tatara T, Shigemi K, Hirose M. Intra-operative nociceptive responses and postoperative major complications after gastrointestinal surgery under general anaesthesia: A prospective cohort study. Eur J Anaesthesiol 2021; 38:1215-1222. [PMID: 33831900 DOI: 10.1097/eja.0000000000001505] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgical procedures stimulate nociception and induce physiological responses according to the balance between nociception and antinociception. The severity of surgical stimuli is associated with major postoperative complications. Although an intra-operative quantitative index representing surgical invasiveness would be useful for anaesthetic management to predict and prevent major complications, no such index is available. OBJECTIVES To identify associations between major complications after gastrointestinal surgery and intra-operative quantitative values from intra-operative nociception monitoring. DESIGN A multi-institutional observational study. SETTING Two university hospitals. PATIENTS Consecutive adult patients undergoing gastrointestinal surgery under general anaesthesia. MAIN OUTCOME MEASURES Averaged values of nociceptive response index from start to end of surgery (mean NR index) and risk scores of the Surgical Mortality Probability Model (S-MPM) were calculated. Pre and postoperative serum C-reactive protein (CRP) levels were obtained. After receiver-operating characteristic (ROC) curve analysis, all patients were divided into groups with high and low mean nociceptive response index. Associations between mean nociceptive response index and postoperative major complications, defined as Clavien-Dindo grade at least IIIa, were examined using logistic regression analysis. RESULTS ROC curve analysis showed a nociceptive response index cut-off value for major complications of 0.83, and we divided patients into two groups with mean nociceptive response index less than 0.83 and at least 0.83. The incidence of major complications was significantly higher in patients with mean nociceptive response index at least 0.83 (23.1%; n = 346) than in patients with mean nociceptive response index less than 0.83 (7.7%; n = 443; P < 0.001). Multivariate analysis revealed emergency surgery, S-MPM risk score, mean nociceptive response index and postoperative CRP levels as independent risk factors for major complications. CONCLUSION Mean nociceptive response index during surgery likely correlates with major complications after gastrointestinal surgery. TRIAL REGISTRATION The current observational study had no intervention, and was therefore, not registered.
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Affiliation(s)
- Hiroki Ogata
- From the Department of Anaesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo (HO, TO, RU, NK, TT, MH), the Department of Anaesthesiology & Reanimatology, Faculty of Medicine Sciences, University of Fukui, Eiheiji-cho, Fukui, Japan (YM, KS)
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Scoping review of the association between postsurgical pain and heart rate variability parameters. Pain Rep 2021; 6:e977. [PMID: 35155967 PMCID: PMC8824397 DOI: 10.1097/pr9.0000000000000977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/07/2021] [Accepted: 10/13/2021] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is Available in the Text. This scoping review provides some evidence of a possible association between heart rate variability and postsurgical pain, although significant variability exists among included studies. Surgical interventions can elicit neuroendocrine and sympathovagal responses, leading to cardiac autonomic imbalance. Cardiac complications account for approximately 30% of postoperative complications. Altered heart rate variability (HRV) was initially described in the 1970s as a predictor of acute coronary syndromes and has more recently been shown to be an independent predictor of postoperative morbidity and mortality after noncardiac surgery. In general, HRV reflects autonomic balance, and altered HRV measures have been associated with anesthetic use, chronic pain conditions, and experimental pain. Despite the well-documented relationship between altered HRV and postsurgical outcomes and various pain conditions, there has not been a review of available evidence describing the association between postsurgical pain and HRV. We examined the relationship between postsurgical pain and HRV. MEDLINE and EMBASE databases were searched until December 2020 and included all studies with primary data. Two reviewers independently assessed risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Review of Interventions. A total of 8 studies and 1002 participants were included. Studies examined the association of postsurgical pain and HRV or analgesia nociception index derived from HRV. There was a statistically significant association between HRV measures and postsurgical pain in 6 of 8 studies. Heterogeneity of studies precluded meta-analyses. No studies reported cardiovascular outcomes. There is a potential association between postsurgical pain and HRV or analgesia nociception index, although results are likely impacted by confounding variables. Future studies are required to better delineate the relationship between postsurgical pain and HRV and impacts on cardiovascular outcomes.
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Effect of Fentanyl Infusion on Heart Rate Variability and Anaesthetic Requirements in Isoflurane-Anaesthetized Horses. Animals (Basel) 2021; 11:ani11102922. [PMID: 34679943 PMCID: PMC8532720 DOI: 10.3390/ani11102922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/24/2021] [Accepted: 09/27/2021] [Indexed: 11/16/2022] Open
Abstract
Controversy continues to surround the use of opioids in equine anaesthesia, with variable effects reported. This blinded clinical study aimed to investigate the influence of a low-dose fentanyl continuous rate infusion (CRI) on isoflurane requirements, parasympathetic tone activity (PTA), and anaesthetic parameters in horses during general anaesthesia. All of the twenty-two horses included in the research underwent a standard anaesthetic protocol. Eleven horses in the fentanyl group (Group F) received a loading dose of fentanyl at 6 µg/kg, followed by a CRI of 0.1 µg/kg/min during anaesthesia. A further 11 horses in the control group (Group C) received equivalent volumes of normal saline. Anaesthetic parameters and PTA index were recorded during anaesthesia. The achieved mean fentanyl plasma concentration was 6.2 ± 0.83 ng/mL. No statistically significant differences between groups were found in isoflurane requirements, MAP values, and mean dobutamine requirements. However, horses in Group F required a significantly lower dose of additional ketamine to maintain a sufficient depth of anaesthesia. Significantly higher PTA values were found in the fentanyl group. Further research is warranted to determine the limitations of PTA monitoring, and the influence of various anaesthetics on its values.
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Abstract
The intraoperative dosing of opioids is a challenge in routine anesthesia as the potential effects of intraoperative overdosing and underdosing are not completely understood. In recent years an increasing number of monitors were approved, which were developed for the detection of intraoperative nociception and therefore should enable a better control of opioid titration. The nociception monitoring devices use either continuous hemodynamic, galvanic or thermal biosignals reflecting the balance between parasympathetic and sympathetic activity, measure the pupil dilatation reflex or the nociceptive flexor reflex as a reflexive response to application of standardized nociceptive stimulation. This review article presents the currently available nociception monitors. Most of these monitoring devices detect nociceptive stimulations with higher sensitivity and specificity than changes in heart rate, blood pressure or sedation depth monitoring devices. There are only few studies on the effect of opioid titration guided by nociception monitoring and the possible postoperative benefits of these devices. All nociception monitoring techniques are subject to specific limitations either due to perioperative confounders (e.g. hypovolemia) or special accompanying medical conditions (e.g. muscle relaxation). There is an ongoing discussion about the clinical relevance of nociceptive stimulation in general anesthesia and the effect on patient outcome. Initial results for individual monitor systems show a reduction in opioid consumption and in postoperative pain level. Nevertheless, current evidence does not enable the routine use of nociception monitoring devices to be recommended as a clear beneficial effect on long-term outcome has not yet been proven.
