Evaluation of Surgical Pleth Index and Analgesia Nociception Index as surrogate pain measures in conscious postoperative patients: an observational study

  • Joo-Hyun Lee
  • Byung-Moon Choi
  • Yu-Ri Jung
  • Yong-Hun Lee
  • Ji-Yeon BangEmail author
  • Gyu-Jeong Noh
Original Research


We evaluated the performance of the Surgical Plethysmographic Index (SPI) and the Analgesia Nociception Index (ANI) as surrogate pain measures and determined their respective cut-off values for detecting pain in conscious postoperative patients. In total, 192 patients after elective surgery were enrolled. Baseline SPI and ANI data were acquired for 10 min in the operating room prior to surgery when the patients rated their pain as 0 on the numerical rating scale (NRS). Upon arrival in the post-anaesthesia care unit (PACU) after surgery, SPI and ANI data were recorded for 10 min. The means of the recorded data at OR and PACU were defined as the values representing baseline and postoperative pain, respectively. SPI and ANI data obtained from 189 patients were analysed, who were anesthetized with propofol (n = 149) or sevoflurane (n = 40). Remifentanil was continuously infused intraoperatively in all patients. The values of SPI and ANI were significantly different in conscious patients without (NRS = 0) and with pain (NRS > 0). The areas under the receiver operating curves for SPI and ANI were 0.73 (P < 0.0001) and 0.67 (P < 0.0001), respectively. The cut-off values for SPI and ANI in predicting postoperative pain were 44 (sensitivity: 84%, specificity: 53%) and 63 (sensitivity: 52%, specificity: 82%), respectively, which are different from those suggested by their respective manufacturers for use in intraoperative state under general anaesthesia. The cut-off values of SPI and ANI for detecting pain were similar regardless of the type of anesthesia.


Conscious Pain Performance Surgical Pleth Index Analgesia Nociception Index 



Analgesia Nociception Index




Heartbeat interval


Heart rate variability


Numerical Rating Scale


Operating room


Patient-controlled analgesia


Post-anaesthesia care unit


Photo-plethysmographic amplitude


Receiver operating curve


Surgical Plethysmographic Index





We thank Dr Joon Seo Lim from the Scientific Publications Team at Asan Medical Center for his editorial assistance in preparing this manuscript. This work was supported by the Ministry of Trade, Industry & Energy, Korea (Grant Number 10047988).

