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Laskou S, Tsaousi G, Pourzitaki C, Papazisis G, Kesisoglou I, Sapalidis K. Efficacy and Safety of Magnesium Sulfate as an Adjunct to Ropivacaine Wound Infiltration in Thyroid Surgery: A Prospective, Double-Blind, Randomized Controlled Trial. J Clin Med 2024; 13:4499. [PMID: 39124765 PMCID: PMC11313512 DOI: 10.3390/jcm13154499] [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: 06/10/2024] [Revised: 07/18/2024] [Accepted: 07/27/2024] [Indexed: 08/12/2024] Open
Abstract
Background/Objective: Wound infiltration with local anesthetics emerges as a promising modality for postoperative pain alleviation. However, such strategies in neck surgery have not been a well-established practice. To assess wound infiltration with ropivacaine plus magnesium sulfate for pain relief following thyroid surgery. Methods: This prospective, double-blind, randomized study enrolled 68 patients who underwent thyroid surgery. Concerning the solution used for surgical wound infiltration, the study participants were randomly allocated into three groups: (1) 100 mg of ropivacaine (Group R); (2) 100 mg of ropivacaine plus magnesium sulfate 10 mg/kg (Group RMg); and (3) normal saline which served as a placebo (Group P). Pain perception both at rest and at movement, was measured using the Visual Analogue Scale (VAS) at 30 min, as well as at 1, 2, 4, 6, 12, and 24 h postoperatively. The total consumption of analgesics in morphine equivalents was also recorded. Moreover, adverse effects and patient satisfaction were recorded. Cortisol, TNF-α, and IL-6 levels were measured 30 min before infiltration and 6 h and 24 h postoperatively. Results: Demographics and clinical characteristics were similar between the groups. The VAS scores at rest and during movement were significantly lower in the RMg group compared to the saline or ropivacaine groups. Total analgesic consumption was also significantly lower in the RMg group. No operation-, wound-, or infiltration-related adverse effects were recorded in the study groups. Better overall satisfaction was obtained for the RMg group. Conclusions: Ropivacaine plus magnesium sulfate wound infiltration provided better pain control and the analgesic effect was more significant, contributing to effective postoperative analgesia in patients undergoing thyroid surgery.
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Affiliation(s)
- Stiliani Laskou
- 3rd Surgical Department, School of Medicine, Aristotle University of Thessaloniki, 1st St. Kiriakidi Str, 54636 Thessaloniki, Greece; (I.K.); (K.S.)
| | - Georgia Tsaousi
- Clinic of Anesthesiology and Intensive Care, School of Medicine, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | - Chryssa Pourzitaki
- Department of Clinical Pharmacology, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, 54006 Thessaloniki, Greece; (C.P.); (G.P.)
| | - Georgios Papazisis
- Department of Clinical Pharmacology, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, 54006 Thessaloniki, Greece; (C.P.); (G.P.)
| | - Isaak Kesisoglou
- 3rd Surgical Department, School of Medicine, Aristotle University of Thessaloniki, 1st St. Kiriakidi Str, 54636 Thessaloniki, Greece; (I.K.); (K.S.)
| | - Konstantinos Sapalidis
- 3rd Surgical Department, School of Medicine, Aristotle University of Thessaloniki, 1st St. Kiriakidi Str, 54636 Thessaloniki, Greece; (I.K.); (K.S.)
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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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Jurth C, Lichtner G, Bienert T, von Dincklage F. The variability in nociceptive flexion reflex threshold measurement is mostly caused by probabilistic effects of the estimation algorithms: a simulation study. Int J Neurosci 2024:1-10. [PMID: 38315138 DOI: 10.1080/00207454.2024.2312991] [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: 03/03/2022] [Accepted: 01/27/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVES The nociceptive flexion reflex (NFR) and its threshold are frequently used to investigate spinal nociception in humans. Since this threshold (NFRT) is a probabilistic measure, specific algorithms are used for NFRT estimation based on the stochastic occurrence of reflexes at different stimulus intensities. We used a validated simulation model of the NFR to investigate the amount of NFRT measurement variability induced by different estimation algorithms in a steady setting of reduced external influences. METHODS We simulated the behavior of different estimation algorithms in subjects with an artificially steady baseline NFRT variability (standard deviation: 0 mA) or low baseline NFRT variability (standard deviation: 0.156 mA), equaling a quiet experimental setting. The obtained data were analyzed for NFRT measurement variability caused by the algorithms compared to the baseline variability reflecting other physiological influences. RESULTS The standard deviation of the NFRT estimated by the different algorithms ranged between 0.381 and 3.464 mA with 96.8% to 99.6% of the measurement variability attributed to the algorithm used. Out of the investigated algorithms the dynamic staircase algorithm was most precise. CONCLUSION The NFRT measurement variability observed during quiet and steady experimental sessions is mostly caused by the properties of the estimation algorithms, due to the probabilistic nature of the reflex occurrence. Our results give reference for choosing the optimal estimation algorithm to improve measurement precision.