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Laghlam D, Naudin C, Coroyer L, Aidan V, Malvy J, Rahoual G, Estagnasié P, Squara P. Virtual reality vs. Kalinox® for management of pain in intensive care unit after cardiac surgery: a randomized study. Ann Intensive Care 2021; 11:74. [PMID: 33983498 PMCID: PMC8119554 DOI: 10.1186/s13613-021-00866-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/03/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction The management of pain and anxiety remains a challenge in the intensive care unit. By distracting patients, virtual reality (VR) may have a role in painful procedures. We compared VR vs. an inhaled equimolar mixture of N2O and O2 (Kalinox®) for pain and anxiety management during the removal of chest drains after cardiac surgery. Methods Prospective, non-inferiority, open-label study. Patients were randomized, for Kalinox® or VR session during drain removal. The analgesia/nociception index (ANI) was monitored during the procedure for objective assessment of pain and anxiety. The primary endpoint was the ΔANI (ANImin − ANI0) during the procedure, based on ANIm (average on 4 min). We prespecified VR as non-inferior to Kalinox® with a margin of 3 points. Self-reported pain and anxiety were also analysed using numeric rate scale (NRS). Results 200 patients were included, 99 in the VR group and 101 in the Kalinox® group; 90 patients were analysed in both groups in per-protocol analysis. The median age was 68.0 years [60.0–74.8]. The ΔANI was − 15.1 ± 12.9 in the Kalinox® group and − 15.7 ± 11.6 in the VR group (NS). The mean difference was, therefore, − 0.6 [− 3.6 to 2.4], including the non-inferiority margin of 3. Patients in the VR group had a significantly higher pain NRS scale immediately after the drain removal, 5.0 [3.0–7.0] vs. 3.0 [2.0–6.0], p = 0.009, but no difference 10 min after. NRS of anxiety did not differ between the two groups. Conclusion Based on the ANI, the current study showed that VR did not reach the statistical requirements for a proven non-inferiority vs. Kalinox® in managing pain and anxiety during chest drain removal. Moreover, VR was less effective based on NRS. More studies are needed to determine if VR might have a place in the overall approach to pain and anxiety in intensive care units. Trial registration NCT, NCT03956264. Registered 20 May 2019, https://clinicaltrials.gov/ct2/show/NCT03956264
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Affiliation(s)
- Driss Laghlam
- Department of Cardiology and Critical Care, CERIC, Clinique Ambroise Paré, 27 boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France.
| | - Cecile Naudin
- Department of Clinical Research, Clinique Ambroise Paré, 27 boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France
| | - Lucas Coroyer
- Department of Cardiology and Critical Care, CERIC, Clinique Ambroise Paré, 27 boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France
| | - Vincent Aidan
- Department of Cardiology and Critical Care, CERIC, Clinique Ambroise Paré, 27 boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France
| | - Julien Malvy
- Department of Cardiology and Critical Care, CERIC, Clinique Ambroise Paré, 27 boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France
| | - Ghilas Rahoual
- Department of Cardiology and Critical Care, CERIC, Clinique Ambroise Paré, 27 boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France
| | - Philippe Estagnasié
- Department of Cardiology and Critical Care, CERIC, Clinique Ambroise Paré, 27 boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France
| | - Pierre Squara
- Department of Cardiology and Critical Care, CERIC, Clinique Ambroise Paré, 27 boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France
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Choi BM, Shin H, Lee JH, Bang JY, Lee EK, Noh GJ. Performance of the Surgical Pleth Index and Analgesia Nociception Index in Healthy Volunteers and Parturients. Front Physiol 2021; 12:554026. [PMID: 33762962 PMCID: PMC7982810 DOI: 10.3389/fphys.2021.554026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 02/08/2021] [Indexed: 11/16/2022] Open
Abstract
Various commercially available nociception devices have been developed to quantify intraoperative pain. The Surgical Pleth Index (SPI) and Analgesia Nociception Index (ANI) are among the analgesic indices that have been widely used for the evaluation of surgical patients. This study aimed to evaluate the clinical performance of the SPI and ANI in conscious healthy volunteers and parturients. Ten healthy volunteers and 10 parturients participated in this study. An algometer was used to induce bone pain in the volunteers until they rated their pain as five on the numerical rating scale (NRS); this procedure was repeated during the administration of remifentanil or normal saline. The study comprised two periods, and the volunteers were infused with different solutions in each period: normal saline during one period and remifentanil during the other in a randomized order. The parturients’ SPI and ANI data were collected for 2 min when they rated their pain levels as 0, 5, and 7 on the NRS, respectively. Both the SPI and ANI values differed significantly between NRS 0 and NRS 5 (P < 0.001) in the volunteers, irrespective of the solution administered (remifentanil or normal saline). At NRS 5, the SPI showed similar values, irrespective of remifentanil administration, while the ANI showed significantly lower values on remifentanil administration (P = 0.028). The SPI and ANI values at NRS 5 and NRS 7 did not differ significantly in the parturients (P = 0.101 for SPI, P = 0.687 for ANI). Thus, the SPI and ANI were effective indices for detecting pain in healthy volunteers and parturients.
