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Gavet M, Cardinali M, Bernady A, Ruiz CC, Allaouchiche B, Junot S. Evaluation of the Surgical Pleth Index (SPI) for the monitoring of the nociception-antinociception balance in dogs undergoing castration: A prospective clinical trial. Res Vet Sci 2024; 175:105320. [PMID: 38838512 DOI: 10.1016/j.rvsc.2024.105320] [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: 10/07/2023] [Revised: 05/29/2024] [Accepted: 05/30/2024] [Indexed: 06/07/2024]
Abstract
The aim of this prospective clinical study was to evaluate the efficacy of the Surgical Pleth Index (SPI), a validated nociception monitor in human anaesthesia, in dogs. The technology uses a plethysmographic signal from a specific pulse oximetry probe to analyse pulse wave amplitudes and heartbeat intervals. Twenty-six healthy dogs anaesthetised for castration were included. SPI, invasive mean arterial pressure (MAP) and heart rate (HR) were continuously monitored. The occurrence or resolution of a haemodynamic reaction (HDR), defined as a > 20% increase in HR and/or MAP, was assessed at predefined times: cutaneous incision, testicles' exteriorization, cutaneous suture, and fentanyl administration. Following nociceptive events, the dogs presenting a HDR showed a significant 8% and 10% increase in SPI at 3 and 5 min respectively, whereas after fentanyl administration, a 13% and 16% significant decrease in SPI were noted. Receiver operating characteristic curves analysis indicated a moderate performance for the dynamic variations of SPI over 1 min to predict a HDR (AUC: 0.68, threshold value: +15%) or its resolution after fentanyl administration (AUC of 0.72, threshold value: -15%) within 3 min. The SPI varied according to perioperative nociceptive events and analgesic treatment; however, its performance to anticipate a HDR was limited with high specificity but low sensivity. Refinement of the algorithm to specifically accommodate for the canine species may be warranted. Further studies are required to evaluate the influence of other factors on the performance of this index.
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Affiliation(s)
- Morgane Gavet
- Université de Lyon, Service d'anesthésie, VetAgro Sup, 1 avenue Bourgelat F-69280 Marcy l'Etoile, France.
| | - Martina Cardinali
- Université de Lyon, Service d'anesthésie, VetAgro Sup, 1 avenue Bourgelat F-69280 Marcy l'Etoile, France
| | - Angelique Bernady
- Université de Lyon, Service d'anesthésie, VetAgro Sup, 1 avenue Bourgelat F-69280 Marcy l'Etoile, France
| | - Clara Conde Ruiz
- Université de Lyon, Service d'anesthésie, VetAgro Sup, 1 avenue Bourgelat F-69280 Marcy l'Etoile, France.
| | - Bernard Allaouchiche
- Université de Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 avenue Bourgelat F-69280 Marcy l'Etoile, France; Université de Lyon, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Réanimation Medicale, 165 Chemin du Grand Revoyet, F-69310 Pierre-Bénite, France
| | - Stephane Junot
- Université de Lyon, Service d'anesthésie, VetAgro Sup, 1 avenue Bourgelat F-69280 Marcy l'Etoile, France; Université de Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, VetAgro Sup, 1 avenue Bourgelat F-69280 Marcy l'Etoile, France.
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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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Kuo YW, Chen YT, Lieu AS, Lee MS, Su YF, Lai HC, Wu ZF. Predicting the optimal concentration of remifentanil for skull pin fixation with hemodynamic and analgesia nociception index monitoring. Sci Rep 2024; 14:6441. [PMID: 38499567 PMCID: PMC10948835 DOI: 10.1038/s41598-024-56283-z] [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: 09/29/2023] [Accepted: 03/04/2024] [Indexed: 03/20/2024] Open
Abstract
Inadequate antinociception during skull pin fixation may cause hemodynamic instability in intracranial surgery. The optimal concentration of remifentanil to provide adequate antinociception and stable hemodynamics during skull pin fixation under analgesia nociception index monitoring is unknown. This study is to assess the 90% effective concentration of remifentanil for skull pin fixation under hemodynamic and analgesia nociception index monitoring. Twenty-six patients were enrolled for intracranial surgery, anesthesia was induced and maintained under total intravenous anesthesia using target-controlled infusion for remifentanil and propofol under analgesia nociception index and bispectral index monitoring. Skull pin fixation was performed at different effect-site concentrations of remifentanil required for Dixon's up-and-down method with a step size of 0.5 ng/ml under bispectral index 40-60. Inadequate antinociception is defined when either ANI < 30 or > 20% in hemodynamic changes from baseline (e.g. heart rate > 100 beats/min, or blood pressure > 180/100 mmHg) and the effect-site concentration of remifentanil is considered as failure. It is considered success as ANI > 30 and < 20% hemodynamic changes from baseline simultaneously. Seven pairs of failure/success were used for probit analysis. The 90% effective concentration of remifentanil for skull pin fixation with adequate antinociception and hemodynamic stability was 4.7 ng/ml.
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Affiliation(s)
- Yi-Wei Kuo
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzyou 1st Rd., Sanmin Dist., Kaohsiung City, 80756, Taiwan, ROC
| | - Ying-Tzu Chen
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzyou 1st Rd., Sanmin Dist., Kaohsiung City, 80756, Taiwan, ROC
| | - Ann-Shung Lieu
- Department of Surgery, Division of Neurosurgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Meei-Shyuan Lee
- School of Public Health, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Yu-Feng Su
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzyou 1st Rd., Sanmin Dist., Kaohsiung City, 80756, Taiwan, ROC
| | - Hou-Chuan Lai
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, #325, Section 2, Chenggung Road, Neihu 114, Taipei, Taiwan, ROC.
| | - Zhi-Fu Wu
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzyou 1st Rd., Sanmin Dist., Kaohsiung City, 80756, Taiwan, ROC.
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, #325, Section 2, Chenggung Road, Neihu 114, Taipei, Taiwan, ROC.
- Department of Anesthesiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC.
- Center for Regional Anesthesia and Pain Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan, ROC.
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Talke P, Talke I. Effect of the Location of Tetanic Stimulation on Autonomic Responses: A Randomized Cross-Over Pilot Study. J Pain Res 2024; 17:209-217. [PMID: 38223663 PMCID: PMC10787570 DOI: 10.2147/jpr.s443058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/28/2023] [Indexed: 01/16/2024] Open
Abstract
Background Tetanic stimuli are used as standardized noxious inputs to investigate nociception. Previous studies have applied tetanic stimuli to various anatomical locations without validating that the resulting physiological responses were independent of the location where tetanic stimuli were applied. Our aim was to investigate the effects of three anatomical tetanic stimulus application sites on physiological variables reflecting autonomic nervous system responses as measured by photoplethysmography (PPG). Methods Under general anesthesia, a five second, 100 hertz, 70 milliamp tetanic stimulus was applied to the ulnar nerve, medial side of the tibia, and thorax (T5 dermatome) (N=12). The effect of tetanic stimuli on PPG-derived variables (AC, DC, and ACDC) and pulse rate at each stimulus location was determined using repeated-measures analysis of variance (ANOVA) followed by Dunnett's post hoc test. Maximum tetanic stimulus-induced changes in PPG-derived variables and pulse rates were compared among the three stimulus locations using ANOVA. Results AC and ACDC values of PPG decreased, and the DC values of PPG increased in response to tetanic stimuli-induced vasoconstriction at each location (p<0.001 for all). The maximum changes in the AC, ACDC, and DC values did not differ between locations (p=NS). There were no significant changes in pulse rate (p=NS). Conclusion The results showed that tetanic stimulation at either of these three locations provides the same autonomic nervous system responses, as measured by PPG. Clinical Trial Registration ClinicalTrials.gov; NCT03648853.
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Affiliation(s)
- Pekka Talke
- Department of Anesthesia and Perioperative Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Isabel Talke
- California Polytechnic State University, San Luis Obispo, CA, USA
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Yang L, Wang X, Wen H. Evaluation of the effectiveness of analgesia nociception index (ANI) predictability for surgical stimuli under personal analgesic sufficiency status (PASS) measured by pre-tetanus-induced ANI: a pilot study. J Clin Monit Comput 2023; 37:1585-1591. [PMID: 37418059 DOI: 10.1007/s10877-023-01044-y] [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: 03/25/2023] [Accepted: 06/09/2023] [Indexed: 07/08/2023]
Abstract
The Analgesia Nociception Index (ANI) is a promising monitor to evaluate the balance of nociception and anti-nociception based on heart rate variability. This prospective, interventional, monocentric pilot study aimed to verify the effectiveness of the personal analgesic sufficiency status (PASS) measured by pre-tetanus-induced ANI variation for surgical stimuli. After Ethics approval and informed consent, participants were anesthetized with sevoflurane and increased effect-site concentrations of remifentanil step by step (2, 4, 6 ng ml-1). At each concentration, a standardized tetanic stimulus was applied (5 s, 60 mA, 50 Hz) with no other noxious stimuli presented. Through all the concentrations, defined the lowest concentration when ANI ≥ 50 as the PASS after tetanic stimuli. The surgical stimulus was conducted under at least 5-min of PASS. Thirty-two participants were analyzed. ANI, systolic blood pressure (SBP), and Heart rate (HR) except the Bispectral Index (BIS) were significantly changed at 2 ng ml-1 after tetanic stimuli, only ANI and SBP were significantly altered at 4 and 6 ng ml-1. ANI could predict inadequate analgesia status (an increase in SBP or HR of more than 20% from the baseline) at 2 and 4 ng ml-1 (P = 0.044, P = 0.049, respectively), but not at 6 ng ml-1. The PASS under pre-tetanus-induced ANI identification didn't meet the analgesic needs under surgical stimuli. Further investigations are required to provide a reliable prediction of individualized analgesia by objective nociception monitors.Trial registration NCT05063461.
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Affiliation(s)
- Lina Yang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Xiaojie Wang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Hong Wen
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China.