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Affiliation(s)
- Carlo Jurth
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Gregor Lichtner
- Department of Anesthesia, Intensive Care, Emergency and Pain Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Thomas Bienert
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Falk von Dincklage
- Department of Anesthesia, Intensive Care, Emergency and Pain Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
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van Rijbroek LS, Noordergraaf GJ, de Man-van Ginkel JM, van Boekel RLM. The association of hemodynamic parameters and clinical demographic variables with acute postoperative pain in female oncological breast surgery patients: A retrospective cohort study. Scand J Pain 2024; 24:sjpain-2023-0066. [PMID: 38460147 DOI: 10.1515/sjpain-2023-0066] [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: 05/25/2023] [Accepted: 01/03/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVES Appropriate administration of intraoperative analgesia is an essential factor in care and reasonable recovery times. Inappropriate intraoperative analgesia puts the patient at risk of acute postoperative pain (APOP). The absence of an objective standard for intraoperative nociceptive monitoring complicates pain care. Heart rate (HR) and mean arterial blood pressure (MABP) have been suggested as useful parameters during general anesthesia for nociceptive monitoring. However, studies focusing on whether intraoperative heart rate variability (HRv) and mean arterial blood pressure variability (MABPv) during general anesthesia can accurately monitor nociception in patients have remained inconclusive. The current study aimed to (1) identify the association of intraoperative heart rate and blood pressure variability in patients undergoing low-risk surgery with the incidence of APOP in the immediate postoperative setting and (2) evaluate the associations of clinical demographic factors with the incidence of APOP. METHODS A retrospective observational cohort study was conducted. The outcome was moderate-to-severe APOP, defined as a numeric rating scale score of ≥ 4. HRv, MABPv, and potential confounders, such as age, body mass index, duration of surgery, smoking, depression, preoperative use of analgesics, and type of surgery, were used as independent variables. RESULTS Data from 764 female oncological breast surgery patients were analyzed. No statistically significant association of HRv and MABPv with APOP was found. Lower age was associated with higher odds of APOP (odds ratio [OR] 0.978, p = 0.001). Increased length of surgery (OR 1.013, p = 0.022) and a history of depression were associated with increased odds of APOP (OR 2.327, p = 0.010). The subtype of surgery was statistically significantly associated with APOP (p = 0.006). CONCLUSIONS Our results suggest that heart rate and blood pressure variability intraoperatively, in female patients undergoing low-risk surgery, are not associated with, and thus not predictive of, APOP in the immediate postoperative setting.
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Affiliation(s)
- Lieselotte S van Rijbroek
- Department of Anesthesiology, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
- Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Gerrit J Noordergraaf
- Department of Anesthesiology, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - Janneke M de Man-van Ginkel
- Nursing Science, Program in Clinical Health Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
- Nursing Science, Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Regina L M van Boekel
- Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, The Netherlands
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Tong C, Miao Q, Zheng J, Wu J. A novel nomogram for predicting the decision to delayed extubation after thoracoscopic lung cancer surgery. Ann Med 2023; 55:800-807. [PMID: 36869647 PMCID: PMC9987746 DOI: 10.1080/07853890.2022.2160490] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
OBJECTIVE Delayed extubation was commonly associated with increased adverse outcomes. This study aimed to explore the incidence and predictors and to construct a nomogram for delayed extubation after thoracoscopic lung cancer surgery. METHODS We reviewed medical records of 8716 consecutive patients undergoing this surgical treatment from January 2016 to December 2017. Using potential predictors to develop a nomogram and using a bootstrap-resampling approach to conduct internal validation. For external validation, we additionally pooled 3676 consecutive patients who underwent this procedure between January 2018 and June 2018. Extubation performed outside the operating room was defined as delayed extubation. RESULTS The rate of delayed extubation was 1.60%. Multivariate analysis identified age, BMI, FEV1/FVC, lymph nodes calcification, thoracic paravertebral blockade (TPVB) usage, intraoperative transfusion, operative time and operation later than 6 p.m. as independent predictors for delayed extubation. Using these eight candidates to develop a nomogram, with a concordance statistic (C-statistic) value of 0.798 and good calibration. After internal validation, similarly good calibration and discrimination (C-statistic, 0.789; 95%CI, 0.748 to 0.830) were observed. The decision curve analysis (DCA) indicated the positive net benefit with the threshold risk range of 0 to 30%. Goodness-of-fit test and discrimination in the external validation were 0.113 and 0.785, respectively. CONCLUSION The proposed nomogram can reliably identify patients at high risk for the decision to delayed extubation after thoracoscopic lung cancer surgery. Optimizing four modifiable factors including BMI, FEV1/FVC, TPVB usage, and operation later than 6 p.m. may reduce the risk of delayed extubation.Key Messages:This study identified eight independent predictors for delayed extubation, among which lymph node calcification and anaesthesia type were not commonly reported.Using these eight candidates to develop a nomogram, we could reliably identify high-risk patients for the decision to delayed extubation.Optimizing four modifiable factors, including BMI, FEV1/FVC, TPVB usage, and operation later than 6 p.m. may reduce the risk of delayed extubation.
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Affiliation(s)
- Chaoyang Tong
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qing Miao
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jijian Zheng
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jingxiang Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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Ledowski T. [New Approaches in Perioperative Algesimetry]. Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:640-653. [PMID: 38056443 DOI: 10.1055/a-2006-9923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
The measurement of anaesthetic depth and muscle relaxation have been routine procedures during general anaesthesia for years. Quantification of intraoperative nociception, on the other hand, is still largely impossible. Various methods have been tested and commercialised for more than 10 years. However, a real breakthrough has not yet been achieved and the routine application of all methods available so far is not without problems. This article explains methodological similarities, but also points to specific aspects of various commercial solutions for perioperative algesimetry.
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Koschmieder KC, Funcke S, Shadloo M, Pinnschmidt HO, Greiwe G, Fischer M, Nitzschke R. Validation of three nociception indices to predict immediate postoperative pain before emergence from general anaesthesia: a prospective double-blind, observational study. Br J Anaesth 2023; 130:477-484. [PMID: 36609057 DOI: 10.1016/j.bja.2022.11.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/25/2022] [Accepted: 11/09/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Nociception monitoring devices are designed to estimate nociception during general anaesthesia. We evaluated the predictive accuracy of heart rate and three nociception indices to predict postoperative pain before emergence from general anaesthesia. METHODS In patients undergoing trauma or orthopaedic surgery, HR, Surgical Pleth Index® (SPI), Pupillary Pain Index® (PPI), and Nociception Level® (NOL) were simultaneously recorded for 5 min after the end of surgery but before return of consciousness. After admission to the recovery room, pain scores were assessed regularly for 2 h. HR, SPI, PPI, and NOL were analysed for their predictive accuracy of postoperative pain and opioid consumption with assessment of area under the receiver operating characteristic (AUC) curves, Spearman rank-correlation coefficient, and regression modelling. RESULTS Data for 60 subjects were analysed. The AUC (95% confidence interval [95% CI]) of the predictive accuracy for moderate-to-severe postoperative pain differed between nociception indices (HR=0.46 [0.29-0.64], P=0.671; SPI=0.46 [0.31-0.61], P=0.621; PPI=0.52 [0.36-0.68], P=0.770; NOL=0.66 [0.51-0.81], P=0.038). In a multivariable logistic regression model, a higher predictive accuracy was found for a multivariable predictor combining NOL values with ASA physical status and information about use of regional anaesthesia (AUC=0.83 [0.72-0.94], P<0.001). CONCLUSIONS Heart rate, Surgical Pleth Index, Pupillary Pain Index, and Nociception Level measured before emergence from general anaesthesia do not yet have sufficient diagnostic accuracy for prediction of postoperative pain. CLINICAL TRIAL REGISTRATION NCT05063227.