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Affiliation(s)
- Byung-Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hangsik Shin
- Department of Biomedical Engineering, College of Engineering, Chonnam National University, Yeosu, South Korea
| | - Joo-Hyun Lee
- Department of Anesthesiology and Pain Medicine, International St. Mary's Hospital, Catholic Kwandong University, Incheon, South Korea
| | - Ji-Yeon Bang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Eun-Kyung Lee
- Department of Statistics, Ewha Womans University, Seoul, South Korea
| | - Gyu-Jeong Noh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.,Department of Clinical Pharmacology and Therapeutics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Tribuddharat S, Sathitkarnmanee T, Sukhong P, Thananun M, Promkhote P, Nonlhaopol D. Comparative study of analgesia nociception index (ANI) vs. standard pharmacokinetic pattern for guiding intraoperative fentanyl administration among mastectomy patients. BMC Anesthesiol 2021; 21:50. [PMID: 33581721 PMCID: PMC7881489 DOI: 10.1186/s12871-021-01272-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/05/2021] [Indexed: 12/01/2022] Open
Abstract
Background The Analgesia Nociception Index (ANI) has been suggested as a non-invasive guide for analgesia. Our objective was to compare the efficacy of ANI vs. standard pharmacokinetic pattern for guiding intraoperative fentanyl administration. Methods This was a prospective, randomized, controlled study of adult female patients undergoing elective mastectomy under general anesthesia. The patients were randomized to the ANI-guided group receiving a loading dose of 75 μg of fentanyl followed by 25 μg when the ANI score was under 50. The Control group received the same loading dose followed by 25 μg every 30 min with additional doses when there were signs of inadequate analgesia (viz., tachycardia or hypertension). Results Sixty patients—30 in each group—were recruited. Although the actual mean ANI score was higher in the ANI-guided than in the Control group (mean difference 2.2; 95% CI: 0.3 to 4.0, P = 0.022), there was no difference in the primary outcome—i.e., intraoperative fentanyl consumption (mean difference − 4.2 μg; 95% CI: − 24.7 to 16.4, P = 0.686 and − 0.14 μg·kg− 1·h− 1; 95% CI: − 0.31 to 0.03, P = 0.105). No difference between groups was shown for either intraoperative blood pressure and heart rate, or for postoperative outcomes (i.e., pain scores, morphine consumption, or sedation scores) in the postanesthesia care unit. Conclusions Intraoperative fentanyl administration guided by ANI was equivalent to that guided by a modified pharmacologic pattern. In a surgical model of mastectomy, the ANI-guided intraoperative administration of fentanyl had no impact on clinical outcomes. Trial registration The study was registered with ClinicalTrials.gov (NCT03716453) on 21/10/2018.
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Affiliation(s)
- Sirirat Tribuddharat
- Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, 123 Mitrapap road, Ampur Muang, Khon Kaen, 40002, Thailand
| | - Thepakorn Sathitkarnmanee
- Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, 123 Mitrapap road, Ampur Muang, Khon Kaen, 40002, Thailand.
| | - Pornlada Sukhong
- Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, 123 Mitrapap road, Ampur Muang, Khon Kaen, 40002, Thailand
| | - Maneerat Thananun
- Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, 123 Mitrapap road, Ampur Muang, Khon Kaen, 40002, Thailand
| | - Parinda Promkhote
- Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, 123 Mitrapap road, Ampur Muang, Khon Kaen, 40002, Thailand
| | - Duangthida Nonlhaopol
- Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, 123 Mitrapap road, Ampur Muang, Khon Kaen, 40002, Thailand
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Rogobete AF, Bedreag OH, Papurica M, Popovici SE, Bratu LM, Rata A, Barsac CR, Maghiar A, Garofil DN, Negrea M, Petcu LB, Toma D, Dumbuleu CM, Rimawi S, Sandesc D. Multiparametric Monitoring of Hypnosis and Nociception-Antinociception Balance during General Anesthesia-A New Era in Patient Safety Standards and Healthcare Management. ACTA ACUST UNITED AC 2021; 57:medicina57020132. [PMID: 33540844 PMCID: PMC7913052 DOI: 10.3390/medicina57020132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 11/16/2022]
Abstract
The development of general anesthesia techniques and anesthetic substances has opened new horizons for the expansion and improvement of surgical techniques. Nevertheless, more complex surgical procedures have brought a higher complexity and longer duration for general anesthesia, which has led to a series of adverse events such as hemodynamic instability, under- or overdosage of anesthetic drugs, and an increased number of post-anesthetic events. In order to adapt the anesthesia according to the particularities of each patient, the multimodal monitoring of these patients is highly recommended. Classically, general anesthesia monitoring consists of the analysis of vital functions and gas exchange. Multimodal monitoring refers to the concomitant monitoring of the degree of hypnosis and the nociceptive-antinociceptive balance. By titrating anesthetic drugs according to these parameters, clinical benefits can be obtained, such as hemodynamic stabilization, the reduction of awakening times, and the reduction of postoperative complications. Another important aspect is the impact on the status of inflammation and the redox balance. By minimizing inflammatory and oxidative impact, a faster recovery can be achieved that increases patient safety. The purpose of this literature review is to present the most modern multimodal monitoring techniques to discuss the particularities of each technique.
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Affiliation(s)
- Alexandru Florin Rogobete
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.F.R.); (O.H.B.); (M.P.); (C.R.B.); (A.M.); (D.S.)
- Anaesthesia and Intensive Care Research Center, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.T.); (C.M.D.)
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania;
| | - Ovidiu Horea Bedreag
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.F.R.); (O.H.B.); (M.P.); (C.R.B.); (A.M.); (D.S.)
- Anaesthesia and Intensive Care Research Center, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.T.); (C.M.D.)
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania;
| | - Marius Papurica
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.F.R.); (O.H.B.); (M.P.); (C.R.B.); (A.M.); (D.S.)
- Anaesthesia and Intensive Care Research Center, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.T.); (C.M.D.)
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania;
| | - Sonia Elena Popovici
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.F.R.); (O.H.B.); (M.P.); (C.R.B.); (A.M.); (D.S.)
- Anaesthesia and Intensive Care Research Center, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.T.); (C.M.D.)
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania;
- Correspondence: (S.E.P.); (L.M.B.); Tel.: +40-728-001-971
| | - Lavinia Melania Bratu
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.F.R.); (O.H.B.); (M.P.); (C.R.B.); (A.M.); (D.S.)
- Correspondence: (S.E.P.); (L.M.B.); Tel.: +40-728-001-971
| | - Andreea Rata
- Department of Vascular Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania;
- Clinic of Vascular Surgery, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania
| | - Claudiu Rafael Barsac
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.F.R.); (O.H.B.); (M.P.); (C.R.B.); (A.M.); (D.S.)
- Anaesthesia and Intensive Care Research Center, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.T.); (C.M.D.)
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania;
| | - Andra Maghiar
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.F.R.); (O.H.B.); (M.P.); (C.R.B.); (A.M.); (D.S.)
- Anaesthesia and Intensive Care Research Center, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.T.); (C.M.D.)
| | - Dragos Nicolae Garofil
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Mihai Negrea
- Faculty of Political, Administrative and Communication Sciences, Babes-Bolyai University, 400376 Cluj Napoca, Romania;
| | - Laura Bostangiu Petcu
- Faculty of Management, The Bucharest University of Economic Studies, 020021 Bucharest, Romania;
| | - Daiana Toma
- Anaesthesia and Intensive Care Research Center, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.T.); (C.M.D.)
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania;
| | - Corina Maria Dumbuleu
- Anaesthesia and Intensive Care Research Center, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.T.); (C.M.D.)
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania;
| | - Samir Rimawi
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania;
| | - Dorel Sandesc
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (A.F.R.); (O.H.B.); (M.P.); (C.R.B.); (A.M.); (D.S.)
- Anaesthesia and Intensive Care Research Center, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.T.); (C.M.D.)
