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

Abstract

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.

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Fig. 1

Abbreviations

ANI:

Analgesia Nociception Index

ECG:

Electrocardiogram

HBI:

Heartbeat interval

HRV:

Heart rate variability

NRS:

Numerical Rating Scale

OR:

Operating room

PCA:

Patient-controlled analgesia

PACU:

Post-anaesthesia care unit

PPGA:

Photo-plethysmographic amplitude

ROC:

Receiver operating curve

SPI:

Surgical Plethysmographic Index

TOF:

Train-of-four

References

  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. https://doi.org/10.1016/j.pain.2008.02.007.

    Article  PubMed  Google 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. https://doi.org/10.1093/bja/aem004.

    CAS  Article  PubMed  Google 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. https://doi.org/10.1109/IEMBS.2009.5332598.

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Gruenewald M, Ilies C. Monitoring the nociception-anti-nociception balance. Best Pract Res Clin Anaesthesiol. 2013;27:235–47. https://doi.org/10.1016/j.bpa.2013.06.007.

    Article  PubMed  Google 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. https://doi.org/10.1097/ALN.0b013e3181d3d641.

    Article  PubMed  Google 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. https://doi.org/10.1093/bja/aet485.

    CAS  Article  PubMed  Google 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. https://doi.org/10.23736/S0375-9393.18.12837-9.

    Article  PubMed  Google 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. https://doi.org/10.1093/bja/aet110.

    CAS  Article  PubMed  Google 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. https://doi.org/10.1093/bja/aes001.

    CAS  Article  PubMed  Google 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. https://doi.org/10.1093/bja/aeq203.

    CAS  Article  PubMed  Google 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. https://doi.org/10.1007/s12630-017-0887-z.

    Article  PubMed  Google 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. https://doi.org/10.1097/EJA.0000000000000304.

    CAS  Article  PubMed  Google 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. https://doi.org/10.1111/j.1365-2044.2008.05834.x.

    CAS  Article  PubMed  Google 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. https://doi.org/10.1093/bja/aet111.

    CAS  Article  PubMed  Google 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. https://doi.org/10.1097/EJA.0000000000000095.

    Article  PubMed  Google 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.

    CAS  Article  Google 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.

    CAS  Article  Google 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.

    CAS  Article  Google Scholar 

  20. 20.

    Aldrete JA. Modifications to the postanesthesia score for use in ambulatory surgery. J Perianesth Nurs. 1998;13:148–55.

    CAS  Article  Google 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. https://doi.org/10.1111/anae.14327.

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Smith WD, Dutton RC, Smith NT. Measuring the performance of anesthetic depth indicators. Anesthesiology. 1996;84:38–51.

    CAS  Article  Google Scholar 

  23. 23.

    Boselli E, Jeanne M. Analgesia/nociception index for the assessment of acute postoperative pain. Br J Anaesth. 2014;112:936–7. https://doi.org/10.1093/bja/aeu116.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Galletly DC, Buckley DH, Robinson BJ, Corfiatis T. Heart rate variability during propofol anaesthesia. Br J Anaesth. 1994;72:219–20.

    CAS  Article  Google 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. https://doi.org/10.1111/anae.13505.

    CAS  Article  PubMed  Google 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. https://doi.org/10.1016/j.ijoa.2012.01.001.

    Article  PubMed  Google 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. https://doi.org/10.1213/01.ane.0000202380.22997.24.

    Article  PubMed  Google Scholar 

  28. 28.

    Metz CE. Basic principles of ROC analysis. Semin Nucl Med. 1978;8:283–98.

    CAS  Article  Google 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. https://doi.org/10.1016/j.clinph.2009.02.170.

    Article  PubMed  Google 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. https://doi.org/10.1097/AJP.0000000000000083.

    Article  PubMed  Google 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. https://doi.org/10.3389/fphys.2018.01199.

    Article  PubMed  PubMed Central  Google 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. https://doi.org/10.1007/bf00605995.

    CAS  Article  PubMed  Google Scholar 

  33. 33.

    Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales. J Clin Nurs. 2005;14:798–804. https://doi.org/10.1111/j.1365-2702.2005.01121.x.

    Article  PubMed  Google 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. https://doi.org/10.1016/j.jpainsymman.2010.08.016.

    Article  PubMed  Google 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. https://doi.org/10.1111/j.1399-6576.2011.02639.x.

    CAS  Article  PubMed  Google Scholar 

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Acknowledgments

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).

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Correspondence to Ji-Yeon Bang.

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Lee, JH., Choi, BM., Jung, YR. et al. Evaluation of Surgical Pleth Index and Analgesia Nociception Index as surrogate pain measures in conscious postoperative patients: an observational study. J Clin Monit Comput 34, 1087–1093 (2020). https://doi.org/10.1007/s10877-019-00399-5

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Keywords

  • Conscious
  • Pain
  • Performance
  • Surgical Pleth Index
  • Analgesia Nociception Index