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Affiliation(s)
- Kim C Koschmieder
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sandra Funcke
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mahshid Shadloo
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans O Pinnschmidt
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gillis Greiwe
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marlene Fischer
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rainer Nitzschke
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Rababa M, Al-Sabbah S. The use of islamic spiritual care practices among critically ill adult patients: A systematic review. Heliyon 2023; 9:e13862. [PMID: 36915488 PMCID: PMC10006532 DOI: 10.1016/j.heliyon.2023.e13862] [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: 11/12/2022] [Revised: 01/14/2023] [Accepted: 02/14/2023] [Indexed: 02/22/2023] Open
Abstract
Spiritual care is essential to the healthcare plans of critically ill patients and their families. However, spiritual care remains neglected and requires healthcare institutions and providers' attention to be incorporated into healthcare management plans, especially for critically ill Muslim patients and their families. To date, no review has been conducted to discuss spiritual care in adult critical care Muslim patients. Spiritual care and Holy Quran recitation have been reported to be practical non-pharmacological interventions for critically ill Muslim patients. However, there is a need for Islamic healthcare institutions and providers to pay further attention to including spiritual care in the healthcare management plans of their patients. Also, future research is recommended to test the effectiveness of incorporating spiritual care in the healthcare plans of critical care patients.
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Affiliation(s)
- Mohammad Rababa
- Adult Health Nursing Department, Faculty of Nursing, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Shatha Al-Sabbah
- Adult Health Nursing Department, Faculty of Nursing, Jordan University of Science and Technology, Irbid, 22110, Jordan
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Tong C, Shen Y, Zhu H, Zheng J, Xu Y, Wu J. Continuous Relationship of Operative Duration with Risk of Adverse Perioperative Outcomes and Early Discharge Undergoing Thoracoscopic Lung Cancer Surgery. Cancers (Basel) 2023; 15:cancers15020371. [PMID: 36672321 PMCID: PMC9856387 DOI: 10.3390/cancers15020371] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/20/2022] [Accepted: 12/28/2022] [Indexed: 01/08/2023] Open
Abstract
Background: For thoracoscopic lung cancer surgery, the continuous relationship and the trigger point of operative duration with a risk of adverse perioperative outcomes (APOs) and early discharge remain unknown. Methods: This study enrolled 12,392 patients who underwent this surgical treatment. Five groups were stratified by operative duration: <60 min, 60−120 min, 120−180 min, 180−240 min, and ≥240 min. APOs included intraoperative hypoxemia, delayed extubation, postoperative pulmonary complications (PPCs), prolonged air leakage (PAL), postoperative atrial fibrillation (POAF), and transfusion. A restricted cubic spline (RCS) plot was used to characterize the continuous relationship of operative duration with the risk of APOs and early discharge. Results: The risks of the aforementioned APOs increased with each additional hour after the first hour. A J-shaped association with APOs was observed, with a higher risk in those with prolonged operative duration compared with those with shorter values. However, the probability of early discharge decreased from 0.465 to 0.350, 0.217, and 0.227 for each additional hour of operative duration compared with counterparts (<60 min), showing an inverse J-shaped association. The 90 min procedure appears to be a tipping point for a sharp increase in APOs and a significant reduction in early discharge. Conclusions: Our findings have important and meaningful implications for risk predictions and clinical interventions, and early rehabilitation, for APOs.
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Affiliation(s)
- Chaoyang Tong
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200052, China
- Department of Anesthesiology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Yaofeng Shen
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200052, China
| | - Hongwei Zhu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200052, China
| | - Jijian Zheng
- Department of Anesthesiology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
- Correspondence: (J.Z.); (J.W.)
| | - Yuanyuan Xu
- Department of Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Jingxiang Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200052, China
- Correspondence: (J.Z.); (J.W.)
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Changes of the nociceptive flexion reflex threshold in patients undergoing cardiac surgery-a prospective clinical pilot study. J Clin Monit Comput 2022; 37:873-880. [PMID: 36565408 DOI: 10.1007/s10877-022-00958-3] [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: 03/17/2022] [Accepted: 11/27/2022] [Indexed: 12/25/2022]
Abstract
Opioid dosage for general anaesthesia and sedation relies on surrogate parameters such as heartrate and blood pressure. This implies the risk of both under- and overdosing. A promising tool to provide target-oriented opioid dosing is measuring the nociceptive flexion reflex threshold (NFRT). The aim of this study was to investigate the individual trajectories and to determine this methods' clinical practicability in the perioperative setting of cardiac surgery. NFRT was measured preoperatively (twice as baseline), immediately after surgery and later in the general ward (primary outcomes). No intraoperative measurements were performed since neuromuscular blockade hinders NFRT assessment. Administered analgesics and pain scores were also recorded (secondary outcomes). Data were collected from August 2019 to March 2020. 264 patients scheduled for cardiac surgery were screened for eligibility. 55 patients were included, 30 rendered datasets for analysis. Thresholds after conclusion of surgery [TICU: median (IQR), 31.1 mA (21.5-50.0 mA)] were significantly higher than preoperatively [Tpre: 9.2 mA (5.4-13.4 mA); P < 0.001]. In 11 patients (36.7%), no immediate postoperative reflex response was elicited. Later, all reflexes returned, but thresholds remained significantly higher than preoperatively [Tpost: 11.9 mA (9.2-16.6 mA); P = 0.043]. NFRT values after surgery were higher compared to baseline measurements. Subsequently they decreased but did not reach their baseline levels. There was no corresponding dose-dependency, suggesting multimodal effects on the nociceptive system. Unless measurements are not prevented by technical issues NFRT-assessment appears to be a future tool to target analgesics in patients not able to self-report pain. Trial registration Study registration: DRKS00021617. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00021617 (registered retrospectively).