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, 300723 Timisoara, Romania;
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Clinical Use of The Parasympathetic Tone Activity Index As a Measurement of Postoperative Analgaesia in Dogs Undergoing Ovariohysterectomy. J Vet Res 2021; 65:117-123. [PMID: 33817404 PMCID: PMC8009586 DOI: 10.2478/jvetres-2021-0004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 12/29/2020] [Indexed: 01/27/2023] Open
Abstract
Introduction While the current tools to assess canine postoperative pain using physiological and behavioural parameters are reliable, an objective method such as the parasympathetic tone activity (PTA) index could improve postoperative care. The aim of the study was to determine the utility of the PTA index in assessing postoperative analgaesia. Material and Methods Thirty healthy bitches of different breeds were randomly allocated into three groups for analgaesic treatment: the paracetamol group (GPARAC, n = 10) received 15 mg/kg b.w., the carprofen group (GCARP, n = 10) 4 mg/kg b.w., and the meloxicam group (GMELOX, n = 10) 0.2 mg/kg b.w. for 48 h after surgery. GPARAC was medicated orally every 8 h, while GCARP and GMELOX were medicated intravenously every 24 h. The PTA index was used to measure the analgaesia–nociception balance 1 h before surgery (baseline), and at 1, 2, 4, 6, 8, 12, 16, 20, 24, 36, and 48 h after, at which times evaluation on the University of Melbourne Pain Scale (UMPS) was made. Results The baseline PTA index was 65 ± 8 for GPARAC, 65 ± 7 for GCARP, and 62 ± 5 for GMELOX. Postoperatively, it was 65 ± 9 for GPARAC, 63 ± 8 for GCARP, and 65 ± 8 for GMELOX. No statistically significant difference existed between baseline values or between values directly after treatments (P = 0.99 and P = 0.97, respectively). The PTA index showed a sensitivity of 40%, specificity of 98.46% and a negative predictive value of 99.07%. Conclusion Our findings suggest that the PTA index measures comfort and postoperative analgaesia objectively, since it showed a clinical relationship with the UMPS.
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Ledowski T, Schlueter P, Hall N. Nociception level index: do intra-operative values allow the prediction of acute postoperative pain? J Clin Monit Comput 2021; 36:349-354. [PMID: 33486658 DOI: 10.1007/s10877-021-00654-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/08/2021] [Indexed: 12/31/2022]
Abstract
Nociception Level Index (NOL) guided analgesia has previously been found to correlate with noxious stimuli during surgery. It was aim of this study to investigate the relationship between intra-operative NOL and acute postoperative pain. After IRB approval, 80 patients scheduled for non-emergency surgery were enrolled. NOL data were recorded from induction of anaesthesia until the end of surgery. After admission to the postoperative acute care unit (PACU), pain scores (numeric rating scale [NRS, 0-10] were obtained 5-minutely for 15 min. NOL data of 74 patients were analyzed. Receiver-operating curve (ROC) analysis identified the NOL reaction to the knife to skin incision (median NOL within 60 s post knife to skin) vs. the median NOL during surgery vs. NOL at the end of surgery to have the highest correlation coefficient (ρ = 0.3; P = 0.01) as well as the highest area under the ROC curve (AUC 0.68; P = 0.01) for the prediction of moderate-severe pain in PACU. A NOL > 20 after skin incision predicted moderate-severe postoperative pain with the highest combined sensitivity (73%) and specificity (58%). A NOL < 10 after skin incision excluded moderate-severe pain in PACU with a negative predictive value of 83%. The NOL reaction to skin incision, but not NOL during surgery appears to allow the exclusion and, to a lesser degree the prediction of moderate-severe pain in PACU. The results may also strengthen the manufacturers recommendation of an intraoperative NOL range of 10-25.Australian New Zealand Clinical Trials Registry: ACTRN12619001596190.
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Affiliation(s)
- Thomas Ledowski
- School of Medicine and Pharmacology, University of Western Australia, Level 2 Royal Perth Hospital MRF Building, Rear 50 Murray Street, Perth, WA, 6000, Australia. .,Royal Perth Hospital, Wellington St, Perth, WA, 6000, Australia.
| | | | - Nyomi Hall
- Royal Perth Hospital, Wellington St, Perth, WA, 6000, Australia
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Packiasabapathy S, Rangasamy V, Sadhasivam S. Pupillometry in perioperative medicine: a narrative review. Can J Anaesth 2021; 68:566-578. [PMID: 33432497 DOI: 10.1007/s12630-020-01905-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 11/07/2020] [Accepted: 11/09/2020] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Pupillometry is a technique for objective quantification of nociception that takes into account the central processing of noxious stimuli and its sympathetic response. This narrative review provides an overview of the physiology of the pupil, the principles of pupillometry, and its potential application in the perioperative environment, especially in nociception monitoring and quantifying responses to opioids. SOURCE Relevant articles, including reports of original investigation, review articles, and meta-analyses were identified from searches of PubMed and Google Scholar databases. Articles that described pupillary physiology and pupillometry, along with original research reports of the application of pupillometry in perioperative and critical care environment were used to synthesize a narrative review. PRINCIPAL FINDINGS Pupillometry is emerging as an objective measure of nociception, especially in patients under general anesthesia, children, non-verbal patients, and critically ill patients who cannot effectively communicate ongoing pain. Portable automated pupillometers have made accurate quantification of pupillary reflexes, including light reflex and dilatation reflex, possible. This technique has been successfully studied in the perioperative setting for a number of applications, including quantification of nociception, response to analgesia, and assessing efficacy of regional blocks. Pupillary oscillations have shown promise in assessing central opioid effects. Pupillometers can also accurately quantify light reflexes during the neurologic evaluation of critically ill patients. CONCLUSIONS Pupillometry is an easy to use non-invasive bedside technique to quantify nociception and monitor opioid effects. It has the potential to personalize pain management in perioperative and intensive care unit environments. Additional studies are needed to further understand the utility of pupillometry in this context.
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Affiliation(s)
- Senthil Packiasabapathy
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, RH 2835, 705 Riley Hospital Drive, Indianapolis, IN, 46202, USA
| | - Valluvan Rangasamy
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, RH 2835, 705 Riley Hospital Drive, Indianapolis, IN, 46202, USA
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, RH 2835, 705 Riley Hospital Drive, Indianapolis, IN, 46202, USA.
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Zhang JW, Lv ZG, Kong Y, Han CF, Wang BG. Wavelet and pain rating index for inhalation anesthesia: A randomized controlled trial. World J Clin Cases 2020; 8:5221-5234. [PMID: 33269258 PMCID: PMC7674720 DOI: 10.12998/wjcc.v8.i21.5221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/05/2020] [Accepted: 09/28/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Wavelet index (WLi) and pain rating index (PRi) are new parameters for regulating general anesthesia depth based on wavelet analysis.