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Nagata O, Matsuki Y, Matsuda S, Hazama K, Fukunaga S, Nakatsuka H, Yasuma F, Maehara Y, Fujioka S, Tajima K, Kondo I, Ginoza I, Hayashi M, Kakinohana M, Shigemi K. Anesthesia Management via an Automated Control System for Propofol, Remifentanil, and Rocuronium Compared to Management by Anesthesiologists: An Investigator-Initiated Study. J Clin Med 2023; 12:6611. [PMID: 37892749 PMCID: PMC10607889 DOI: 10.3390/jcm12206611] [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: 09/10/2023] [Revised: 10/09/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND We previously developed an automated total intravenous anesthesia control system that uses new closed-loop system algorithms to administer propofol, remifentanil, and rocuronium based on the bispectral index and train-of-four data. We recently improved this automated control system by adding a safety mechanism and using a modified monitoring device. METHODS Patients scheduled for elective surgery were randomly assigned to closed-loop feedback control (automatic group) or the manual administration of propofol, remifentanil, and rocuronium (manual group). The proportion of time during which the proper management of three-agent anesthesia was maintained during surgery was determined as the primary endpoint. RESULTS The proportion of time during which the three components of sedation, analgesia, and muscle relaxation were adequately controlled was 87.21 ± 12.79% in the automatic group, which was non-inferior to the proportion of 65.19 ± 20.16% in the manual group (p < 0.001). Adverse events during the operative or postoperative observation periods were significantly less frequent in the automatic group (54 patients, 90.0%) than in the manual group (60 patients, 100.0%; p = 0.027). CONCLUSION Our three-agent automated control system, which features an improved muscle relaxation monitor and safety mechanism added to the basic control algorithms, maintained sedation, analgesia, and muscle relaxation appropriately in a manner non-inferior to anesthesiologists without compromising safety.
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Affiliation(s)
- Osamu Nagata
- Department of Anesthesiology and Reanimatology, University of Fukui, Fukui 910-1193, Japan; (O.N.)
| | - Yuka Matsuki
- Department of Anesthesiology and Reanimatology, University of Fukui, Fukui 910-1193, Japan; (O.N.)
| | - Shuko Matsuda
- Department of Anesthesiology and Reanimatology, University of Fukui, Fukui 910-1193, Japan; (O.N.)
| | - Keita Hazama
- Department of Anesthesiology and Intensive Care Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima 730-8518, Japan
| | - Saiko Fukunaga
- Department of Anesthesiology and Intensive Care Medicine, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Hideki Nakatsuka
- Department of Anesthesiology and Intensive Care Medicine, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Fumiyo Yasuma
- Department of Anesthesiology, Center Hospital of the National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Yasuhiro Maehara
- Department of Anesthesiology, Center Hospital of the National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Shoko Fujioka
- Departments of Anesthesiology, The Jikei University School of Medicine, Tokyo 105-8461, Japan
| | - Karin Tajima
- Departments of Anesthesiology, The Jikei University School of Medicine, Tokyo 105-8461, Japan
| | - Ichiro Kondo
- Departments of Anesthesiology, The Jikei University School of Medicine, Tokyo 105-8461, Japan
| | - Itaru Ginoza
- Department of Anesthesiology, University of the Ryukyu, Okinawa 903-0213, Japan
| | - Misuzu Hayashi
- Department of Anesthesiology, University of the Ryukyu, Okinawa 903-0213, Japan
| | - Manabu Kakinohana
- Department of Anesthesiology, University of the Ryukyu, Okinawa 903-0213, Japan
| | - Kenji Shigemi
- Department of Anesthesiology and Reanimatology, University of Fukui, Fukui 910-1193, Japan; (O.N.)
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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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Hum B, Christophides A, Jin Z, Elias M, Taneja K, Bergese SD. The validity and applications of the analgesia nociception index: a narrative review. Front Surg 2023; 10:1234246. [PMID: 37638120 PMCID: PMC10448251 DOI: 10.3389/fsurg.2023.1234246] [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: 06/03/2023] [Accepted: 07/31/2023] [Indexed: 08/29/2023] Open
Abstract
Pain refers to the subjective, unpleasant experience that is related to illness or injury. In contrast to pain, nociception refers to the physiological neural processing of noxious stimuli, such as intra-operative surgical stimuli. One novel device, the Analgesia Nociception Index (ANI), aims to objectively measure intra-operative nociception by analyzing the heart rate variability in patients undergoing surgery. Through this method of nociceptive monitoring, the ANI device aims to provide an objective, continuous evaluation of patient comfort levels and allow anesthesiologists to better manage surgical stress and patient analgesia, perhaps with even better efficacy than current practices used to assess nociception. Additionally, ANI may have clinical application in settings outside of the operating room, such as in the intensive care unit. In this narrative review, we compiled and summarized the findings of many studies that have investigated ANI's validity and applications in different clinical settings. Currently, the literature appears mostly supportive of ANI's ability to detect nociception in both surgical and non-surgical settings. However, the ability for ANI to provide clinical benefits, such as decreased intra-operative opioid use, post-operative opioid use, and post-operative pain compared to standard practices appear controversial. Because of the wide variety of methodology, clinical settings, patient populations, and limitations in these studies, more investigation of ANI is needed before any firm conclusions can be drawn on its clinical benefits.
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Affiliation(s)
- Bill Hum
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, United States
| | - Alexa Christophides
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, United States
| | - Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, United States
| | - Murad Elias
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, United States
| | - Kamil Taneja
- Medical Scientist Training Program, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States
| | - Sergio D. Bergese
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, United States
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Ruíz-López P, Domínguez JM, Morgaz J, Quirós-Carmona S, Navarrete-Calvo R, Gómez-Villamandos RJ, Fernández-Sarmiento JA, Granados MM. Evaluation of the Averaged Parasympathetic Tone Activity and Its Dynamic Variation to Assess Intraoperative Nociception in Relation to Hemodynamic Changes in Dogs. Vet Q 2023:1-19. [PMID: 37467574 PMCID: PMC10367571 DOI: 10.1080/01652176.2023.2239311] [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: 12/08/2022] [Revised: 05/15/2023] [Accepted: 07/15/2023] [Indexed: 07/21/2023] Open
Abstract
This study aimed to determine the performance of the averaged parasympathetic tone activity (PTAm) and its dynamic variation (ΔPTA) to assess intraoperative nociception in relation to heart rate (HR) and direct mean arterial pressure (MAP) in dogs undergoing laparoscopic ovariectomy. This prospective, observational, clinical study included 32 bitches. The PTAm, HR, MAP, and bispectral index (BIS) were assessed before (pre-stimulus), as well as 1 min and 2 min after, four surgical stimuli: insufflation, introduction of trocars, and removal of the left and right ovaries. A two-way ANOVA was performed to compare PTAm, HR, MAP, and BIS data across surgical stimuli. A ≥20% drop in PTAm or a ≥20% increase in HR and/or MAP regarding the pre-stimulus values was considered a PTAm-drop and/or a hemodynamic response, respectively. The performance of PTAm pre-stimulus, PTAm 1 min, and ΔPTA in predicting the hemodynamic response was assessed by calculation of the area under the receiver operating characteristic (ROC) curve. At insufflation, PTAm decreased after 1 (p = 0.010) and 2 (p = 0.045)min, and ΔPTA was different (p = 0.005) between dogs that presented hemodynamic response and dogs that did not. At PTAm-drop, MAP increased after 1 min (p = 0.001) and 2 min (p = 0.001) with respect to pre-stimulus value, whereas HR and BIS did not change. ROC curves showed a threshold value of PTAm pre-stimulus ≤51 to detect hemodynamic response (sensitivity 69%, specificity 52%). The PTAm and ΔPTA only assessed intraoperative nociception during insufflation. The PTAm pre-stimulus association to the hemodynamic response in anaesthetized dogs showed poor sensitivity and no specificity.
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Affiliation(s)
- Patricia Ruíz-López
- Department of Large Animal Surgery, Anaesthesia and Orthopedics, Faculty of Veterinary Medicine, University of Ghent, 9820 Merelbeke, Belgium
| | - Juan Manuel Domínguez
- Animal Medicine and Surgery Department, Faculty of Veterinary Medicine, University of Cordoba, 14014 Cordoba, Spain
| | - Juan Morgaz
- Animal Medicine and Surgery Department, Faculty of Veterinary Medicine, University of Cordoba, 14014 Cordoba, Spain
| | - Setefilla Quirós-Carmona
- Animal Medicine and Surgery Department, Faculty of Veterinary Medicine, University of Cordoba, 14014 Cordoba, Spain
| | - Rocío Navarrete-Calvo
- Animal Medicine and Surgery Department, Faculty of Veterinary Medicine, University of Cordoba, 14014 Cordoba, Spain
| | | | | | - M M Granados
- Animal Medicine and Surgery Department, Faculty of Veterinary Medicine, University of Cordoba, 14014 Cordoba, Spain
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10
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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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Chemam S, Cailliau E, Bert D, Tavernier B, Constant I, Sabourdin N. Nociception level response to calibrated stimulations in children: First assessment of the nociception level index in pediatric anesthesia. Anaesth Crit Care Pain Med 2023; 42:101207. [PMID: 36863410 DOI: 10.1016/j.accpm.2023.101207] [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: 11/21/2022] [Revised: 02/16/2023] [Accepted: 02/20/2023] [Indexed: 03/04/2023]
Abstract
INTRODUCTION Intraoperative monitoring of nociception has made great progress in adult anesthesia. However, pediatric data are scarce. The Nociception Level (NOL) is one of the most recent indexes of nociception. Its originality is that it provides a multiparametric assessment of nociception. In adults, NOL monitoring allowed lower perioperative opioid requirements, hemodynamic stability, and qualitative postoperative analgesia. So far, the NOL has never been used in children. Our objective was to validate the ability of NOL to provide a quantitative assessment of nociception in anesthetized children. METHODS In 5-12 years old children anesthetized with sevoflurane and alfentanil (10 µg kg-1), before surgical incision, we performed three standardized tetanic stimulations (5 s, 100 Hz) of different intensities (10-30-60 mA) in a randomized order. NOL, heart rate, blood pressure and Analgesia-Nociception Index variations were assessed after each stimulation. RESULTS Thirty children were included. Data were analyzed with a covariance pattern linear mixed regression model. NOL increased after the stimulations (p < 0.05 at each intensity). NOL response was influenced by stimulation intensity (p < 0.001). Heart rate and blood pressure were barely modified by the stimulations. Analgesia-Nociception Index decreased after the stimulations (p < 0.001 at each intensity). Analgesia-Nociception index response was not influenced by stimulation intensity (p = 0.064). NOL and Analgesia-Nociception Index responses were significantly correlated (Pearson r = 0.47; p < 0.001). CONCLUSIONS NOL allows a quantitative assessment of nociception under anesthesia in 5-12 years-old children. This study provides a solid basis for all future investigations on NOL monitoring in pediatric anesthesia. REGISTRATION NCT05233449.