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Jurth C, Zimmermann V, Schaaf L, Lezius F, Bublitz VK, Lichtner G, von Dincklage F. Investigation of behavioral pain scale, critical care pain observation tool, nociceptive flexion reflex and pupillary dilatation reflex as predictors of behavioral reactions to nociceptive procedures in critically ill patients unable to self-report pain. Eur J Pain 2022; 26:2074-2082. [PMID: 35959740 DOI: 10.1002/ejp.2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 06/20/2022] [Accepted: 08/07/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Procedural pain is a common burden in critical care treatment and the prediction of nociceptive reactions remains challenging. Thus, we investigated the behavioral pain scale (BPS), the critical pain observational Tool (CPOT), the nociceptive flexion reflex (NFR), the pupillary dilation reflex (PDR), the Richmond agitation-sedation scale (RASS) as predictors of behavioral reactions to nociceptive procedures. METHODS In this monocentric, prospective, observational study we analyzed data of 128 critically ill adults unable to self-report pain to investigate the predictability of behavioral reactions to two procedures: endotracheal suctioning and turning. Next to routine clinical data, CPOT, BPS, PDR, NFR, RASS, propofol and sufentanil doses were recorded before the procedures. RESULTS For endotracheal suctioning, NFR, BPS, CPOT, RASS showed predictive performances significantly better than chance, but none of them performed significantly better than the sufentanil dose rate. For turning, BPS, CPOT, RASS showed predictive performances significantly better than chance, but only the RASS performed significantly better than the propofol dose rate. CONCLUSIONS Behavioral reactions to both investigated clinical procedures can be predicted by observational scales or nociceptive reflexes. For endotracheal suctioning, none of the predictors performed superior to using the sufentanil dose rate as a predictor. As using sufentanil as a predictor requires no extra effort in contrast to the other predictors, none of the here investigated tools seem advisable for predicting behavioral reactions to endotracheal suctioning. For patient turning, the RASS predicts reactions better than any other tool.
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Affiliation(s)
- C Jurth
- Charité - Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Charité Mitte und Campus Virchow-Klinikum, Berlin, Germany
| | - V Zimmermann
- Charité - Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Charité Mitte und Campus Virchow-Klinikum, Berlin, Germany
| | - L Schaaf
- Charité - Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Charité Mitte und Campus Virchow-Klinikum, Berlin, Germany
| | - F Lezius
- HELIOS Klinikum Berlin-Buch, Klinik für Anästhesie, perioperative Medizin und Schmerztherapie, Berlin, Germany
| | - V K Bublitz
- Charité - Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Charité Mitte und Campus Virchow-Klinikum, Berlin, Germany
| | - G Lichtner
- Universitätsmedizin Greifswald, Klinik für Anästhesie, Intensiv-, Notfall- und Schmerzmedizin, Greifswald, Germany
| | - F von Dincklage
- Universitätsmedizin Greifswald, Klinik für Anästhesie, Intensiv-, Notfall- und Schmerzmedizin, Greifswald, Germany
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Schick B, Schmid S, Mayer B, Wagner D, Walter S, Gruss S, Jungwirth B, Barth E. [Potential effect of the stimulus threshold level of the nociceptive flexion reflex (NFRT) on mortality and delirium incidence in the critically ill patient: a retrospective cohort analysis]. DIE ANAESTHESIOLOGIE 2022; 71:921-929. [PMID: 36166064 PMCID: PMC9514181 DOI: 10.1007/s00101-022-01206-8] [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: 04/18/2022] [Revised: 08/05/2022] [Accepted: 08/25/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Mortality and delirium in critically ill patients are affected by the provided analgesics and sedatives. The deeper the sedation and the higher the dose of analgesics applied, the more difficult it is to assess pain and the depth of sedation. Therefore, instrumental measurement methods, such as the measurement of the stimulus threshold of the nociceptive flexion reflex (NFRT), are becoming increasingly more important. OBJECTIVE The aim of the present study is to investigate a potential association between the level of the nociceptive flexion reflex, mortality, and the occurrence of delirium. MATERIAL AND METHODS By retrospectively analyzing a pilot data set of 57 ICU patients from the interdisciplinary surgical ICU of Ulm University Hospital surveyed between 11/2018 and 03/2020, a possible association between the NFRT, mortality, and the occurrence of delirium was calculated in an adjusted logistic regression model. Depending on the cut-off value, the stimulus threshold corridors result in the following comparison pairs: < 20 mA vs. 20-40 mA/20-50 mA/20-60 mA, > 40 mA vs. 20-40 mA, > 50 mA vs. 20-50 mA and > 60 mA vs. 20-60 mA. Results are presented as odds ratios (OR) adjusted for age, sex, height, TISS-28, SAPS II, RASS, BPS, and applied analgesics. Pain assessment was performed, in addition to the Behavioral Pain scale, ≥ 3 times daily by measuring NFRT. RESULTS A statistically nonsignificant tendency for an increase in mortality incidence occurred with an NFRT > 50 mA, versus a stimulus threshold corridor of 20-50 mA (OR 3.3, CI: 0.89-12.43, p = 0.07). A trend toward a reduction in delirium incidence occurred at an NFRT < 20 mA, versus a stimulus threshold corridor of 20-40 mA (OR 0.40, CI: 0.18-0.92, p = 0.03). CONCLUSION Based on the level of the NFRT, no recommendation can be made at this point to adjust the analgesic regimen of critically ill patients, who are unable to communicate. The observation of a tendency towards an increase in mortality at high stimulus thresholds or a reduction in the occurrence of delirium at low stimulus thresholds of the NFRT must be verified in standardized studies.