AIM To investigate the safety and efficacy of using WLi or PRi in sevoflurane anesthesia.
METHODS This randomized controlled trial enrolled 66 patients scheduled for elective posterior lumbar interbody fusion surgery under sevoflurane anesthesia between September 2017 and February 2018. A random number generator was used to assign the eligible patients to three groups: Systolic blood pressure (SBP) monitoring group, WLi monitoring group, and PRi monitoring group. The main anesthesiologist was aware of the patient grouping and intervention used. The primary endpoint was anesthesia recovery time. Secondary endpoints included extubation time, sevoflurane consumption, number of unwanted events/ interventions, number of adverse events and postoperative visual analogue scale for pain.
RESULTS A total of 62 patients were included in the final analysis (SBP group, n = 21; WLi group, n = 21; and PRi group, n = 20). There were no significant differences among the three groups in patient age, gender distribution, body mass index, American Society of Anesthesiologists class, duration of surgery, or duration of anesthesia. Anesthesia recovery time was shorter in the WLi and PRi groups than in the SBP group with no significant difference between the WLi and PRi groups. Extubation time was shorter in the WLi and PRi groups than in the SBP group. Sevoflurane consumption was lower in the WLi and PRi groups than in the SBP group. Nicardipine was more commonly needed to treat hypertension in the WLi and PRi groups than in the SBP group.
CONCLUSION Regulation of sevoflurane anesthesia depth with WLi or PRi reduced anesthesia recovery time, extubation time and sevoflurane consumption without intraoperative unwanted events.
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Affiliation(s)
- Jian-Wen Zhang
- Department of Anesthesiology, Sanbo Brain Hospital, Capital Medical University, Beijing 100093, China
- Department of Anesthesiology, Shanxi Dayi Hospital, Taiyuan 030032, Shanxi Province, China
| | - Zhi-Gan Lv
- Department of Anesthesiology, Shanxi Dayi Hospital, Taiyuan 030032, Shanxi Province, China
| | - Ying Kong
- Department of Anesthesiology, Shanxi Dayi Hospital, Taiyuan 030032, Shanxi Province, China
| | - Chong-Fang Han
- Department of Anesthesiology, Shanxi Dayi Hospital, Taiyuan 030032, Shanxi Province, China
| | - Bao-Guo Wang
- Department of Anesthesiology, Sanbo Brain Hospital, Capital Medical University, Beijing 100093, China
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Six S, Laureys S, Poelaert J, Maîresse O, Theuns P, Bilsen J, Deschepper R. Neurophysiological Assessments During Continuous Sedation Until Death Put Validity of Observational Assessments Into Question: A Prospective Observational Study. Pain Ther 2020; 10:377-390. [PMID: 33151515 PMCID: PMC8119559 DOI: 10.1007/s40122-020-00214-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/19/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction In case of untreatable suffering at the end of life, continuous sedation until death (CSD) may be the only treatment option left. Because these patients cannot communicate anymore, caregivers have to rely on behavioral observation to assess the patient’s comfort. Recently, however, a number of studies from the neurosciences have shown that sometimes consciousness and pain are undetectable with these traditional behavioral methods. The aim of this study was to find out if subjective caregiver assessments of consciousness and pain would be confirmed by objective neurophysiological measures. Methods In this prospective observational study, we observed patients from the start of palliative sedation until death. Subjective caregiver assessments of level of consciousness and pain based on behavioral observations were compared with objective measures from neurophysiological monitoring devices. Results We collected and analyzed 108 subjective caregiver assessments in a sample of 12 patients and 32 assessments by traditionally used observational scales. We compared these with objective neurophysiological measures. Sensitivity and specificity of caregivers’ subjective assessments of consciousness was 23.6 and 91.1% respectively, with an accuracy of 54.0% and interrater reliability (κ) of 0.13. For pain, this was 0 and 94.79%, respectively, an accuracy of 88%, and an inter-rater reliability (κ) of − 0.063. Agreement between caregivers’ subjective assessments and objective neurophysiological measures of consciousness and pain was very poor. Conclusions Caregivers’ subjective assessment of level of consciousness and pain during CSD is unreliable compared with objective neurophysiological monitoring. Our results suggest that assessments of patient comfort during CSD could have been improved substantially by including objective monitoring of level of consciousness and pain. Trial Registration The protocol for this observational study has been registered retrospectively at Clinical-Trials.gov (ID NCT03273244).
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Affiliation(s)
- Stefaan Six
- Mental Health and Wellbeing Research Group, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Jette, Belgium.
- Coma Science group, Cyclotron Research Centre and Neurology Department, University and University Hospital of Liège, Avenue de l'hôpital 11, 4000, Liège, Belgium.
| | - Steven Laureys
- Coma Science group, Cyclotron Research Centre and Neurology Department, University and University Hospital of Liège, Avenue de l'hôpital 11, 4000, Liège, Belgium
| | - Jan Poelaert
- Department of Anesthesiology and Perioperative Medicine, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Jette, Belgium
| | - Olivier Maîresse
- Department of Experimental and Applied Psychology, Vrije Universiteit Brussel, Pleinlaan 2, 1000, Brussels, Belgium
| | - Peter Theuns
- Department of Experimental and Applied Psychology, Vrije Universiteit Brussel, Pleinlaan 2, 1000, Brussels, Belgium
| | - Johan Bilsen
- Mental Health and Wellbeing Research Group, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Jette, Belgium
| | - Reginald Deschepper
- Mental Health and Wellbeing Research Group, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Jette, Belgium
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40
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Vide S, Castro A, Correia R, Cabral T, Lima D, Nunes CS, Gambús P, Amorim P. Foreseeing postoperative pain in neurosurgical patients: pupillometry predicts postoperative pain ratings-an observational study. J Clin Monit Comput 2020; 35:1111-1118. [PMID: 32729066 DOI: 10.1007/s10877-020-00570-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 07/23/2020] [Indexed: 01/03/2023]
Abstract
Pupillary reflex dilation (PRD) is triggered by noxious stimuli and diminished by opioid administration. In the postoperative period, PRD has been shown to be correlated with pain reporting and a useful tool to guide opioid administration. In this study we assessed whether pupillary measurements taken before extubation were related with the patient's reported pain in the Post-Anesthesia Care Unit (PACU) using the Numerical Rating Scale (NRS). Our objective was to evaluate the correlation of PRD and pupillary variables measured intraoperatively with postoperative pain under the same opioid concentration. This was a prospective observational study of 26 neurosurgical patients undergoing general anesthesia exclusively with propofol and remifentanil. A portable infrared pupillometer was used to provide an objective measure of pupil size and PRD (using the Pupillary Pain Index) before extubation. Pain ratings were obtained from patients after recovery of consciousness, while remifentanil was maintained at 2 ng/mL. A significant correlation was observed between NRS scores and pre-extubation PPI (rS = 0.62; P = 0.002), as well as between NRS scores and pupil diameter before tetanic stimulation PPI (rS = 0.56, P = 0.006). We also found a negative correlation between pupil diameter and age (rS = - 0.42, P = 0.04). The statistically significant correlation between pre-extubation PPI scores and NRS scores, as well as between the pupillary diameter before tetanic stimulation and NRS scores suggest the possibility of titrating analgesia at the end of the intraoperative period based on individual responses. This could allow clinicians to identify the ideal remifentanil concentration for the postoperative period.