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Affiliation(s)
- Sarah Chemam
- Department of Anesthesiology and Intensive Care, CHU Armand Trousseau, GRC 29, Sorbonne University, APHP, 75012 Paris, France; University of Paris EA 7323: Pharmacologie et Evaluation des Thérapeutiques chez l'Enfant et la Femme Enceinte, 75006 Paris, France
| | | | - Dina Bert
- Department of Anesthesiology and Intensive Care, CHU Lille, Pôle d'Anesthésie-Réanimation, 59000 Lille, France
| | - Benoît Tavernier
- Department of Anesthesiology and Intensive Care, CHU Lille, Pôle d'Anesthésie-Réanimation, 59000 Lille, France; University of Lille, ULR 2694 - METRICS: Évaluation des Technologies de santé et des Pratiques médicales, CHU Lille, 59000 Lille, France
| | - Isabelle Constant
- Department of Anesthesiology and Intensive Care, CHU Armand Trousseau, GRC 29, Sorbonne University, APHP, 75012 Paris, France; University of Paris EA 7323: Pharmacologie et Evaluation des Thérapeutiques chez l'Enfant et la Femme Enceinte, 75006 Paris, France
| | - Nada Sabourdin
- Department of Anesthesiology and Intensive Care, CHU Armand Trousseau, GRC 29, Sorbonne University, APHP, 75012 Paris, France; University of Paris EA 7323: Pharmacologie et Evaluation des Thérapeutiques chez l'Enfant et la Femme Enceinte, 75006 Paris, France.
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12
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Adequacy of Anaesthesia for Nociception Detection during Vitreoretinal Surgery. Life (Basel) 2023; 13:life13020505. [PMID: 36836862 PMCID: PMC9967373 DOI: 10.3390/life13020505] [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: 11/10/2022] [Revised: 01/27/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
Vitreoretinal surgery (VRS) is one of the most widely performed precise procedures in ophthalmic surgery; the majority of cases are carried out under regional anaesthesia (RA) only. However, in specific situations (such as when the patient fails to cooperate with the operator for various reasons), general anaesthesia (GA), alone or in combination with GA (combined general-regional anaesthesia, CGR), is the only safe way to perform VRS. While monitoring the efficacy of an intraoperative rescue opioid analgesia (IROA) during surgery (assessing the adequacy of anaesthesia (AoA)) may be challenging, the surgical pleth index (SPI) is a useful tool for detecting the reaction to noxious stimuli and allows for the rational titration of opioid analgesics (AO) during surgery. The current study investigated the influence of the SPI-based titration of fentanyl (FNT) in combination with various pre-emptive analgesia (PA) techniques on intraoperative pain perception during various stages of VRS performed under AoA. A total of 176 patients undergoing VRS under GA were enrolled in the study. They were randomly assigned to one of the five following study arms: Group GA (control group)-patients who received general anaesthesia alone; Group PBB-GA with preprocedural peribulbar block (with 0.5% bupivacaine and 2% lidocaine); Group T-GA with preventive, topical 2% proparacaine; Group M-GA with a preprocedural intravenous infusion of 1.0 g of metamizole; and Group P-GA with a preprocedural intravenous infusion of 1.0 g of paracetamol. The whole procedure was divided in four stages: Stage 1 and 2-preoperative assessment, PA administration, and the induction of GA; Stage 3-intraoperative observation; Stage 4-postoperative observation. the SPI values were monitored during all stages. The occurrence of nociception (expressed as ∆SPI >15) during various manipulations in the surgical field was observed, as were cumulative doses of rescue analgesia, depending on the PA administered. During the course of VRS, rescue FNT doses varied depending on the stage of surgery and the group investigated. The majority of patients, regardless of their group allocation, needed complementary analgesia during trocar insertion, with Group GA patients requiring the highest doses. Likewise, the highest cumulative doses of IROA were noted during endophotocoagulation in Group GA. Preventive PBB and topical anaesthesia were proven to be most efficient in blunting the response to speculum installation, while topical anaesthesia and paracetamol infusion were shown to be more efficient analgesics during endophotocoagulation than other types used PA. In the performed study, none of the PA techniques used were superior to GA with FNT dosing under the SPI with respect to providing efficient analgesia throughout the whole surgery; there was a necessity to administer a rescue OA dose in both the control and investigated groups.
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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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Lai HC, Lai MF, Huang YH, Yu JC, Tseng WC, Wu ZF. Comparison of Single Target-Controlled Infusion Pump-Delivered Mixed Propofol and Remifentanil with Two Target-Controlled Infusion Pumps-Delivered Propofol and Remifentanil in Patients Undergoing Breast Cancer Surgery-A Prospective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2094. [PMID: 36767461 PMCID: PMC9915350 DOI: 10.3390/ijerph20032094] [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: 12/05/2022] [Revised: 01/14/2023] [Accepted: 01/20/2023] [Indexed: 06/18/2023]
Abstract
Total intravenous anesthesia (TIVA) with remifentanil and propofol (RP) is considered to be an ideal type of general anesthesia (GA) for pediatric and adult patients undergoing medical procedures. However, delivery of an RP mixture by target-controlled infusion (TCI) for GA in surgical procedures has not been described. We investigated the merit of this approach for breast cancer surgery. Eighty-four patients (n = 42 per group) were randomly allocated to propofol and remifentanil either delivered by separate TCI pumps (S group) or in an RP mixture by a single TCI pump (M group). Dosages were adjusted based on the bispectral index (BIS) and the analgesia nociception index (ANI). The primary outcomes were adequate anesthesia (BIS 40-60 and ANI 50-70, respectively), acceptable hemodynamic fluctuations (<30% of baseline) with less frequent TCI pump adjustments, bolus injections of anesthetics, and total consumption of anesthetics during the procedure. The secondary endpoints included time of emergence from anesthesia, patient satisfaction, postoperative pain, rescue with opioids, and adverse events. The characteristics of patients, hemodynamic parameters, BIS and ANI scores, duration of surgery, anesthesia, and emergence were not significantly different between groups. The adjustment frequency of TCI was significantly higher in the S group (3 (range 0-6) vs. 2 (0-6) times; p = 0.005). The total dosage of anesthetics, pain rating, patient satisfaction, need for opioids postoperatively, and incidence of adverse events were not significantly different. We have demonstrated that this RP mixture provided adequate hypnotic and analgesic effects under BIS and ANI monitoring in patients undergoing breast cancer surgery within 1 h.
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Affiliation(s)
- Hou-Chuan Lai
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei 11490, Taiwan
| | - Meng-Fu Lai
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei 11490, Taiwan
| | - Yi-Hsuan Huang
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei 11490, Taiwan
| | - Jyh-Cherng Yu
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital and National Defense Medical Center, Taipei 11490, Taiwan
| | - Wei-Cheng Tseng
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei 11490, Taiwan
| | - Zhi-Fu Wu
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei 11490, Taiwan
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80756, Taiwan
- Department of Anesthesiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Center for Regional Anesthesia and Pain Medicine, Wan Fang Hospital, Taipei Medical University, Taipei 11696, Taiwan
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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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Predicting personalised remifentanil effect site concentration for surgical incision using the nociception level index: A prospective calibration and validation study. Eur J Anaesthesiol 2022; 39:918-927. [PMID: 36125017 DOI: 10.1097/eja.0000000000001751] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Inadequate antinociception can cause haemodynamic instability. The nociception level (NOL) index measures response to noxious stimuli, but its capacity to predict optimal antinociception is unknown. OBJECTIVE To determine if NOL index change to a tetanic stimulus in cardiac and noncardiac surgery patients could predict the required remifentanil concentration for haemodynamic stability at skin incision. DESIGN A prospective two-phase cohort study. SETTING University hospital. PATIENTS Patients undergoing remifentanil-propofol target controlled infusion (TCI) anaesthesia. INTERVENTIONS During the calibration phase, investigators evaluated the tetanic stimulus induced NOL index change under standardised TCI remifentanil-propofol anaesthesia during a no-touch period [bispectral index (BIS) between 40 and 60, NOL index under 15]. If the NOL index change was 20 or greater following tetanic stimulation, investigators repeated the tetanus at higher remifentanil concentrations until the response was blunted. Surgeons incised the skin at this remifentanil concentration. The investigators derived a prediction model and in the validation phase calculated, using the NOL response to a single tetanus, the required incision remifentanil concentration for the start of surgery. MAIN OUTCOME Haemodynamic stability at incision [i.e. maximum heart rate (HR) < 20% increase from baseline, minimum HR (40 bpm) and mean arterial pressure (MAP) ± <20% of baseline]. RESULTS During the calibration phase, no patient had hypertension. Two patients had a HR increase slightly greater than 20% (25.4 and 26.7%) within the first 2 min of surgery, but neither of these two patients had a HR above 76 bpm. Two patients were slightly hypotensive after incision (MAP 64 and 73 mmHg). During the validation phase, neither tachycardia nor hypotension occurred, but MAP increased to 21.5% above baseline for one patient. CONCLUSION During a no-touch period in patients under steady-state general anaesthesia [propofol effect site concentration (Ce) required for BIS between 40 and 60], the NOL index response to a tetanic stimulus under remifentanil antinociception can be used to personalise remifentanil Ce for the start of surgery and ensure stable haemodynamics. TRIAL REGISTRATION ClinicalTrials.gov: NCT03324269.
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Jean WH, Sutikno P, Fan SZ, Abbod MF, Shieh JS. Comparison of Deep Learning Algorithms in Predicting Expert Assessments of Pain Scores during Surgical Operations Using Analgesia Nociception Index. SENSORS (BASEL, SWITZERLAND) 2022; 22:5496. [PMID: 35897999 PMCID: PMC9330343 DOI: 10.3390/s22155496] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/10/2022] [Accepted: 07/18/2022] [Indexed: 06/15/2023]
Abstract
There are many surgical operations performed daily in operation rooms worldwide. Adequate anesthesia is needed during an operation. Besides hypnosis, adequate analgesia is critical to prevent autonomic reactions. Clinical experience and vital signs are usually used to adjust the dosage of analgesics. Analgesia nociception index (ANI), which ranges from 0 to 100, is derived from heart rate variability (HRV) via electrocardiogram (ECG) signals, for pain evaluation in a non-invasive manner. It represents parasympathetic activity. In this study, we compared the performance of multilayer perceptron (MLP) and long short-term memory (LSTM) algorithms in predicting expert assessment of pain score (EAPS) based on patient's HRV during surgery. The objective of this study was to analyze how deep learning models differed from the medical doctors' predictions of EAPS. As the input and output features of the deep learning models, the opposites of ANI and EAPS were used. This study included 80 patients who underwent operations at National Taiwan University Hospital. Using MLP and LSTM, a holdout method was first applied to 60 training patients, 10 validation patients, and 10 testing patients. As compared to the LSTM model, which had a testing mean absolute error (MAE) of 2.633 ± 0.542, the MLP model had a testing MAE of 2.490 ± 0.522, with a more appropriate shape of its prediction curves. The model based on MLP was selected as the best. Using MLP, a seven-fold cross validation method was then applied. The first fold had the lowest testing MAE of 2.460 ± 0.634, while the overall MAE for the seven-fold cross validation method was 2.848 ± 0.308. In conclusion, HRV analysis using MLP algorithm had a good correlation with EAPS; therefore, it can play role as a continuous monitor to predict intraoperative pain levels, to assist physicians in adjusting analgesic agent dosage. Further studies may consider obtaining more input features, such as photoplethysmography (PPG) and other kinds of continuous variable, to improve the prediction performance.