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Affiliation(s)
- B. Schick
- grid.410712.10000 0004 0473 882XKlinik für Anästhesiologie und Intensivmedizin, Sektion Interdisziplinäre Operative Intensivmedizin, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Deutschland
| | - S. Schmid
- grid.410712.10000 0004 0473 882XKlinik für Anästhesiologie und Intensivmedizin, Sektion Interdisziplinäre Operative Intensivmedizin, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Deutschland
| | - B. Mayer
- grid.6582.90000 0004 1936 9748Institut für Epidemiologie und Medizinische Biometrie, Universität Ulm, Schwabstr. 13, 89075 Ulm, Deutschland
| | - D. Wagner
- grid.410712.10000 0004 0473 882XKlinik für Anästhesiologie und Intensivmedizin, Sektion Interdisziplinäre Operative Intensivmedizin, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Deutschland
| | - S. Walter
- grid.6582.90000 0004 1936 9748Klinik für Psychosomatische Medizin und Psychotherapie, Sektion medizinische Psychologie, Universität Ulm, Frauensteige 6, 89075 Ulm, Deutschland
| | - S. Gruss
- grid.6582.90000 0004 1936 9748Klinik für Psychosomatische Medizin und Psychotherapie, Sektion medizinische Psychologie, Universität Ulm, Frauensteige 6, 89075 Ulm, Deutschland
| | - B. Jungwirth
- grid.410712.10000 0004 0473 882XKlinik für Anästhesiologie und Intensivmedizin, Sektion Interdisziplinäre Operative Intensivmedizin, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Deutschland
| | - E. Barth
- grid.410712.10000 0004 0473 882XKlinik für Anästhesiologie und Intensivmedizin, Sektion Interdisziplinäre Operative Intensivmedizin, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Deutschland
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Schick B, Mayer B, Walter S, Gruss S, Stitz R, Stitz P, Barth E. Measurement of the nociceptive flexion reflex threshold in critically ill patients - a randomized observational pilot study. BMC Anesthesiol 2021; 21:270. [PMID: 34740318 PMCID: PMC8569046 DOI: 10.1186/s12871-021-01490-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 10/26/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Pain detection and treatment is a major challenge in the care of critically ill patients, rendered more complex by the need to take into consideration the risk of insufficient or excessive analgesia. The nociceptive flexion reflex threshold (NFRT) has become the established basis for measuring the level of analgesia in the perioperative context. However, it remains unclear whether NFRT measurement can be usefully applied to mechanically ventilated, analgosedated critically ill patients who are unable to communicate. Therefore, the aim of the present study was to investigate whether there is an association between the NFRT measurement and the Behavioral Pain Scale (BPS) in critically ill, analgosedated, and mechanically ventilated patients and whether the NFRT measurement can also detect potential excessive analgesia. METHODS This prospective, observational, randomized single-center pilot study included patients admitted to the surgical Intensive Care Unit of University Hospital Ulm, Germany, all of whom were analgosedated and intubated. Major exclusion criteria were defined as the need for the administration of neuromuscular blocking agents or neurological diseases associated with peripheral nerve conduction restriction. Initial NFRT and BPS measurements were conducted within 12 h after admission. A structured pain assessment was performed at least twice daily until extubation throughout the observation period thereafter (Group A: BPS + NFRT, Group B: BPS). RESULTS 114 patients were included in the study. NFRT is associated negatively with BPS. NFRT was almost twice as high in patients with a Richmond Agitation Sedation Scale (RASS) score of -5 than in patients with a RASS score ≥ -4 (RASS -5 - NFRT: 59.40 vs. RASS -4 - NFRT: 29.00, p < 0.001). CONCLUSIONS NFRT measurement is associated negatively with the BPS in critically ill patients. NFRT measurement provides guidance for the evaluation of nociceptive processes in patients with RASS scores ≤ -4, in whom analgesia level is often difficult to assess. However, in order to identify excessive analgesia and derive therapeutic consequences, it is necessary to gradually decrease analgesics and sedatives until a stimulus threshold is reached at which the patient does not feel pain. TRIAL REGISTRATION Retrospectively registered in the German Clinical Trials Register, registration number DRKS00021149, date of registration: March 26, 2020. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00021149 .
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Affiliation(s)
- Benedikt Schick
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
| | - Benjamin Mayer
- Institute of Epidemiology and Medical Biometry, Ulm University, Schwabstraße 13, 89075, Ulm, Germany
| | - Steffen Walter
- Department of Medical Psychology, Ulm University, Frauensteige 6, 89075, Ulm, Germany
| | - Sascha Gruss
- Department of Medical Psychology, Ulm University, Frauensteige 6, 89075, Ulm, Germany
| | - Ronald Stitz
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Pauline Stitz
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Eberhard Barth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
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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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Corrêa LM, Grados FM. Retrospective assessment of the relationship between intraoperative nociception and postoperative analgesia requirements in dogs undergoing thoracic surgery. Vet Rec 2021; 190:e514. [PMID: 34091932 DOI: 10.1002/vetr.514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/24/2021] [Accepted: 05/11/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND The analgesia management of thoracic surgery can be challenging and debate exists regarding the efficacy of pre-emptive analgesia and its relationship with postoperative pain. The aim of this study was to assess the relationship between intraoperative nociception and postoperative pain in dogs undergoing thoracic surgery. If proven, effective prevention of intraoperative nociception could imply prospective lower postoperative analgesia requirements. METHODS The study was retrospective and observational. Clinical records from dogs undergoing thoracic surgery (2015-2019) were reviewed and cases were allocated to one of two groups: NOCI-FREE - dogs with no evidence of intraoperative nociception; NOCI - dogs that required intraoperative rescue analgesia to address a nociceptive response. Pre-anaesthetic medication, locoregional analgesia, intraoperative infusions and rescue analgesia were used. Additionally, postoperative pain scores and analgesia plans were registered and compared between groups. RESULTS Our study failed to identify a difference in the postoperative pain scores and analgesia requirements between dogs having signs of intraoperative nociception and those without. Additionally, the use of postoperative analgesic preventive infusions and rescue analgesia was similar for both NOCI and NOCI-FREE. Being on an intraoperative infusion of opioids, dexmedetomidine or lidocaine was identified as a protective factor for nociception [OR = 11; (4.15-29.7)]. CONCLUSIONS In the population studied, it appears that dogs showing signs of nociception intraoperatively do not necessarily show higher pain scores nor do they need additionally pain relief in the postoperative period.