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Affiliation(s)
- Sérgio Vide
- Department of Anesthesia, Unidade Local de Saúde de Matosinhos - Hospital Pedro Hispano, R. de Dr. Eduardo Torres, 4464-513, Matosinhos, Portugal. .,Department of Anesthesiology, Center for Clinical Research in Anesthesia, Centro Hospitalar do Porto, Porto, Portugal. .,Systems Pharmacology Effect Control & Modeling (SPEC-M) Research Group, Anesthesiology Department, Hospital CLINIC de Barcelona, Barcelona, Spain.
| | - Ana Castro
- Hospital Santa Maria Maior, Barcelos, Portugal
| | - Rui Correia
- Department of Anesthesiology, Center for Clinical Research in Anesthesia, Centro Hospitalar do Porto, Porto, Portugal
| | - Tiago Cabral
- Department of Anesthesia, Hospital Divino Espírito Santo, Ponta Delgada, Portugal
| | - Deolinda Lima
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Catarina S Nunes
- Department of Anesthesiology, Center for Clinical Research in Anesthesia, Centro Hospitalar do Porto, Porto, Portugal.,Department of Sciences and Technology, Universidade Aberta, Porto, Portugal
| | - Pedro Gambús
- Systems Pharmacology Effect Control & Modeling (SPEC-M) Research Group, Anesthesiology Department, Hospital CLINIC de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), NeuroImmunology Research Group, Barcelona, Spain
| | - Pedro Amorim
- Department of Anesthesiology, Center for Clinical Research in Anesthesia, Centro Hospitalar do Porto, Porto, Portugal
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Anderson TA. Intraoperative Analgesia-Nociception Monitors: Where We Are and Where We Want To Be. Anesth Analg 2020; 130:1261-1263. [PMID: 32287133 DOI: 10.1213/ane.0000000000004473] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- T Anthony Anderson
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
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42
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Kühlmann AYR, van Rosmalen J, Staals LM, Keyzer-Dekker CMG, Dogger J, de Leeuw TG, van der Toorn F, Jeekel J, Wijnen RMH, van Dijk M. Music Interventions in Pediatric Surgery (The Music Under Surgery In Children Study). Anesth Analg 2020; 130:991-1001. [DOI: 10.1213/ane.0000000000003983] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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43
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Anderson TA, Segaran JR, Toda C, Sabouri AS, De Jonckheere J. High-Frequency Heart Rate Variability Index: A Prospective, Observational Trial Assessing Utility as a Marker for the Balance Between Analgesia and Nociception Under General Anesthesia. Anesth Analg 2020; 130:1045-1053. [PMID: 31008745 DOI: 10.1213/ane.0000000000004180] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Maintaining a balance between nociception and analgesia perioperatively reduces morbidity and improves outcomes. Current intraoperative analgesic strategies are based on subjective and nonspecific parameters. The high-frequency heart rate (HR) variability index is purported to assess the balance between nociception and analgesia in patients under general anesthesia. This prospective observational study investigated whether intraoperative changes in the high-frequency HR variability index correlate with clinically relevant nociceptive stimulation and the addition of analgesics. METHODS Instantaneous and mean high-frequency HR variability indexes were measured continuously in 79 adult subjects undergoing general anesthesia for laparoscopic cholecystectomy. The indexes were compared just before and 2 minutes after direct laryngoscopy, orogastric tube placement, first skin incision, and abdominal insufflation and just before and 6 minutes after the administration of IV hydromorphone. RESULTS Data from 65 subjects were included in the final analysis. The instantaneous index decreased after skin incision ([SEM], 58.7 [2.0] vs 47.5 [2.0]; P < .001) and abdominal insufflation (54.0 [2.0] vs 46.3 [2.0]; P = .002). There was no change in the instantaneous index after laryngoscopy (47.2 [2.2] vs 40.3 [2.3]; P = .026) and orogastric tube placement (49.8 [2.3] vs 45.4 [2.0]; P = .109). The instantaneous index increased after hydromorphone administration (58.2 [1.9] vs 64.8 [1.8]; P = .003). CONCLUSIONS In adult subjects under general anesthesia for laparoscopic cholecystectomy, changes in the high-frequency HR variability index reflect alterations in the balance between nociception and analgesia. This index might be used intraoperatively to titrate analgesia for individual patients. Further testing is necessary to determine whether the intraoperative use of the index affects patient outcomes.
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Affiliation(s)
- T Anthony Anderson
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Joshua R Segaran
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Chihiro Toda
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - A Sassan Sabouri
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Julien De Jonckheere
- Perinatal Environment and Health, Faculté of Médicine, University of Lille, Centre Hospitalier Universitaire, Lille, France
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Ramos-Luengo A, Gardeta Pallarés A, Asensio Merino F. Usefulness of ANI (analgesia nociception index) monitoring for outpatient saphenectomy surgery outcomes: an observational study. J Clin Monit Comput 2020; 35:491-497. [PMID: 32107719 DOI: 10.1007/s10877-020-00491-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/21/2020] [Indexed: 10/24/2022]
Abstract
The Analgesia Nociception Index (ANI), derived from heart rate variability is a proposed guide to obtain an adequate control of the analgesic component during anaesthesia. This single blind observational study was designed to evaluate the relationship between intraoperative ANI values and length of stay in Day Surgery Units (DSU) in patients undergoing varicose vein intervention. 131 patients (ASA I-II) scheduled for elective varicose vein surgery were studied. A propofol closed-loop TCI was used to maintain a specific level of BIS. To control analgesia, a remifentanil TCI was used, modifying the target according to hemodynamic changes. Patients were included in the ANI > 50 sub-group or in the ANI < 50 sub-group depending on whether the ANI value was greater than 50 for at least 60% of the anaesthesia maintenance period (AMP) or not. The primary endpoint was the length of stay in DSU. Other variables studied were ANI values, duration of the AMP, remifentanil TCI target average, postoperative pain, rescue-analgesia needs and postoperative nausea and vomiting (PONV) were analysed. Statistical analysis of length of stay in DSU was performed with Mann-Whitney test. ANI > 50 sub-group showed a lower length of stay in the DSU [165 min (118-212) vs 186.5 min (119-254), p = 0.0425]. Discharge timing from DSU was statistically different among study sub-groups (p = 0.005). An adequate nociception level measured by ANI during varicose vein surgery might reduce the length of stay at DSU. Further studies are needed to assess the usefulness of ANI in other anaesthesia conditions.