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Affiliation(s)
- Wei-Horng Jean
- Department of Mechanical Engineering, Yuan Ze University, Taoyuan 320, Taiwan; (W.-H.J.); (P.S.)
- Department of Anesthesiology, Far Eastern Memorial Hospital, Banqiao District, New Taipei City 220, Taiwan
| | - Peter Sutikno
- Department of Mechanical Engineering, Yuan Ze University, Taoyuan 320, Taiwan; (W.-H.J.); (P.S.)
| | - Shou-Zen Fan
- Department of Anesthesiology, College of Medicine, National Taiwan University, Taipei 100, Taiwan;
- Department of Anesthesiology, En Chu Kong Hospital, New Taipei City 237, Taiwan
| | - Maysam F. Abbod
- Department of Electronics and Electrical Engineering, Brunel University London, London UB8 3PH, UK
| | - Jiann-Shing Shieh
- Department of Mechanical Engineering, Yuan Ze University, Taoyuan 320, Taiwan; (W.-H.J.); (P.S.)
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Lebrun S, Boccara J, Cailliau E, Herbet M, Tavernier B, Constant I, Sabourdin N. Quantitative assessment of a pediatric nociception monitor in children under sevoflurane anesthesia. Reg Anesth Pain Med 2022; 47:rapm-2022-103547. [PMID: 35654480 DOI: 10.1136/rapm-2022-103547] [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: 02/03/2022] [Accepted: 04/26/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Intraoperative monitoring of nociception has recently made substantial progress in adult anesthesia. In contrast, pediatric data are scarce. Newborn-Infant Parasympathetic Evaluation (NIPE index, Mdoloris Medical Systems, Loos, France) is the first nociception index specifically designed for young children. It is a dimensionless index comprised between 0 and 100. Two previous studies suggested that NIPE could indeed 'detect' nociception in anesthetized children. The objective of our study was to investigate if NIPE allowed to detect and to provide a quantitative assessment of nociception in children. METHODS Children were anesthetized with sevoflurane, and received a bolus of alfentanil (10 µg/kg before intubation). Before surgical incision, each participant received three tetanic stimulations (5 s, 100 Hertz) with a 5 min interval, in a randomized order: 10, 30 and 60 milliamps. NIPE and heart rate variations were assessed after each stimulation. RESULTS Thirty children (2.4±1.6 years) were included. Mean delay between alfentanil and the first stimulation was 19±4 min. Mean baseline NIPE was 75±10. NIPE variation after the stimulations was significant at 10, 30 and 60 mA (linear mixed regression model, p<0.001). The intensity of stimulation significantly influenced the amplitude of NIPE variation (linear mixed regression model p<0.001), but had no statistically significant effect on heart rate variation (p=0.52). DISCUSSION NIPE might allow a quantitative assessment of nociception in young children in these anesthetic conditions. This study provides a basis for future research investigating the potential benefits of NIPE-guided intraoperative analgesia in pediatric anesthesia. TRIAL REGISTRATION NUMBER NCT04381637.
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Affiliation(s)
- Sebastien Lebrun
- Anesthesiology, CHU Armand Trousseau, GRC 29, Sorbonne University, APHP, Paris, France
- EA 7323: Pharmacologie et Evaluation des Thérapeutiques chez L'enfant et la Femme Enceinte, University of Paris, Paris, France
| | - Johanna Boccara
- Anesthesiology, CHU Armand Trousseau, GRC 29, Sorbonne University, APHP, Paris, France
| | | | | | - Benoit Tavernier
- Anesthesiology, CHU Lille, Pôle d'Anesthésie-Réanimation, Lille, France
- ULR 2694 - METRICS: Évaluation des Technologies de santé et des Pratiques médicales, University of Lille, Lille, France
| | - Isabelle Constant
- Anesthesiology, CHU Armand Trousseau, GRC 29, Sorbonne University, APHP, Paris, France
- EA 7323: Pharmacologie et Evaluation des Thérapeutiques chez L'enfant et la Femme Enceinte, University of Paris, Paris, France
| | - Nada Sabourdin
- Anesthesiology, CHU Armand Trousseau, GRC 29, Sorbonne University, APHP, Paris, France
- EA 7323: Pharmacologie et Evaluation des Thérapeutiques chez L'enfant et la Femme Enceinte, University of Paris, Paris, France
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Abstract
PURPOSE OF REVIEW Monitoring of intraoperative nociception has made substantial progress in adult anesthesia during the last 10 years. Several monitors have been validated and their use has been associated with intraoperative or postoperative benefits in the adult population. In pediatric anesthesia, less data are available. However, several recent publications have assessed the performance of nociception monitors in children, and investigated their potential benefits in this context. This review will describe the main validated intraoperative nociception monitors, summarize adult findings and describe the available pediatric data. RECENT FINDINGS Six intraoperative nociception indices were included in this review. Among them, four have shown promising results in children: Surgical Pleth Index (GE-Healthcare, Helsinki, Finland), Analgesia-Nociception Index (Mdoloris Medical Systems, Loos, France), Newborn-Infant Parasympathetic Evaluation (Mdoloris Medical Systems), and Pupillometry (IDMED, Marseille, France). The relevance of Skin Conductance (MedStorm innovations, AS, Oslo, Norway) under general anesthesia could not be established. Finally, the Nociception Level (Medasense, Ramat Gan, Israel) still requires to be investigated in children. SUMMARY To date, four monitors may provide a relevant assessment of intraoperative nociception in children. However, the potential clinical benefits associated with their use to guide analgesia remain to be demonstrated.
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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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Zheng ZH, Yeh TT, Yeh CC, Lin PA, Wong CS, Lee PY, Lu CH. Multimodal Analgesia with Extended-Release Dinalbuphine Sebacate for Perioperative Pain Management in Upper Extremity Trauma Surgery: A Retrospective Comparative Study. Pain Ther 2022; 11:643-653. [PMID: 35426567 PMCID: PMC9098781 DOI: 10.1007/s40122-022-00383-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/25/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Patients undergoing upper extremity fracture surgery (UEFS) commonly suffer from unbearable acute pain. Opioids remain the mainstay of moderate to severe pain alleviation, although there is a growing concern regarding the increasing trend in misuse and abuse. This study aimed to observe the safety and efficacy of dinalbuphine sebacate (DS), a novel extended-release analgesic, along with multimodal analgesia (MMA) for post-UEFS pain control. Methods We retrospectively reviewed the records of patients undergoing UEFS between August 2020 and January 2021. Eligible patients were included and divided into two groups, depending on the analgesic regimen. In the DS group, 150 mg DS was administered intramuscularly at least 12 h pre-operatively, while in the conventional analgesia (CA) group, 40 mg parecoxib was given within 3 h before surgery. Intraoperative fentanyl administration was guided by the Analgesia Nociception Index System in both groups. For breakthrough pain, fentanyl was used as rescue medicine in the postanaesthesia care unit while tramadol and parecoxib were administered in the ward. Results Forty-nine patients were allocated to the DS group and 60 patients were allocated to the CA group. In comparison with the CA group, the proportion of patients requiring opioids for breakthrough pain post-operatively was significantly lower in the DS group (fentanyl: 31% vs. 68%, p < 0.001; tramadol: 27% vs. 70%, p < 0.001). The DS group also consumed lower amounts of post-operative rescue opioids. Furthermore, both mean worst and least pain scores were significantly lower in the DS group from post-operative day (POD) 1 to POD 5. There was no significant difference in intraoperative consumption of fentanyl or incidence of adverse events. Conclusion This result suggests that extended-release DS is a suitable analgesic incorporated in MMA and a promising solution to the misuse and abuse of opioids.
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Ruíz-López P, Morgaz J, Quirós-Carmona S, Navarrete-Calvo R, Domínguez JM, Gómez-Villamandos RJ, Granados MM. Parasympathetic Tone Changes in Anesthetized Horses after Surgical Stimulation, and Morphine, Ketamine, and Dobutamine Administration. Animals (Basel) 2022; 12:ani12081038. [PMID: 35454284 PMCID: PMC9027407 DOI: 10.3390/ani12081038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/13/2022] [Accepted: 04/15/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary A parasympathetic tone activity (PTA) monitor has been developed similar to the analgesia nociception index (ANI) used in human medicine to evaluate the changes in the autonomic nervous system based on heart rate variability. The autonomic nervous system acts unconsciously and regulates body functions (autonomic response). Examples of autonomic response are decreases of heart rate or/and blood pressure due to an increase of parasympathetic tone activity. It is important to know how stimuli and medication may affect the autonomic nervous system since they can modify heart rate and blood pressure. This study attempts to find how a surgical nociceptive stimulus, along with the administration of medication frequently used in horses, can affect mean parasympathetic tone activity (PTAm) (one of the values of the PTA monitor), heart rate and blood pressure in clinically anesthetized horses. Values of the PTAm, heart rate, and blood pressure were registered before and after surgical incision and after the administration of morphine, ketamine, and dobutamine at defined time points. No changes were found after the incision or the administration of morphine and dobutamine. It seems that only ketamine affects the autonomic nervous system by decreasing PTAm. Abstract Autonomic nervous system (ANS) activity can modify cardiovascular parameters in response to nociceptive stimuli or drugs in anesthetized animals. The aim of this study was to determine if a surgical nociceptive stimulus and morphine, ketamine, and dobutamine administration would modify ANS activity observed as a change in the mean parasympathetic tone activity (PTAm) in anesthetized horses. In 20 anesthetized horses, heart rate (HR), mean arterial pressure (MAP), and PTAm were monitored before and 1, 3, and 5 min after surgical incision, and before and 10 min after the administration of morphine (0.2 mg/kg IV). If nystagmus or spontaneous ventilation was observed, ketamine (0.5 mg/kg IV) was given, and the three variables were registered before and 3 and 5 min afterward. If MAP reached ≤62 mmHg, a dobutamine infusion was administered, and the three variables were recorded before and 5 min after starting/increasing the infusion (0.25 μg/kg/min IV every 5 min). The three variables were registered before and 1, 3, and 5 min after a PTAm decrease of ≥20%, HR increase of ≥10%, or MAP increase of ≥20%. The PTAm decreased 3 min after the administration of ketamine and 1 min after a PTA event. The surgical incision, dobutamine, and morphine did not modify PTAm. The absence of changes in ANS activity after the nociceptive stimulus and lack of correlation between PTAm and HR or MAP suggest that PTAm is a poor indicator of sympathetic activation under the study conditions. Ketamine seems to affect ANS activity by decreasing PTAm.