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Effects of pupillary reflex dilation-guided opioid administration on remifentanil and morphine consumption during laparoscopic surgery: A randomised controlled trial. Eur J Anaesthesiol 2021; 38:975-984. [PMID: 33913678 DOI: 10.1097/eja.0000000000001491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Analysis of pupillary reflex dilation (PRD) assesses the balance of nociception--antinociception. Laparoscopic surgery induces haemodynamic variations that are misleading. During laparoscopy, PRD guidance helps differentiate haemodynamic changes because of excess nociception from secondary changes related to the reflex release of endocrine factors. OBJECTIVE The present study evaluated the effect of PRD-guided antinociception on the administration of intra-operative remifentanil and immediate postoperative morphine consumption in patients undergoing elective laparoscopic surgery. DESIGN The study was a single-blind, randomised controlled trial. SETTING The study took place at two sites at the University Hospital of Nancy from March 2014 to November 2017. PATIENTS A total of 100 patients who underwent scheduled laparoscopic surgery were included. INTERVENTIONS Patients were randomly given remifentanil guided by PRD (PRD-guided) or standard anaesthesia care (control). MAIN OUTCOME MEASURES The primary outcome was intra-operative remifentanil consumption. Secondary outcomes included morphine consumption in the immediate postoperative period and the number of intra-operative haemodynamic events. RESULTS Data from 95 patients were analysed. Intraoperative remifentanil consumption was lower in the PRD-guided group than in the control group: median [IQR], 0.09 [0.07 to 0.11] vs. 0.14 [0.12 to 0.16] μg kg min, with a mean difference (95% confidence Interval, CI) of 0.048 (0.035 to 0.060) μg kg min; P < 0.0001. Morphine consumption was 0.13 [0.1 to 0.5] vs. 0.15 [0.11 to 0.4] mg kg (P = 0.52) in the PRD-guided and control groups, respectively. The number of hypertensive and tachycardia events was greater in the PRD-guided group than in the control group: Hypertensive events 60.4 vs. 32.6%, relative risk 1.85 (95% CI, 1.24 to 2.84), P = 0.004; tachycardia events 31.6% vs. 4.3%, relative risk 2.09 (95% CI, 1.45 to 2.84), P < 0.001. CONCLUSIONS When PRD is used to differentiate between haemodynamic events arising from noxious stimuli and those events because of other nonsurgical stimuli, then intra-operative remifentanil administration is reduced intra-operatively during laparoscopic surgery but there was no change in postoperative morphine consumption. TRIAL REGISTRATION Clinicaltrials.gov NCT02116868.
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Jakuscheit A, Weth J, Lichtner G, Horas K, Rehberg-Klug B, von Dincklage F. Perioperative predictability of unsatisfactory functional outcomes 6 months after hip arthroplasty. J Orthop 2021; 24:34-41. [PMID: 33679026 DOI: 10.1016/j.jor.2021.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 02/07/2021] [Indexed: 11/26/2022] Open
Abstract
Background Aiming at an early identification of patients with an unsatisfactory outcome after hip arthroplasty we investigated the pre-, intra- and early postoperative predictability. Methods Using logistic regression models at nine different time points we calculated the area under the curve of the receiver operating characteristic (ROC-AUC) to compare the predictability of an unsatisfactory outcome. Results The predictability of unsatisfactory outcomes increased significantly from a ROC-AUC (95% CI) of 0.73 (0.62-0.84) in the preoperative setting to 0.85 (0.77-0.94) on day 2 after surgery. Conclusion Most of the patients with unsatisfactory outcomes can be identified during the first days after surgery.
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Affiliation(s)
- Axel Jakuscheit
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Germany
| | - Johannes Weth
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Gregor Lichtner
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Konstantin Horas
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Germany
| | - Benno Rehberg-Klug
- Département d'Anesthésiologie, Pharmacologie et SIC, Hôpitaux Universitaires de Genève HUG, Rue Gabrielle-Perret-Gentil 4, 1205, Genève, Switzerland
| | - Falk von Dincklage
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
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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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Bartholmes F, M. Malewicz N, Ebel M, K. Zahn P, H. Meyer-Frießem C. Pupillometric Monitoring of Nociception in Cardiac Anesthesia. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:833-840. [PMID: 33593477 PMCID: PMC8021968 DOI: 10.3238/arztebl.2020.0833] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 12/19/2019] [Accepted: 05/27/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND High-dose opioids are conventionally used for cardiac anesthesia, but without monitoring of nociception. In non-cardiac surgical procedures the intra - operative dose of opioids can be individualized and reduced with pupillometric monitoring of the pupillary pain index (PPI; scale 1-9). A randomized controlled trial was carried out to explore whether pupillometry can be used for nociception monitoring in cardiac anesthesia and whether it leads to opioid reduction. METHODS A sample of 57 cardiac surgery patients receiving continuously administered sufentanil (initial dosage 0.7 μg*kg-¹*h-¹) was divided into a PPI group (sufentanil reduction if PPI<3 up to a minimum of 0.15 μg*kg-¹*h-¹, n=32) and a control group (standard anesthesia; n = 25). The primary outcome was the time from the end of anesthesia to extubation. The secondary outcomes were total intraoperative dose of sufentanil/noradrenaline, postoperative pain intensity (numeric rating scale [NRS] 0-10) and intraoperative awareness. German Clinical Trials Registry no. DRKS 00012329. RESULTS The primary outcome, extubation time, did not differ between the two groups (1.14 h, 95% confidence interval [-0.99; 3.27], p = 0.592). Compared with the control patients (68% male, age 70 ± 10.4 years, PPI 1.1 ± 0.2), the mean sufentanil infusion rate in the PPI patients (81% male, age 68 ± 10.3 years, PPI 1.1 ± 0.2) decreased by 81.8% (-0.68 μg*kg-¹*h-¹ [-0,7; -0.67], p<0.001) to the predetermined minimum level, without intraoperative awareness. Moreover, the noradrenaline dose was reduced by 56% (1235.51 μg [321.91; 2149.12], p = 0.005) and the postoperative pain intensity by 45% (2.11 NRS [0.93; 3.3] after 24 h, p = 0.003). CONCLUSION Pupillometry is appropriate for nociception monitoring in cardiac anesthesia. Thereby a considerable reduction of intraoperative opioids as well as increased intraoperative hemodynamic stability was achieved and postoperative opioid-induced hyperalgesia was prevented. The consistently low PPI scores, indicating adequate analgesia, suggest that further reduction of opioid doses is feasible.