Compliance with ethical standards

Competing interests



  1. 1.
    Gorczyca R, Filip R, Walczak E. Psychological aspects of pain. Ann Agric Environ Med. 2013;1:23–7.Google Scholar
  2. 2.
    Daoust R, Beaulieu P, Manzini C, Chauny JM, Lavigne G. Estimation of pain intensity in emergency medicine: a validation study. Pain. 2008;138:565–70. Scholar
  3. 3.
    Huiku M, Uutela K, van Gils M, Korhonen I, Kymalainen M, Merilainen P, Paloheimo M, Rantanen M, Takala P, Viertio-Oja H, Yli-Hankala A. Assessment of surgical stress during general anaesthesia. Br J Anaesth. 2007;98:447–55. Scholar
  4. 4.
    Jeanne M, Logier R, De Jonckheere J, Tavernier B. Validation of a graphic measurement of heart rate variability to assess analgesia/nociception balance during general anesthesia. Conf Proc IEEE Eng Med Biol Soc. 2009;2009:1840–3. Scholar
  5. 5.
    Gruenewald M, Ilies C. Monitoring the nociception-anti-nociception balance. Best Pract Res Clin Anaesthesiol. 2013;27:235–47. Scholar
  6. 6.
    Chen X, Thee C, Gruenewald M, Wnent J, Illies C, Hoecker J, Hanss R, Steinfath M, Bein B. Comparison of surgical stress index-guided analgesia with standard clinical practice during routine general anesthesia: a pilot study. Anesthesiology. 2010;112:1175–83. Scholar
  7. 7.
    Gruenewald M, Willms S, Broch O, Kott M, Steinfath M, Bein B. Sufentanil administration guided by surgical pleth index vs standard practice during sevoflurane anaesthesia: a randomized controlled pilot study. Br J Anaesth. 2014;112:898–905. Scholar
  8. 8.
    Theerth KA, Sriganesh K, Reddy KM, Chakrabarti D, Umamaheswara-Rao GS. Analgesia Nociception Index-guided intraoperative fentanyl consumption and postoperative analgesia in patients receiving scalp block versus incision-site infiltration for craniotomy. Minerva Anestesiol. 2018;84:1361–8. Scholar
  9. 9.
    Boselli E, Daniela-Ionescu M, Begou G, Bouvet L, Dabouz R, Magnin C, Allaouchiche B. Prospective observational study of the non-invasive assessment of immediate postoperative pain using the analgesia/nociception index (ANI). Br J Anaesth. 2013;111:453–9. Scholar
  10. 10.
    Hamunen K, Kontinen V, Hakala E, Talke P, Paloheimo M, Kalso E. Effect of pain on autonomic nervous system indices derived from photoplethysmography in healthy volunteers. Br J Anaesth. 2012;108:838–44. Scholar
  11. 11.
    Ilies C, Gruenewald M, Ludwigs J, Thee C, Hocker J, Hanss R, Steinfath M, Bein B. Evaluation of the surgical stress index during spinal and general anaesthesia. Br J Anaesth. 2010;105:533–7. Scholar
  12. 12.
    Issa R, Julien M, Decary E, Verdonck O, Fortier LP, Drolet P, Richebe P. Evaluation of the analgesia nociception index (ANI) in healthy awake volunteers. Can J Anaesth. 2017;64:828–35. Scholar
  13. 13.
    Jess G, Pogatzki-Zahn EM, Zahn PK, Meyer-Friessem CH. Monitoring heart rate variability to assess experimentally induced pain using the analgesia nociception index: a randomised volunteer study. Eur J Anaesthesiol. 2016;33:118–25. Scholar
  14. 14.
    Ledowski T, Ang B, Schmarbeck T, Rhodes J. Monitoring of sympathetic tone to assess postoperative pain: skin conductance vs surgical stress index. Anaesthesia. 2009;64:727–31. Scholar
  15. 15.
    Ledowski T, Tiong WS, Lee C, Wong B, Fiori T, Parker N. Analgesia nociception index: evaluation as a new parameter for acute postoperative pain. Br J Anaesth. 2013;111:627–9. Scholar
  16. 16.
    Thee C, Ilies C, Gruenewald M, Kleinschmidt A, Steinfath M, Bein B. Reliability of the surgical Pleth index for assessment of postoperative pain: a pilot study. Eur J Anaesthesiol. 2015;32:44–8. Scholar
  17. 17.
    Schnider TW, Minto CF, Gambus PL, Andresen C, Goodale DB, Shafer SL, Youngs EJ. The influence of method of administration and covariates on the pharmacokinetics of propofol in adult volunteers. Anesthesiology. 1998;88:1170–82.CrossRefGoogle Scholar
  18. 18.