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Affiliation(s)
- Patricia Ruíz-López
- Department of Surgery and Anesthesia of Domestic Animals, Faculty of Veterinary Medicine, University of Ghent, 9820 Merelbeke, Belgium
- Correspondence: (P.R.-L.); (J.M.)
| | - Juan Morgaz
- Animal Medicine and Surgery Department, Faculty of Veterinary Medicine, University of Córdoba, 14014 Cordoba, Spain; (S.Q.-C.); (R.N.-C.); (J.M.D.); (R.J.G.-V.); (M.M.G.)
- Correspondence: (P.R.-L.); (J.M.)
| | - Setefilla Quirós-Carmona
- Animal Medicine and Surgery Department, Faculty of Veterinary Medicine, University of Córdoba, 14014 Cordoba, Spain; (S.Q.-C.); (R.N.-C.); (J.M.D.); (R.J.G.-V.); (M.M.G.)
| | - Rocío Navarrete-Calvo
- Animal Medicine and Surgery Department, Faculty of Veterinary Medicine, University of Córdoba, 14014 Cordoba, Spain; (S.Q.-C.); (R.N.-C.); (J.M.D.); (R.J.G.-V.); (M.M.G.)
| | - Juan Manuel Domínguez
- Animal Medicine and Surgery Department, Faculty of Veterinary Medicine, University of Córdoba, 14014 Cordoba, Spain; (S.Q.-C.); (R.N.-C.); (J.M.D.); (R.J.G.-V.); (M.M.G.)
| | - Rafael Jesús Gómez-Villamandos
- Animal Medicine and Surgery Department, Faculty of Veterinary Medicine, University of Córdoba, 14014 Cordoba, Spain; (S.Q.-C.); (R.N.-C.); (J.M.D.); (R.J.G.-V.); (M.M.G.)
| | - M. M. Granados
- Animal Medicine and Surgery Department, Faculty of Veterinary Medicine, University of Córdoba, 14014 Cordoba, Spain; (S.Q.-C.); (R.N.-C.); (J.M.D.); (R.J.G.-V.); (M.M.G.)
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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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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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Niebhagen F, Golde C, Koch T, Hübler M. [Does NoL monitoring affect opioid consumption during da Vinci prostatectomy?]. DIE ANAESTHESIOLOGIE 2022; 71:683-688. [PMID: 35925157 PMCID: PMC9427871 DOI: 10.1007/s00101-022-01126-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 02/28/2022] [Accepted: 04/12/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Administration of opioids to suppress pain plays a major role in modern anesthesia. Measuring depth of hypnosis and neuromuscular recovery are already well established, and devices for pain monitoring are available. Nonetheless pain monitoring is rare in clinical practice. Recently, the pain monitoring device PMD200 (Medasense Biometrics™ , Israel) was introduced. It non-invasively measures heart rate, heart rate variability, skin resistance, resistance variability, temperature and movement to calculate a nociception level (NoL) index. The NoL index range starts at zero, which is equivalent to being painless, and goes up to a value of 100. The validity and reliability of NoL monitoring is the content of current studies. OBJECTIVE We tested the hypothesis if the use of the PMD200 significantly reduces opioid consumption during da Vinci prostatectomy. MATERIAL AND METHODS A total of 50 male patients were included in this randomized, single blinded study. Exclusion criteria were arrhythmia because the pain monitoring device requires a sinus rhythm for reliable results. Patients received a weight-adjusted sufentanil bolus (0.3 µg/kg ideal body weight) during induction of anesthesia. Additionally, they received 10 µg of sufentanil before skin incision. Both groups received total intravenous anesthesia with propofol and continuous muscle relaxation through cis-atracurium. In the control group (CONT; n = 26), a standardized sufentanil bolus of 10 µg were administered by common criteria (heart rate/blood pressure increase, lacrimation, gut feeling) at the anesthesiologist's discretion. In the intervention group (INT; n = 24), patients received the standardized sufentanil bolus when the NoL index was above 25 for 2 min, which corresponds to the manufacturer's recommendation. The NoL index and bolus administrations were recorded for every patient. In the control group, the display of the pain monitor showing the NoL index was not visible for the anesthesiologist. Postoperatively, pain/nausea scores and piritramide consumption were taken every 10 min for 1h in the recovery room. None of the patients had prior chronic pain with long-term use of painkillers. Statistics were done using Mann-Whitney U‑test, Kolmogorov-Smirnov test and Levene test. RESULTS Sufentanil bolus administrations, normalized for duration of surgery, were not significantly lower in the intervention group (p = 0.065). We noticed a significant difference in variation of opioid administrations (p = 0.033). Sufentanil boluses per hour in the INT were normally distributed (p = 0.2), whereas in CONT they were not (p = 0.003). Postoperative data like nausea, opioid consumption and pain scale showed no differences between groups. CONCLUSION The use of PMD200 did not significantly reduce cumulative opioid consumption. Following on we must reject the initial hypothesis. The difference in sufentanil bolus variances may point to an individualized antinociceptive therapy when NoL monitoring is used. We suppose patients with high opioid demands are detected and patients with low opioid demands did not receive unnecessary opioids. This assumption is only true if the PMD200 measures the entity pain. Further studies with more participants during surgery with higher tissue damage could lead to more convincing data and conclusions.
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Affiliation(s)
- F. Niebhagen
- grid.412282.f0000 0001 1091 2917Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307 Dresden, Deutschland
| | - C. Golde
- grid.412282.f0000 0001 1091 2917Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307 Dresden, Deutschland
| | - T. Koch
- grid.412282.f0000 0001 1091 2917Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307 Dresden, Deutschland
| | - M. Hübler
- grid.4488.00000 0001 2111 7257Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Krankenhaus St. Joseph-Stift Dresden (Lehrkrankenhaus der TU Dresden), Dresden, Deutschland
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Bansal S, Muthukalai S, Chakrabarti D, Umamaheswara Rao GS. Reliability of analgesia nociception index (ANI) and surgical pleth index (SPI) during episodes of bleeding – A pilot study. Indian J Anaesth 2022; 66:505-510. [PMID: 36111088 PMCID: PMC9469000 DOI: 10.4103/ija.ija_20_22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/03/2022] [Accepted: 07/05/2022] [Indexed: 11/04/2022] Open
Abstract
Background and Aims: Methods: Results: Conclusion:
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Shahiri TS, Richebé P, Richard-Lalonde M, Gélinas C. Description of the validity of the Analgesia Nociception Index (ANI) and Nociception Level Index (NOL) for nociception assessment in anesthetized patients undergoing surgery: a systematized review. J Clin Monit Comput 2021; 36:623-635. [PMID: 34783941 DOI: 10.1007/s10877-021-00772-3] [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: 01/22/2021] [Accepted: 10/17/2021] [Indexed: 11/29/2022]
Abstract
Maintaining optimum analgesia in anesthetized patients is challenging due to the inability to self-report pain or exhibit pain-related behaviours. The Analgesia Nociception Index (ANI) (based on heart rate variability [HRV]) and the Nociception Level Index (NOL) (based on HRV, photoplethysmography, skin conductance, and temperature) both include HRV and provide continuous index monitoring for nociception assessment. The research question was: "What are the validation strategies of the NOL and ANI for nociception assessment in anesthetized patients?". The objectives were to describe and analyze the validation strategies and results. A systematized review was conducted using a comprehensive search with keywords under three concepts (nociception/pain, ANI/NOL, and validity) in four databases. A quality assessment using an adapted GRADE approach for measurement tools, and a risk of bias assessment using QUADAS-2 tool were performed by two reviewers. Out of 525 results, 15 validation studies were included. Strategies included hypothesis testing, discriminative, and criterion validation. Significant changes in ANI/NOL values were found in response to nociceptive stimuli at different opioid concentrations (hypothesis testing). Higher ANI/NOL values were observed during nociceptive stimuli (discriminative). AUCs ranging from 0.83 to 0.99 were obtained to detect nociceptive stimuli (criterion). Both technologies performed superiorly in detecting nociceptive stimuli compared to individual monitoring of HR and blood pressure. Although the aforementioned validation strategies are deemed appropriate, in the absence of a gold standard, criterion validation findings should be interpreted with caution. Moreover, reliability could be examined using test-retest with consistent ANI/NOL values during a stable time-interval.
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Affiliation(s)
- T Shiva Shahiri
- Ingram School of Nursing, McGill University, Montréal, Canada.,Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital - CIUSSS West-Central Montréal, Montréal, Canada
| | - Philippe Richebé
- Department of Anesthesiology and Pain Medicine, University of Montréal, Hôpital Maisonneuve-Rosemont - CIUSSS Est-de-lÏle-de-Montréal, Montréal, Canada
| | - Melissa Richard-Lalonde
- Ingram School of Nursing, McGill University, Montréal, Canada.,Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital - CIUSSS West-Central Montréal, Montréal, Canada
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montréal, Canada. .,Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital - CIUSSS West-Central Montréal, Montréal, Canada.
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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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Deep learning via ECG and PPG signals for prediction of depth of anesthesia. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2021.102663] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Impact of chronic treatment by β1-adrenergic antagonists on Nociceptive-Level (NOL) index variation after a standardized noxious stimulus under general anesthesia: a cohort study. J Clin Monit Comput 2021; 36:109-120. [PMID: 33398545 DOI: 10.1007/s10877-020-00626-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/01/2020] [Indexed: 10/22/2022]
Abstract
During the perioperative period, nociception control is certainly one of the anesthesiologist's main objectives when assuming care of a patient. There exists some literature demonstrating that the nociceptive stimuli experienced during surgery are responsible for peripheral and central sensitization phenomena, which can in turn lead to persistent postsurgical pain. An individualized approach to the evaluation and treatment of perioperative nociception is beneficial in order to avoid the sensitization phenomena that leads to prolonged postoperative pain and to minimize the consumption of opiates and their adverse effects. In terms of sensitivity, specificity, and positive/negative predictive values when compared to heart rate (HR) and mean arterial pressure (MAP), recent literature has shown that the NOL variation (ΔNOL) is the best index to distinguish noxious from non-noxious stimuli. Chronic treatment with β1-adrenergic antagonists may constitute a limitation to the use of the NOL index. β1-adrenergic antagonists induce a depressive action on the heart rate, which results in a limitation of its variability after a noxious stimulus. Since heart rate and heart rate variability are two parameters integrated into the NOL index, the validity of the NOL index in a population of patients receiving β1-adrenergic antagonists has not yet been determined. Our study sought to explore the NOL index, the BIS, and the heart rate variation in a group of patients under chronic treatment with β1-adrenergic antagonists submitted to standardized noxious stimulus under general anesthesia. We then compared those results to a control group of patients from our previous study (CJA group) that received no β1-adrenergic antagonist chronic treatment. The patients in this study were subjected to a standardized anesthetic protocol from induction up to 3 min after a standardized tetanic stimulus to the ulnar nerve at a frequency of 100 Hz and an amperage of 70 mA, for a duration of 30 s. Data were electronically recorded to obtain NOL, BIS, and heart rate values every 5 s for the duration of the protocol. The NOL maximal mean value reached after noxious stimulation was not different between our two cohorts (CJA: 30(14) versus BETANOL: 36(14) (p = 0.12)). There was no statistically significant difference between our cohorts in regards of the NOL AUC representing the variation of the NOL over a 180 s period (CJA: 595(356) versus BETANOL: 634(301) (p = 0.30)). However, a repeated measurement ANCOVA identified slight statistically significant differences between our cohorts in the peak of variation of the NOL index between 20 and 65 s after noxious stimulation, the NOL index of the cohort of beta-blocked patients being higher than the CJA patients. Moreover, the time to reach the maximum value was not different (CJA: 73(37) versus BETANOL: 63(41) (p = 0.35)). NOL sensitivity and specificity to detect a noxious stimulus under general anesthesia were similar in patients taking beta-blockers or not, and were better than those of heart rate and Bispectral index (AUC NOL 0.97, CI(0.92-1), versus AUC BIS 0.78, CI(0.64-0.89) and AUC HR 0.66, CI(0.5-0.8)). In conclusion, the NOL index is a reliable monitor to assess nociception in a population of patients under chronic beta-blocker therapy. Patients under such therapy achieve similar maximal NOL values over a 180 s period after a standardized noxious stimulus and the NOL variation over time, represented by the AUC is not significantly different from a cohort of non-beta-blocked patients. Whether the patient takes beta-blockers or not, sensitivity of the NOL index is greater than that seen for BIS index or heart rate to detect an experimental noxious stimulus under general anesthesia.