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Affiliation(s)
- Felix Bartholmes
- BG-Universitätsklinikum Bergmannsheil gGmbH Bochum, Klinik für Anästhesie, Intensiv- und Schmerzmedizin
| | - Nathalie M. Malewicz
- BG-Universitätsklinikum Bergmannsheil gGmbH Bochum, Klinik für Anästhesie, Intensiv- und Schmerzmedizin
| | - Melanie Ebel
- BG-Universitätsklinikum Bergmannsheil gGmbH Bochum, Klinik für Anästhesie, Intensiv- und Schmerzmedizin
| | - Peter K. Zahn
- BG-Universitätsklinikum Bergmannsheil gGmbH Bochum, Klinik für Anästhesie, Intensiv- und Schmerzmedizin
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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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Jure FA, Arguissain FG, Biurrun Manresa JA, Graven-Nielsen T, Andersen OK. Stimulus predictability moderates the withdrawal strategy in response to repetitive noxious stimulation in humans. J Neurophysiol 2020; 123:2201-2208. [DOI: 10.1152/jn.00028.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Innate defensive behaviors such as reflexes are found across all species, constituting preprogrammed responses to external threats that are not anticipated. Previous studies indicated that the excitability of the reflex arcs like spinal nociceptive withdrawal reflex (NWR) pathways in humans are modulated by several cognitive factors. This study assesses how the predictability of a threat affects the biomechanical pattern of the withdrawal response, showing that distal and proximal muscles are differentially modulated by descending control.
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Affiliation(s)
- Fabricio A. Jure
- Integrative Neuroscience, SMI®, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Federico G. Arguissain
- Integrative Neuroscience, SMI®, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
- Center for Neuroplasticity and Pain (CNAP), SMI®, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - José A. Biurrun Manresa
- Center for Neuroplasticity and Pain (CNAP), SMI®, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
- Centro de Investigaciones y Transferencia de Entre Ríos (CITER) CONICET-UNER, Entre Ríos, Argentina
| | - Thomas Graven-Nielsen
- Center for Neuroplasticity and Pain (CNAP), SMI®, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Ole Kæseler Andersen
- Integrative Neuroscience, SMI®, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
- Center for Neuroplasticity and Pain (CNAP), SMI®, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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22
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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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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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Opioid-free anaesthesia: Pro: damned if you don't use opioids during surgery. Eur J Anaesthesiol 2019; 36:247-249. [PMID: 30817359 DOI: 10.1097/eja.0000000000000966] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Objective monitoring of nociception: a review of current commercial solutions. Br J Anaesth 2019; 123:e312-e321. [PMID: 31047645 DOI: 10.1016/j.bja.2019.03.024] [Citation(s) in RCA: 134] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/11/2019] [Accepted: 03/04/2019] [Indexed: 11/22/2022] Open
Abstract
Nociception, in contrast to pain, is not a subjective feeling, but the physiological encoding and processing of nociceptive stimuli. However, monitoring nociception remains a challenge in attempts to lower the incidence of acute postoperative pain and the move towards a more automated approach to analgesia and anaesthesia. To date, several commercialised devices promise a more accurate reflection of nociception than the traditionally used vital signs, blood pressure and heart rate. This narrative review presents an overview of existing technologies and commercially available devices, and offers a perspective for future research. Although firm conclusions about individual methods may be premature, none currently appears to offer a sufficiently broad applicability. Furthermore, there is currently no firm evidence for any clinically relevant influence of such devices on patient outcome. However, the available monitors have significantly aided the understanding of underlying mechanisms and identification of potential pitfalls.
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Wildemeersch D, Peeters N, Saldien V, Vercauteren M, Hans G. Pain assessment by pupil dilation reflex in response to noxious stimulation in anaesthetized adults. Acta Anaesthesiol Scand 2018; 62:1050-1056. [PMID: 29671874 PMCID: PMC6099429 DOI: 10.1111/aas.13129] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/05/2018] [Accepted: 03/08/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND In response to noxious stimulation, pupillary dilation reflex (PDR) occurs even in anaesthetized patients. The aim of the study was to evaluate the ability of pupillometry with an automated increasing stimulus intensity to monitor intraoperative opioid administration. METHODS Thirty-four patients undergoing elective surgery were enrolled. Induction by propofol anaesthesia was increased progressively until the sedation depth criteria (SeD) were attained. Subsequently, a first dynamic pupil measurement was performed by applying standardized nociceptive stimulation (SNS). A second PDR evaluation was performed when remifentanil reached a target effect-site concentration. Automated infrared pupillometry was used to determine PDR during nociceptive stimulations generating a unique pupillary pain index (PPI). Vital signs were measured. RESULTS After opioid administration, anaesthetized patients required a higher stimulation intensity (57.43 mA vs 32.29 mA, P < .0005). Pupil variation in response to the nociceptive stimulations was significantly reduced after opioid administration (8 mm vs 28 mm, P < .0005). The PPI score decreased after analgesic treatment (8 vs 2, P < .0005), corresponding to a 30% decrease. The elicitation of PDR by nociceptive stimulation was performed without changes in vital signs before (HR 76 vs 74/min, P = .09; SBP 123 vs 113 mm Hg, P = .001) and after opioid administration (HR 63 vs 62/min, P = .4; SBP 98.66 vs 93.77 mm Hg, P = .032). CONCLUSIONS During propofol anaesthesia, pupillometry with the possibility of low-intensity standardized noxious stimulation via PPI protocol can be used for PDR assessment in response to remifentanil administration.