    Schnider TW, Minto CF, Shafer SL, Gambus PL, Andresen C, Goodale DB, Youngs EJ. The influence of age on propofol pharmacodynamics. Anesthesiology. 1999;90:1502–16.CrossRefGoogle Scholar
  19. 19.
    Minto CF, Schnider TW, Egan TD, Youngs E, Lemmens HJ, Gambus PL, Billard V, Hoke JF, Moore KH, Hermann DJ, Muir KT, Mandema JW, Shafer SL. Influence of age and gender on the pharmacokinetics and pharmacodynamics of remifentanil. I. Model development. Anesthesiology. 1997;86:10–23.CrossRefGoogle Scholar
  20. 20.
    Aldrete JA. Modifications to the postanesthesia score for use in ambulatory surgery. J Perianesth Nurs. 1998;13:148–55.CrossRefGoogle Scholar
  21. 21.
    Choi BM, Park C, Lee YH, Shin H, Lee SH, Jeong S, Noh GJ, Lee B. Development of a new analgesic index using nasal photoplethysmography. Anaesthesia. 2018;73:1123–30. Scholar
  22. 22.
    Smith WD, Dutton RC, Smith NT. Measuring the performance of anesthetic depth indicators. Anesthesiology. 1996;84:38–51.CrossRefGoogle Scholar
  23. 23.
    Boselli E, Jeanne M. Analgesia/nociception index for the assessment of acute postoperative pain. Br J Anaesth. 2014;112:936–7. Scholar
  24. 24.
    Galletly DC, Buckley DH, Robinson BJ, Corfiatis T. Heart rate variability during propofol anaesthesia. Br J Anaesth. 1994;72:219–20.CrossRefGoogle Scholar
  25. 25.
    Wujtewicz MA, Hasak L, Twardowski P, Zabul E, Owczuk R. Evaluation of the relationship between baseline autonomic tone and the vagotonic effect of a bolus dose of remifentanil. Anaesthesia. 2016;71:823–8. Scholar
  26. 26.
    Le Guen M, Jeanne M, Sievert K, Al Moubarik M, Chazot T, Laloe PA, Dreyfus JF, Fischler M. The Analgesia Nociception Index: a pilot study to evaluation of a new pain parameter during labor. Int J Obstet Anesth. 2012;21:146–51. Scholar
  27. 27.
    Natalini G, Rosano A, Franceschetti ME, Facchetti P, Bernardini A. Variations in arterial blood pressure and photoplethysmography during mechanical ventilation. Anesth Analg. 2006;103:1182–8. Scholar
  28. 28.
    Metz CE. Basic principles of ROC analysis. Semin Nucl Med. 1978;8:283–98.CrossRefGoogle Scholar
  29. 29.
    Pinto S, Turkman A, Pinto A, Swash M, de Carvalho M. Predicting respiratory insufficiency in amyotrophic lateral sclerosis: the role of phrenic nerve studies. Clin Neurophysiol. 2009;120:941–6. Scholar
  30. 30.
    Jeanne M, Delecroix M, De Jonckheere J, Keribedj A, Logier R, Tavernier B. Variations of the analgesia nociception index during propofol anesthesia for total knee replacement. Clin J Pain. 2014;30:1084–8. Scholar
  31. 31.
    Yang Y, Seok HS, Noh GJ, Choi BM, Shin H. Postoperative pain assessment indices based on photoplethysmography waveform analysis. Front Physiol. 2018;9:1199. Scholar
  32. 32.
    Seymour RA. The use of pain scales in assessing the efficacy of analgesics in post-operative dental pain. Eur J Clin Pharmacol. 1982;23:441–4. Scholar
  33. 33.
    Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales. J Clin Nurs. 2005;14:798–804. Scholar
  34. 34.
    Hjermstad MJ, Fayers PM, Haugen DF, Caraceni A, Hanks GW, Loge JH, Fainsinger R, Aass N, Kaasa S, European Palliative Care Research C. Studies comparing Numerical Rating Scales, Verbal Rating Scales, and Visual Analogue Scales for assessment of pain intensity in adults: a systematic literature review. J Pain Symptom Manage. 2011;41:1073–93. Scholar
  35. 35.
    Hans P, Verscheure S, Uutela K, Hans G, Bonhomme V. Effect of a fluid challenge on the Surgical Pleth Index during stable propofol-remifentanil anaesthesia. Acta Anaesthesiol Scand. 2012;56:787–96. Scholar

Copyright information

© Springer Nature B.V. 2019

Authors and Affiliations

  1. 1.Department of Anaesthesiology and Pain Medicine, International St. Mary’s HospitalCatholic Kwandong UniversityIncheonKorea
  2. 2.Department of Anaesthesiology and Pain Medicine, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
  3. 3.Department of Clinical Pharmacology and Therapeutics, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea

Personalised recommendations