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Jozefowicz E, Sabourdin N, Fontaine V, Lambelin V, Lejeune V, Menu H, Bourai M, Tavernier B. Prediction of reactivity during tracheal intubation by pre-laryngoscopy tetanus-induced ANI variation. J Clin Monit Comput 2021; 36:93-101. [PMID: 33387153 DOI: 10.1007/s10877-020-00624-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 11/24/2020] [Indexed: 11/30/2022]
Abstract
The ANI is a nociception monitor based on the high frequency parts of heart rate variability. Tracheal intubation may induce potentially deleterious hemodynamic disturbances or motor reactions if analgesia is inadequate. We investigated whether ANI modification generated by a standardized moderate short tetanic stimulation performed before laryngoscopy could predict hemodynamic or somatic reactions to subsequent intubation. We designed a prospective, interventional, monocentric, pilot study. Regional ethics board approved the study, written informed consent was obtained from each participant. Before laryngoscopy, under steady-state total intravenous anaesthesia with propofol and remifentanil, the ulnar nerve was stimulated with a 5 s tetanus (70 mA, 50 Hz). After another steady-state period, orotracheal intubation was performed. ANI variation, hemodynamic parameters and somatic reactions associated with tetanus and intubation were collected. To assess the predictability of hemodynamic or somatic reaction during laryngoscopy by tetanus-induced ANI variation, we calculated the area under the corresponding Receiver Operating Characteristic curve (AUCROC) and the 95% confidence intervals. Thirty-five patients were analyzed. ANI decreased by 21 ± 17 after tetanus. Regarding the ability of tetanus-induced ANI variation to predict hemodynamic or somatic reactions during subsequent intubation, the AUCROCs [95% CI] were 0.61 [0.41-0.81] and 0.52 [0.31-0.72] respectively. ANI varied after a short moderate tetanic stimulation performed before laryngoscopy but this variation was not predictive of a hemodynamic or somatic reaction during intubation.Trial registration NCT04354311, April 20th 2020, retrospectively registered.
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Affiliation(s)
- Elsa Jozefowicz
- CHU Lille, Pôle d'Anesthésie-Réanimation, 59000, Lille, France
| | - Nada Sabourdin
- Department of Anesthesiology, Armand Trousseau University Hospital, DMU DREAM, APHP, GRC 29, Sorbonne Université, Paris, France.
| | | | | | - Vincent Lejeune
- CHU Lille, Pôle d'Anesthésie-Réanimation, 59000, Lille, France
| | - Herve Menu
- CHU Lille, Pôle d'Anesthésie-Réanimation, 59000, Lille, France
| | - Mohamed Bourai
- CHU Lille, Pôle d'Anesthésie-Réanimation, 59000, Lille, France
| | - Benoit Tavernier
- CHU Lille, Pôle d'Anesthésie-Réanimation, 59000, Lille, France.,Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des Technologies de santé et des Pratiques médicales, 59000, Lille, France
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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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Desflurane and sevoflurane differentially affect activity of the subthalamic nucleus in Parkinson's disease. Br J Anaesth 2020; 126:477-485. [PMID: 33160604 DOI: 10.1016/j.bja.2020.09.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 09/10/2020] [Accepted: 09/10/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Desflurane and sevoflurane are commonly used during inhalational anaesthesia, but few studies have investigated their effects on deep cerebral neuronal activity. In addition, the association between subthalamic nucleus (STN) neurophysiology and general anaesthesia induced by volatile anaesthetics are not yet identified. This study aimed to identify differences in neurophysiological characteristics of the STN during comparable minimal alveolar concentration (MAC) desflurane and sevoflurane anaesthesia for deep brain stimulation (DBS) in patients with Parkinson's disease. METHODS Twelve patients with similar Parkinson's disease severity received desflurane (n=6) or sevoflurane (n=6) during DBS surgery. We obtained STN spike firing using microelectrode recording at 0.5-0.6 MAC and compared firing rate, power spectral density, and coherence. RESULTS Neuronal firing rate was lower with desflurane (47.4 [26.7] Hz) than with sevoflurane (63.9 [36.5] Hz) anaesthesia (P<0.001). Sevoflurane entrained greater gamma oscillation power than desflurane (62.9% [0.9%] vs 57.0% [1.5%], respectively; P=0.002). There was greater coherence in the theta band of the desflurane group compared with the sevoflurane group (13% vs 6%, respectively). Anaesthetic choice did not differentially influence STN mapping accuracy or the clinical outcome of DBS electrode implantation. CONCLUSIONS Desflurane and sevoflurane produced distinct neurophysiological profiles in humans that may be associated with their analgesic and hypnotic actions.
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Chen W, Feng Y, Chen X, Jiang F, Miao J, Chen S, Chen H. Comparison of Three Normalization Methods in Monitoring Analgesic Depth with Photoplethysmographic Diastolic Interval. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2020:5971-5975. [PMID: 33019332 DOI: 10.1109/embc44109.2020.9175443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The purpose of the present study was to investigate the ability of three different normalization methods, namely root mean square (RMS) value, mean value, and maximum which referred to pulse beat interval (PBI), based on photoplethysmographic diastolic interval (DI) in response to laryngeal mask airway (LMA) insertion under various remifentanil concentrations during general anesthesia. Sixty patients were randomly allocated to one of the four groups to receive a possible remifentanil effect-compartment target concentration (Ceremi) of 0, 1, 3, or 5 ng/ml, and an effect-compartment target controlled infusion of propofol to maintain the state entropy (SE) at 40~60. Three normalized measures DIRMS, DIMean, and DIPBI were compared with the DI values without normalization. Before LMA insertion, only DI showed a considerable correlation with remifentanil concentrations. DIRMS and DIMean performed better than DI in discriminating 'insufficient' concentrations (0 and 1 ng/ml) from 'sufficient' concentrations (3 and 5 ng/ml). DIRMS was superior to all other variables in grading analgesic depth after nociceptive event occurred with PK value of 0.836. These results demonstrate that the normalization using RMS value, compared to using mean value and maximum, seems to provide a more effective approach for signal pre-processing.
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Chen W, Feng Y, Chen X, Jiang F, Miao J, Chen S, Chen H. Effect of Laryngeal Mask Airway Insertion on Parameters Derived From Catacrotic Phase of Photoplethysmography Under Different Concentrations of Remifentanil. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE 2020; 8:2700609. [PMID: 33178499 PMCID: PMC7647452 DOI: 10.1109/jtehm.2020.3017368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 05/25/2020] [Accepted: 07/29/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Some parameters have been extracted from photoplethysmography (PPG) with a good relativity with nociception, but without encouraging results in qualifying the balance of nociception-anti-nociception (NAN). The features of PPG have not been thoroughly depicted and more prospective univariate parameters deserve to be explored. The aim of this study was to investigate the ability of parameters derived from catacrotic phase of PPG to grade the level of analgesia. METHODS 45 patients with ASA I or II were randomized to receive a remifentanil effect-compartment target controlled infusion (Ceremi) of 0, 1, or 3 ng/ml, and a propofol effect-compartment target controlled infusion to maintain an acceptable level of hypnosis with state entropy (SE) at 40~60. Laryngeal mask airway (LMA) insertion was applied as a noxious stimulus. Five diastole-related parameters, namely diastolic interval (DI), diastolic slope (DS), the minimum slope during catacrotic phase (DSmin), the interval between DSmin and its nearest trough (DTI), and area difference ratio (ADR), were extracted. Pulse beat interval (PBI) was calculated as a reference parameter. RESULTS LMA insertion elicited a significant variation in all parameters except ADR during Ceremi of 0 and 1 ng/ml. Compared to PBI (prediction probability ([Formula: see text]) = 0.796), the parameters of DI, DS, and DTI presented a better consistence with the level of anti-nociceptive medication, with [Formula: see text] of 0.825, 0.822, and 0.822 respectively. CONCLUSION The features extracted from catacrotic phase of PPG, including DI, DS, and DTI, could provide a promising potential to qualify the balance of NAN.