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Affiliation(s)
- D. Wildemeersch
- Department of AnaesthesiaAntwerp University Hospital (UZA)EdegemBelgium
- Multidisciplinary Pain CentreAntwerp University Hospital (UZA)EdegemBelgium
- Laboratory for Pain ResearchUniversity of Antwerp (UA)WilrijkBelgium
| | - N. Peeters
- Department of AnaesthesiaAntwerp University Hospital (UZA)EdegemBelgium
| | - V. Saldien
- Department of AnaesthesiaAntwerp University Hospital (UZA)EdegemBelgium
| | - M. Vercauteren
- Multidisciplinary Pain CentreAntwerp University Hospital (UZA)EdegemBelgium
- Laboratory for Pain ResearchUniversity of Antwerp (UA)WilrijkBelgium
| | - G. Hans
- Department of AnaesthesiaAntwerp University Hospital (UZA)EdegemBelgium
- Multidisciplinary Pain CentreAntwerp University Hospital (UZA)EdegemBelgium
- Laboratory for Pain ResearchUniversity of Antwerp (UA)WilrijkBelgium
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Wildemeersch D, Baeten M, Peeters N, Saldien V, Vercauteren M, Hans G. Pupillary dilation reflex and pupillary pain index evaluation during general anaesthesia: a pilot study. Rom J Anaesth Intensive Care 2018; 25:19-23. [PMID: 29756058 DOI: 10.21454/rjaic.7518.251.wil] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background Pupillary response by pupillary dilatation reflex (PDR) is a robust reflex, even measurable during general anaesthesia. However, the ability of infrared pupillometry to detect PDR differences obtained by intraoperative opioid administration in anaesthesized patients remains largely unknown. We analyzed the performance of automated infrared pupillometry in detecting differences in pupillary dilatation reflex response by a inbuilt standardized nociceptive stimulation program in patients under general anesthesia with a standardized propofol/fentanyl scheme. Methods In this single center, interventional cohort study 38 patients (24-74 years) were enrolled. Patients were anesthetized with propofol until loss of consciousness. Two dynamic pupil measurements were performed in each patient (before opioid administration and after opioid steady state). Automated infrared pupillometry was used to determine PDR during nociceptive stimulations (10-60 mA) applied by a inbuilt pupillary pain index protocol (PPI) to the skin area innervated by the median nerve. Increasing stimulations by protocol are device specific and automatically performed until pupil dilation of > 13%. Pupil characteristics, blood pressure, heart rate values were collected. Results After opioid administration, patients needed a higher stimulation intensity (45.26 mA vs 30.79 mA, p = 0.00001). PPI score showed a reduction after analgesic treatment (5.21 vs 7.68, p = 0.000001), resulting in a 32.16% score reduction. Conclusions PDR via automated increased tetanic stimulation may reflect opioid effect under general anaesthesia. Further research is required to detect possible confounding factors such as medication interaction and optimization of individualized opioid dosage.
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Affiliation(s)
- Davina Wildemeersch
- Department of Anaesthesiology, Antwerp University Hospital, Edegem, Belgium.,Multidisciplinary Pain Centre, Antwerp University Hospital, Edegem, Belgium.,Pain Research Laboratory, University of Antwerp, Edegem, Belgium
| | - Michiel Baeten
- Department of Anaesthesiology, Antwerp University Hospital, Edegem, Belgium
| | - Natasja Peeters
- Department of Anaesthesiology, Antwerp University Hospital, Edegem, Belgium
| | - Vera Saldien
- Department of Anaesthesiology, Antwerp University Hospital, Edegem, Belgium
| | - Marcel Vercauteren
- Multidisciplinary Pain Centre, Antwerp University Hospital, Edegem, Belgium.,Pain Research Laboratory, University of Antwerp, Edegem, Belgium
| | - Guy Hans
- Department of Anaesthesiology, Antwerp University Hospital, Edegem, Belgium.,Multidisciplinary Pain Centre, Antwerp University Hospital, Edegem, Belgium.,Pain Research Laboratory, University of Antwerp, Edegem, Belgium
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von Dincklage F, Jakuscheit A, Weth J, Lichtner G, Jurth C, Rehberg-Klug B. Higher doses of intraoperative analgesia are associated with lower levels of persistent pain and less analgesic consumption six months after total hip arthroplasty. Eur J Pain 2017; 22:691-699. [DOI: 10.1002/ejp.1145] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2017] [Indexed: 11/10/2022]
Affiliation(s)
- F. von Dincklage
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin; Charité - Universitätsmedizin Berlin; Germany
| | - A. Jakuscheit
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin; Charité - Universitätsmedizin Berlin; Germany
| | - J. Weth
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin; Charité - Universitätsmedizin Berlin; Germany
| | - G. Lichtner
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin; Charité - Universitätsmedizin Berlin; Germany
| | - C. Jurth
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin; Charité - Universitätsmedizin Berlin; Germany
| | - B. Rehberg-Klug
- Département d'Anesthésiologie, Pharmacologie et SIC; Hôpitaux Universitaires de Genève HUG; Switzerland
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