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Affiliation(s)
- Adolfo Ramos-Luengo
- Department of Anesthesiology, Hospital Universitario Severo Ochoa, Leganés, Spain.
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45
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Köprülü AŞ, Haspolat A, Gül YG, Tanrikulu N. Can postoperative pain be predicted? New parameter: analgesia nociception index. Turk J Med Sci 2020; 50. [PMID: 31731328 PMCID: PMC7080375 DOI: 10.3906/sag-1811-194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 10/29/2019] [Indexed: 11/03/2022] Open
Abstract
Background/aim The Analgesia Nociception Index (ANI) is a new method of identifying nociception-analgesia balance. In this study, we investigate the correlation between the ANI and numeric rating scale (NRS) values immediately before and after extubation. The NRS values were recorded in the postanesthesia care unit, in a group of patients who underwent laparoscopic cholecystectomy, with the aim of evaluating the potential use of ANI values in the prediction of postoperative pain levels. Materials and methods The ANI and NRS values, heartbeat rate (HR), systolic and diastolic arterial pressure (SAP/DAP), and oxygen saturation (SpO2) values of the patients were recorded into three groups based on the initial NRS values recorded in the postanesthesia care unit (group I: NRS ≤ 3, group II: NRS 4–6, group III: NRS ≥ 7). Patients whose ANI values were lower than 47, considered as the pain threshold, and the groups to which these patients belonged were also recorded. Results Statistically significant increases were noted in HR, SAP, and DAP after extubation, while there was no significant change in ANI values. A weak correlation was identified between the ANI and NRS values of all patient groups. Conclusion We failed to identify a correlation between ANI and NRS values before and after extubation. Previous studies suggested that the ANI provides more valuable information in anesthetized patients, whereas our findings show that it is ineffective in the prediction of potential postoperative pain.
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Affiliation(s)
- Ali Şefik Köprülü
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, İstanbul Yeni Yüzyıl University, İstanbul, Turkey
| | - Ali Haspolat
- Anesthesia and Intensive Care Clinics, İstanbul Şişli Vocational High School, İstanbul, Turkey
| | - Yaşar Gökhan Gül
- Anesthesiology Clinics, Kolan Bayrampaşa Hospital, İstanbul, Turkey
| | - Nurşen Tanrikulu
- Anesthesia and Intensive Care Clinics, İstanbul Şişli Vocational High School, İstanbul, Turkey
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46
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Ledowski T, Schmitz-Rode I. Predicting acute postoperative pain by the Qnox score at the end of surgery: a prospective observational study. Br J Anaesth 2019; 124:222-226. [PMID: 31759614 DOI: 10.1016/j.bja.2019.09.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/31/2019] [Accepted: 09/16/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND The QNox score (Quantium Medical S.L., distributed by Fresenius Kabi) has recently been introduced as a tool to quantify intraoperative analgesia. Being based on the analysis of electroencephalographic data, QNox is distinctly different to other methods of nociception monitoring that rely almost entirely on the assessment of sympathetic activity. However, there are currently no published data to validate use of QNox in a clinical setting. We investigated the value of pre-arousal QNox data at the end of surgery for prediction of acute postoperative pain in the PACU. METHODS A total of 150 patients scheduled for non-emergency surgery under sevoflurane-opioid general anaesthesia were included in the study. At the end of surgery but before patient arousal, QNox was measured minutely for 5 min. After admission to the recovery room, pain scores (numeric rating scale [NRS], 0-10) were obtained 5 minutely for 15 min. RESULTS Data from 144 patients were analysed. QNox before arousal showed no correlation (ρ=0.057) with acute postoperative pain in the PACU. Furthermore, the score was found to have no value for the prediction of acute postoperative pain (area under the receiver operating curve, 0.501; 95% confidence interval, 0.406-0.597). CONCLUSION QNox at the end of surgery before arousal showed no association with and allowed no prediction of acute pain in the PACU. CLINICAL TRIAL REGISTRATION ACTRN12618001662257.
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Affiliation(s)
- Thomas Ledowski
- University of Western Australia, Perth, Australia; Royal Perth Hospital, Perth, Australia.
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47
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Lim BG. Nociception monitoring tools using autonomic tone changes for intraoperative analgesic guidance in pediatric patients. Anesth Pain Med (Seoul) 2019; 14:380-392. [PMID: 33329766 PMCID: PMC7713809 DOI: 10.17085/apm.2019.14.4.380] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 09/30/2019] [Indexed: 12/03/2022] Open
Abstract
Nociception monitoring devices using changes in autonomic nervous system activity have been developed in numerous ways. Although there have been few studies conducted on children, compared to the relatively higher number of studies on adults, most of the nociception monitors in children, as in adults, appear to be more useful than the standard clinical practice that uses hemodynamic parameters in the evaluation and treatment of intraoperative nociception (pain) during general anesthesia. Particularly, when monitoring the surgical pleth index (SPI) in anesthetized children, the application of a new target range of SPI values (≤ 40) to the SPI monitoring criteria seems to be necessary for providing a more proper intraoperative analgesia. The analgesia nociception index (ANI) shows promising results in anesthetized adults, and recently, positive results along with cardiorespiratory coherence have been reported in pediatric patients. Newborn infant parasympathetic evaluation (NIPE) could be useful for providing adequate analgesia in newborns, infants, and children under 2 years of age in anesthetized or awake states. In cases of skin conductance and pupillometry, further studies are needed. Understanding the pros, cons, and limitations of these nociception monitoring tools will provide more effective and safe intraoperative analgesia to pediatric patients undergoing general anesthesia, and it may also help to plan and conduct promising research on the use of perioperative nociception monitoring in pediatric patients in the future.
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Affiliation(s)
- Byung Gun Lim
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
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Abstract
PURPOSE OF REVIEW In an unconscious patient, there can be significant challenges to monitoring nociception and proper dosing of analgesic medications. The traditional measures of intraoperative nociception have poor sensitivity and specificity with little predictive value in postoperative outcomes such as postoperative pain, opioid-induced side effects, length of stay or incidence of opioid use disorder. To date, several monitoring modalities are in development to establish objective measures of the balance between nociception and analgesia with the goal of guiding anesthesiologists and improve patient outcomes. In this review, some of the most promising monitoring modalities are discussed with the most recent findings. RECENT FINDINGS Multiple modalities are beginning to demonstrate utility compared with traditional care. Most, but not all, of these studies show decreased intraoperative opioid use and some show lower pain scores and opioid requirements in the postanesthesia care unit. SUMMARY Recent evidence points to promising efficacy for these monitoring modalities; however, this field is in its infancy. More investigation is required to demonstrate differences in outcome compared with traditional care, and these differences need to be of sufficient import to achieve widespread adoption.