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Affiliation(s)
- Wanlin Chen
- College of Biomedical Engineering and Instrument ScienceZhejiang UniversityHangzhou310027China
- Zhejiang Provincial Key Laboratory of Cardio-Cerebral Vascular Detection Technology and Medicinal Effectiveness AppraisalHangzhou310027China
| | - Ying Feng
- Department of AnesthesiaWomen’s Hospital, School of MedicineZhejiang UniversityHangzhou310006China
| | - Xinzhong Chen
- Zhejiang Provincial Key Laboratory of Cardio-Cerebral Vascular Detection Technology and Medicinal Effectiveness AppraisalHangzhou310027China
- Department of AnesthesiaWomen’s Hospital, School of MedicineZhejiang UniversityHangzhou310006China
| | - Feng Jiang
- College of Biomedical Engineering and Instrument ScienceZhejiang UniversityHangzhou310027China
- Zhejiang Provincial Key Laboratory of Cardio-Cerebral Vascular Detection Technology and Medicinal Effectiveness AppraisalHangzhou310027China
| | - Jiajun Miao
- College of Biomedical Engineering and Instrument ScienceZhejiang UniversityHangzhou310027China
- Zhejiang Provincial Key Laboratory of Cardio-Cerebral Vascular Detection Technology and Medicinal Effectiveness AppraisalHangzhou310027China
| | - Shali Chen
- College of Biomedical Engineering and Instrument ScienceZhejiang UniversityHangzhou310027China
- Zhejiang Provincial Key Laboratory of Cardio-Cerebral Vascular Detection Technology and Medicinal Effectiveness AppraisalHangzhou310027China
| | - Hang Chen
- College of Biomedical Engineering and Instrument ScienceZhejiang UniversityHangzhou310027China
- Zhejiang Provincial Key Laboratory of Cardio-Cerebral Vascular Detection Technology and Medicinal Effectiveness AppraisalHangzhou310027China
- Zhejiang LaboratoryConnected Healthcare Big Data Research CenterHangzhou311121China
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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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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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Chen W, Jiang F, Chen X, Feng Y, Miao J, Chen S, Jiao C, Chen H. Photoplethysmography-derived approximate entropy and sample entropy as measures of analgesia depth during propofol-remifentanil anesthesia. J Clin Monit Comput 2020; 35:297-305. [PMID: 32026257 DOI: 10.1007/s10877-020-00470-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 01/22/2020] [Indexed: 11/28/2022]
Abstract
The ability to monitor the physiological effect of the analgesic agent is of interest in clinical practice. Nonstationary changes would appear in photoplethysmography (PPG) during the analgesics-driven transition to analgesia. The present work studied the properties of nonlinear methods including approximate entropy (ApEn) and sample entropy (SampEn) derived from PPG responding to a nociceptive stimulus under various opioid concentrations. Forty patients with ASA I or II were randomized to receive one of the four possible remifentanil effect-compartment target concentrations (Ceremi) of 0, 1, 3, and 5 ng·ml-1 and a propofol effect-compartment target-controlled infusion to maintain the state entropy (SE) at 50 ± 10. Laryngeal mask airway (LMA) insertion was applied as a standard noxious stimulation. To optimize the performance of ApEn and SampEn, different coefficients were carefully evaluated. The monotonicity of ApEn and SampEn changing from low Ceremi to high Ceremi was assessed with prediction probabilities (PK). The result showed that low Ceremi (0 and 1 ng·ml-1) could be differentiated from high Ceremi (3 and 5 ng·ml-1) by ApEn and SampEn. Depending on the coefficient employed in algorithm: ApEn with k = 0.15 yielded the largest PK value (0.875) whereas SampEn gained its largest PK of 0.867 with k = 0.2. Thus, PPG-based ApEn and SampEn with appropriate k values have the potential to offer good quantification of analgesia depth under general anesthesia.
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Affiliation(s)
- Wanlin Chen
- College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China.,Key Lab of Biomedical Engineering of Ministry of Education, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Laboratory of Cardio-Cerebral Vascular Detection Technology and Medicinal Effectiveness Appraisal, Hangzhou, China
| | - Feng Jiang
- College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China.,Key Lab of Biomedical Engineering of Ministry of Education, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Laboratory of Cardio-Cerebral Vascular Detection Technology and Medicinal Effectiveness Appraisal, Hangzhou, China
| | - Xinzhong Chen
- Zhejiang Provincial Key Laboratory of Cardio-Cerebral Vascular Detection Technology and Medicinal Effectiveness Appraisal, Hangzhou, China.,Department of Anesthesia, Women's Hospital School of Medicine Zhejiang University, Hangzhou, China
| | - Ying Feng
- Department of Anesthesia, Women's Hospital School of Medicine Zhejiang University, Hangzhou, China
| | - Jiajun Miao
- College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China.,Key Lab of Biomedical Engineering of Ministry of Education, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Laboratory of Cardio-Cerebral Vascular Detection Technology and Medicinal Effectiveness Appraisal, Hangzhou, China
| | - Shali Chen
- College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China.,Key Lab of Biomedical Engineering of Ministry of Education, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Laboratory of Cardio-Cerebral Vascular Detection Technology and Medicinal Effectiveness Appraisal, Hangzhou, China
| | - Cuicui Jiao
- Department of Anesthesia, Women's Hospital School of Medicine Zhejiang University, Hangzhou, China
| | - Hang Chen
- College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China. .,Key Lab of Biomedical Engineering of Ministry of Education, Zhejiang University, Hangzhou, China. .,Zhejiang Provincial Key Laboratory of Cardio-Cerebral Vascular Detection Technology and Medicinal Effectiveness Appraisal, Hangzhou, China. .,Connected Healthcare Big Data Research Center, Zhejiang Lab, Hangzhou, China.
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40
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Susano MJ, Vide S, Ferreira AD, Amorim P. Effects of varying remifentanil concentrations on Analgesia Nociception Index® under propofol: an observational study. J Clin Monit Comput 2020; 35:199-205. [PMID: 31916221 DOI: 10.1007/s10877-020-00457-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 01/03/2020] [Indexed: 11/28/2022]
Abstract
Analgesia Nociception Index monitor provides a measurement of the nociception and anti-nociception balance based on heart-rate variability. The aim was to assess the ability of Analgesia Nociception Index (ANI) to detect standard noxious stimulation during anesthesia at different opioid concentrations in comparison to hemodynamic and Bispectral Index parameters. Sixteen patients undergoing general anesthesia with propofol and remifentanil. Standardized tetanic electrical stimulation was applied without any other concurrent stimuli, while different effect site concentrations of remifentanil were increased step-by-step (0.5, 1.5, 3.0, 5 and 7 ng/ml). For each tetanic stimulus, values of the different variables 60 s before and 120 s following the stimulus were analyzed. ANI values decreased significantly 120 s after the stimulus when compared to the mean ANI 60 s before the stimulus (P < 0.01). At lower remifentanil concentrations (0.5 ng/ml), all variables except electromyogram from the Bispectral Index significantly changed after the stimulus but in the higher concentrations (5.0 and 7.0 ng/ml) there was not a significant change. The other variables did not change significantly after the noxious stimulation. ANI was the only variable that positively correlated with the different remifentanil concentrations (R = 0.959, P = 0.01). Our study showed that there was a significant decrease in Analgesia Nociception Index after a tetanic stimulation while hemodynamic and BIS parameters did not change, suggesting that the Analgesia Nociception Index may perform better than traditional hemodynamic parameters at reflecting noxious stimulation. Analgesia Nociception Index significantly changed at lower, but not at higher, remifentanil concentrations.
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Affiliation(s)
- Maria J Susano
- Department of Anesthesiology, Center for Clinical Research in Anesthesiology, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Champalimaud Clinical Centre, Champalimaud Foundation, Lisboa, Portugal
| | - Sérgio Vide
- Department of Anesthesiology, Center for Clinical Research in Anesthesiology, Centro Hospitalar Universitário do Porto, Porto, Portugal. .,Department of Anesthesia, Unidade Local de Saúde de Matosinhos - Hospital Pedro Hispano, Matosinhos, Portugal.
| | - Ana D Ferreira
- Unidade de Saúde Pública ACeS Grande Porto V - Porto Ocidental, Porto, Portugal.,Faculty of Medicine of the University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Pedro Amorim
- Department of Anesthesiology, Center for Clinical Research in Anesthesiology, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Department of Anesthesiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
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Dostalova V, Schreiberova J, Bartos M, Kukralova L, Dostal P. Surgical Pleth Index and Analgesia Nociception Index for intraoperative analgesia in patients undergoing neurosurgical spinal procedures: a comparative randomized study. Minerva Anestesiol 2019; 85:1265-1272. [DOI: 10.23736/s0375-9393.19.13765-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ruíz-López P, Domínguez JM, Granados MDM. Intraoperative nociception-antinociception monitors: A review from the veterinary perspective. Vet Anaesth Analg 2019; 47:152-159. [PMID: 32007442 DOI: 10.1016/j.vaa.2019.09.006] [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: 04/08/2019] [Revised: 08/12/2019] [Accepted: 09/24/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To review monitors currently available for the assessment of nociception-antinociception in veterinary medicine. DATABASES USED PubMed, Web of Science and Google Scholar. The results were initially filtered manually based on the title and the abstract. CONCLUSIONS The provision of adequate antinociception is difficult to achieve in veterinary anaesthesia. Currently, heart rate and arterial blood pressure are used to monitor the response to a noxious stimulus during anaesthesia, with minimum alveolar concentration-sparing effect and stress-related hormones used for this purpose in research studies. However, since none of these variables truly assess intraoperative nociception, several alternative monitoring devices have been developed for use in humans. These nociceptive-antinociceptive monitoring systems derive information from variables, such as electroencephalography, parasympathetic nervous system (PNS) response, sympathetic nervous system response and electromyography. Several of these monitoring systems have been investigated in veterinary medicine, although few have been used to assess intraoperative nociception in animals. There is controversy regarding their effectiveness and clinical use in animals. A nociceptive-antinociceptive monitoring system based on the PNS response has been developed for use in cats, dogs and horses. It uses the parasympathetic tone activity index, which is believed to detect inadequate intraoperative nociception-antinociception balance in veterinary anaesthesia. Nonetheless, there are limited published studies to date, and cardiovascular variables remain the gold standard. Consequently, further studies in this area are warranted.
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Affiliation(s)
- Patricia Ruíz-López
- Anaesthesiology Unit, Animal Medicine and Surgery Department, Faculty of Veterinary Medicine, University of Córdoba, Córdoba, Spain.
| | - Juan Manuel Domínguez
- Anaesthesiology Unit, Animal Medicine and Surgery Department, Faculty of Veterinary Medicine, University of Córdoba, Córdoba, Spain
| | - María Del Mar Granados
- Anaesthesiology Unit, Animal Medicine and Surgery Department, Faculty of Veterinary Medicine, University of Córdoba, Córdoba, 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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Ghanty I, Schraag S. The quantification and monitoring of intraoperative nociception levels in thoracic surgery: a review. J Thorac Dis 2019; 11:4059-4071. [PMID: 31656682 DOI: 10.21037/jtd.2019.08.62] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Nociception is the unconscious perception of a stimulus applied by trauma or surgery and expressed through a response of the autonomous nervous system. Local anaesthetics (LAs), opioids and other modulating agents such as ketamine are usually utilised to blunt nociception as a component during general anaesthesia (GA) and surgery. The effectiveness of these measures, however, are still difficult to quantify and monitoring of anti-nociception has been confined to assess variation of heart rate (HR) or blood pressure (BP). Recently, various monitoring concepts have been introduced to quantify nociception more systematically and on the other hand guide anti-nociceptive interventions more appropriately. This review describes the various technologies, their performance in clinical studies and provides a critical appraisal with particular application to thoracic anaesthesia and surgery and their relevance in the context of chronic pain after surgery.