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Soral M, Altun GT, Dinçer PÇ, Arslantaş MK, Aykaç Z. Effectiveness of the Analgesia Nociception Index Monitoring in Patients Who Undergo Colonoscopy with Sedo-Analgesia. Turk J Anaesthesiol Reanim 2019; 48:50-57. [PMID: 32076680 PMCID: PMC7001798 DOI: 10.5152/tjar.2019.45077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 03/12/2019] [Indexed: 01/21/2023] Open
Abstract
Objective The objective of this study was to improve the patient comfort and safety during procedures done under anaesthesia and sedation. The analgesia nociception index (ANI) noninvasively provides information on the nociception-antinociception balance, and it can be used to assess analgesia objectively. We aimed to compare the effects of analgesia management with conventional methods and with ANI monitoring on total opioid consumption, sedation and analgesia levels in patients who underwent colonoscopy using sedo-analgesia. Methods Adult patients (n=102), scheduled for procedural sedation, were prospectively analysed. After the induction with propofol and ketamine, infusions of propofol (2 mg kg−1 h−1) and remifentanil (0.05 mcg kg−1 min−1) were started. In Group A, remifentanil infusions were titrated to maintain the ANI value between 50 and 70, whereas in Group C, analgesic requirements were met according to the attending anaesthetist’s intention. The heart rate, blood pressure, respiratory rate, SpO2, BIS, Numeric Rating Scale (NRS) and Ramsay Sedation Scale were monitored. Complications, analgesics consumption, duration of the procedure, demographic information, NRS and the Modified Aldrete Score were evaluated. Results A total remifentanil amount used in Group A was 66.51±47.87 mcg and 90.15±58.17 mcg in Group C (p=0.011); there was no difference in total amounts of ketamine and propofol given. There was a negative correlation between ANI and NRS scores of Group A patients at Minute 0 at the level of 0.402, which was significant statistically (p=0.003). Conclusion Opioid consumption was diminished when ANI monitoring was used, and thus the patient safety was improved. Further studies with longer procedure times and with a greater number of patients are required to demonstrate whether there is a difference in side effects and recovery times.
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Affiliation(s)
| | - Gülbin Töre Altun
- Department of Anaesthesiology and Reanimation, Marmara University Pendik Training and Research Hospital, İstanbul, Turkey
| | - Pelin Çorman Dinçer
- Department of Anaesthesiology and Reanimation, Marmara University School of Medicine, İstanbul, Turkey
| | - Mustafa Kemal Arslantaş
- Department of Anaesthesiology and Reanimation, Marmara University School of Medicine, İstanbul, Turkey
| | - Zuhal Aykaç
- Department of Anaesthesiology and Reanimation, Marmara University School of Medicine, İstanbul, Turkey
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Leitão CJ, Lima-Rodríguez JR, Ferreira F, Avelino C, Sánchez-Margallo FM, Antunes L. Parasympathetic Tone Activity Evaluation to Discriminate Ketorolac and Ketorolac/Tramadol Analgesia Level in Swine. Anesth Analg 2019; 129:882-889. [PMID: 31425233 DOI: 10.1213/ane.0000000000003573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Evaluation of nociceptive-antinociceptive balance during general anesthesia is still challenging and routinely based on clinical criteria. Analgesic drug delivered may be optimized with parasympathetic tone activity (PTA) monitor. This study compares ketorolac and ketorolac/tramadol balance analgesia using a PTA monitor. METHODS Pain intensity response was assessed using a 0-100 numerical state scale (PTA) after nociceptive stimuli in pigs under stable sevoflurane anesthesia. Bispectral index, heart rate, noninvasive blood pressure, and respiratory parameters were also measured. Animals were divided into 3 groups: without analgesia, ketorolac, and ketorolac/tramadol. Mean values or mean areas under the curve (AUC) in selected time periods were compared over time and between groups through a mixed-model repeated measures analysis of variance and nonparametric Kruskal-Wallis tests, followed by Bonferroni or Dunn's multiple comparisons. RESULTS It was observed a significant decrease in the PTA AUC mean value after application of the stimulus in animals treated without analgesia and only with ketorolac. The PTA AUC mean value in the control group was significantly lower than the corresponding mean in ketorolac group. The ketorolac/tramadol group showed the highest PTA AUC mean values, significantly different from those obtained for the other 2 groups, with no significant differences detected over time. Bispectral index means showed no statistically significant differences either over time periods or between different treatment groups. Heart rate showed only a statistically significant increase in AUC mean between without analgesia and ketorolac/tramadol group, in the time period after the stimulus application. Noninvasive blood pressure means showed no statistically significant differences over time and between treatment groups. CONCLUSIONS This study shows that a low dose combination of ketorolac and tramadol is sufficient to block the pain responses induced with a needle holder in pigs 20 minutes after its administration. The PTA monitor was able to clearly recognize the analgesic level between treatments and may be used to optimize analgesic drug delivered.
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Affiliation(s)
- Carlos J Leitão
- From the Center for the Research and Technology of Agro-Environmental and Biological Sciences (CITAB)
- Department of Veterinarian Sciences, School of Agricultural and Veterinary Sciences School (ECAV), University of Trás-os-Montes and Alto Douro (UTAD), Vila Real, Portugal
| | | | - Fatima Ferreira
- Department of Mathematics, School of Science and Technology (ECT), University of Trás-os-Montes and Alto Douro, Vila Real, Portugal
- Center of Mathematics of the University of Minho - UTAD Pole (CMAT-UTAD), Vila Real, Portugal
| | - Catarina Avelino
- Department of Mathematics, School of Science and Technology (ECT), University of Trás-os-Montes and Alto Douro, Vila Real, Portugal
- Center of Mathematics of the University of Minho - UTAD Pole (CMAT-UTAD), Vila Real, Portugal
- Center for Computational and Stochastic Mathematics (CEMAT), Higher Technical Institute, University of Lisboa (IST-UL), University of Lisboa (IST-UL), Lisboa, Portugal
| | | | - Luís Antunes
- From the Center for the Research and Technology of Agro-Environmental and Biological Sciences (CITAB)
- Department of Veterinarian Sciences, School of Agricultural and Veterinary Sciences School (ECAV), University of Trás-os-Montes and Alto Douro (UTAD), Vila Real, Portugal
- Institute of Research and Innovation in Health, University of Porto, Porto, Portugal
- Laboratory Animal Science Group, Institute of Molecular and Cellular Biology (IBMC), University of Porto, Porto, Portugal
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