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Affiliation(s)
- Ismael Ghanty
- Department of Perioperative Medicine, Golden Jubilee National Hospital, Clydebank, UK
| | - Stefan Schraag
- Department of Perioperative Medicine, Golden Jubilee National Hospital, Clydebank, UK
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Efficacy of the Parasympathetic Tone Activity monitor to assess nociception in healthy dogs anaesthetized with propofol and sevoflurane. Vet Anaesth Analg 2019; 47:103-110. [PMID: 31635963 DOI: 10.1016/j.vaa.2019.05.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 05/13/2019] [Accepted: 05/24/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare a Parasympathetic Tone Activity (PTA) monitor with cardiovascular changes in invasive mean arterial pressure (IMAP) and heart rate (HR) when evaluating the response to nociceptive stimuli in anaesthetized dogs. STUDY DESIGN Prospective experimental study. ANIMALS A group of nine (seven male and two female) adult Beagle dogs weighing 13.4 ± 1.5 kg (mean ± standard deviation). METHODS Anaesthesia was induced with propofol and maintained with sevoflurane in oxygen. Electrical stimuli of different nociceptive intensities were applied for 30 seconds. Stimuli were classified in each patient according to the response obtained (relevant change ≥ 20%) as low (no response), medium (PTA only) or high (PTA and IMAP/HR). Immediate and averaged values of PTA, IMAP and HR were recorded every second from 60 seconds before to 120 seconds after application of the nociceptive stimulus. Time to nociceptive response and peak response were evaluated with analysis of variance and t test. RESULTS Immediate PTA baseline values did not differ significantly before application of the low, medium and high stimuli (73 ± 15, p = 0.966). Immediate PTA response was observed with the medium stimulus at 33 ± 7 seconds with a maximum decrease of 57 ± 13% at 69 ± 5 seconds. With the high stimulus, the immediate PTA response was of a similar magnitude to the medium stimulus with a response at 28 ± 7 seconds (p = 0.221) and a maximum decrease of 68 ± 15% (p = 0.115) at 72 ± 7 seconds (p = 0.436). The cardiovascular change occurred (22 ± 8 seconds) prior to the immediate PTA response (p = 0.032). CONCLUSIONS AND CLINICAL RELEVANCE The PTA monitor detected nociceptive stimuli at lower intensities than those eliciting cardiovascular changes. However, nociceptive stimuli of higher intensities provoked cardiovascular changes that occurred before a PTA response was observed.
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Differentiation of skin incision and laparoscopic trocar insertion via quantifying transient bradycardia measured by electrocardiogram. J Clin Monit Comput 2019; 34:753-762. [PMID: 31432382 DOI: 10.1007/s10877-019-00378-w] [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: 09/12/2018] [Accepted: 08/15/2019] [Indexed: 10/26/2022]
Abstract
Most surgical procedures involve structures deeper than the skin. However, the difference in surgical noxious stimulation between skin incision and laparoscopic trocar insertion is unknown. By analyzing instantaneous heart rate (IHR) calculated from the electrocardiogram, in particular the transient bradycardia in response to surgical stimuli, this study investigates surgical noxious stimuli arising from skin incision and laparoscopic trocar insertion, and their difference. Thirty-five patients undergoing laparoscopic cholecystectomy were enrolled in this prospective observational study. Sequential surgical steps including umbilical skin incision (11 mm), umbilical trocar insertion (11 mm), xiphoid skin incision (5 mm), xiphoid trocar insertion (5 mm), subcostal skin incision (3 mm), and subcostal trocar insertion (3 mm) were investigated. IHR was derived from electrocardiography and calculated by the modern time-varying power spectrum. Similar to the classical heart rate variability analysis, the time-varying low frequency power (tvLF), time-varying high frequency power (tvHF), and tvLF-to-tvHF ratio (tvLHR) were calculated. Prediction probability (PK) analysis and global pointwise F-test were used to compare the statistical performance between indices and the heart rate readings from the patient monitor. Analysis of IHR showed that surgical stimulus elicits a transient bradycardia, followed by the increase of heart rate. Transient bradycardia is more significant in trocar insertion than skin incision (p < 0.001 for tvHF). The IHR change quantifies differential responses to different surgical intensity. Serial PK analysis demonstrates de-sensitization in skin incision, but not in laparoscopic trocar insertion. Quantitative indices present the transient bradycardia introduced by noxious stimulation. The results indicate different effects between skin incision and trocar insertion.
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Aubrun F, Nouette-Gaulain K, Fletcher D, Belbachir A, Beloeil H, Carles M, Cuvillon P, Dadure C, Lebuffe G, Marret E, Martinez V, Olivier M, Sabourdin N, Zetlaoui P. Revision of expert panel's guidelines on postoperative pain management. Anaesth Crit Care Pain Med 2019; 38:405-411. [DOI: 10.1016/j.accpm.2019.02.011] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Park M, Kim BJ, Kim GS. Prediction of postoperative pain and analgesic requirements using surgical pleth index: a observational study. J Clin Monit Comput 2019; 34:583-587. [PMID: 31209663 DOI: 10.1007/s10877-019-00338-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 06/12/2019] [Indexed: 11/25/2022]
Abstract
The aim of this study was to evaluate the performance of surgical pleth index (SPI) measured before arousal from general anaesthesia for prediction of immediate postoperative pain and postoperative opioid requirement during postoperative 48 h. After obtaining ethical approval and written informed consent, we enrolled 51 patients undergoing liver resection under isoflurane based general anaesthesia using laryngeal mask airway in this prospective observational study. Data relating to SPI values were recorded every 30 s for the last 3 min of surgery (bispectral index < 60 at all times). Postoperative pain intensity was assessed using a 0-10 numerical rating scale (NRS) every 10 min in the recovery room. The relationships between SPI with postoperative pain score and opioid requirement were analysed. A receiver-operating characteristic curve (ROC) was used to evaluate the performance of SPI to predict NRS ≥ 5. SPI value was significantly associated with the highest pain score in the recovery room (r = 0.63, p < 0.001). An SPI value of 60, which showed the highest sensitivity and specificity, was defined post hoc as the cut-off for moderate-severe pain (NRS ≥ 5). When compared the patients who showed SPI value over 60 or not, there was significant difference in the amount of fentanyl consumption during postoperative 48 h (1093 ± 406 µg vs. 766 ± 369 µg, p = 0.014; SPI ≥ 60 vs. SPI < 60). SPI measured before arousal after inhalation anaesthesia was associated with immediate postoperative pain and postoperative opioid consumption.
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Affiliation(s)
- MiHye Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Ilwon-Ro, Gangnam-Gu, Seoul, 06351, South Korea
| | - Byung Jun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Ilwon-Ro, Gangnam-Gu, Seoul, 06351, South Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Ilwon-Ro, Gangnam-Gu, Seoul, 06351, South Korea.
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Renaud-Roy E, Stöckle PA, Maximos S, Brulotte V, Sideris L, Dubé P, Drolet P, Tanoubi I, Issa R, Verdonck O, Fortier LP, Richebé P. Correlation between incremental remifentanil doses and the Nociception Level (NOL) index response after intraoperative noxious stimuli. Can J Anaesth 2019; 66:1049-1061. [DOI: 10.1007/s12630-019-01372-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 02/16/2019] [Accepted: 02/18/2019] [Indexed: 12/30/2022] Open
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Chanques G, Tarri T, Ride A, Prades A, De Jong A, Carr J, Molinari N, Jaber S. Analgesia nociception index for the assessment of pain in critically ill patients: a diagnostic accuracy study. Br J Anaesth 2019; 119:812-820. [PMID: 29121287 DOI: 10.1093/bja/aex210] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2017] [Indexed: 01/07/2023] Open
Abstract
Background Behavioural pain tools are used in Intensive Care Unit (ICU) patients unable to self-report their pain-intensity but need sustained efforts to educate and train the ICU team because of the subjective nature of these clinical tools. This study measured the validity and performance of an electrophysiological monitoring tool based on the spectral analysis of heart rate variability, the Analgesia Nociception Index (ANI) which varies from 0 (minimal parasympathetic tone, maximal stress-response and pain) to 100 (maximal parasympathetic tone, minimal stress-response and pain). Methods Mean-ANI (ANIm) and Instant-ANI (ANIi) were continuously recorded then compared with the Behavioral Pain Scale (BPS) before, during and after routine care procedures in critically-ill non-comatose patients. Results 969 assessments were performed in 110 patients. ANIi was the most discriminative pain tool. It was significantly correlated with BPS (r=-0.30; 95%CI -0.37 to -0.25; P<0.001). For an ANIi threshold of 42.5, the sensitivity, specificity, positive and negative predictive values were respectively 61.4%, 77.4%, 37.0%, and 90.4%. Compared with the BPS, ANIi had no significantly different ability to change during turning and tracheal-suctioning but changed significantly more during dressing change. ANIi increased independently with age, obesity and severity of illness, and controlled mechanical-ventilation, vasopressors use and analgesia. ANIi decreased independently when vigilance status and respiratory rate increased. ANIm demonstrated poor psychometric properties to detect pain. Conclusions Despite low sensitivity/specificity, ANIi≥43 had a Negative-Predictive-Value of 90%. Hence ANIi may be of highest benefit for excluding significant pain. A randomized controlled trial should compare sedation-analgesia protocols based on ANIi to presently recommended behavioural-pain-tools.
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Affiliation(s)
- G Chanques
- Department of Anaesthesia & Critical Care Medicine, University of Montpellier Saint Eloi Hospital, 34295 Montpellier cedex 5, France.,PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, 34295 Montpellier cedex 5, France
| | - T Tarri
- Department of Anaesthesia & Critical Care Medicine, University of Montpellier Saint Eloi Hospital, 34295 Montpellier cedex 5, France
| | - A Ride
- Department of Anaesthesia & Critical Care Medicine, University of Montpellier Saint Eloi Hospital, 34295 Montpellier cedex 5, France
| | - A Prades
- Department of Anaesthesia & Critical Care Medicine, University of Montpellier Saint Eloi Hospital, 34295 Montpellier cedex 5, France
| | - A De Jong
- Department of Anaesthesia & Critical Care Medicine, University of Montpellier Saint Eloi Hospital, 34295 Montpellier cedex 5, France.,PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, 34295 Montpellier cedex 5, France
| | - J Carr
- Department of Anaesthesia & Critical Care Medicine, University of Montpellier Saint Eloi Hospital, 34295 Montpellier cedex 5, France
| | - N Molinari
- Department of Statistics, University of Montpellier La Colombière Hospital, 34295 Montpellier cedex 5, France
| | - S Jaber
- Department of Anaesthesia & Critical Care Medicine, University of Montpellier Saint Eloi Hospital, 34295 Montpellier cedex 5, France.,PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, 34295 Montpellier cedex 5, France
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