Nociception Level Index (NOL) guided analgesia has previously been found to correlate with noxious stimuli during surgery. It was aim of this study to investigate the relationship between intra-operative NOL and acute postoperative pain. After IRB approval, 80 patients scheduled for non-emergency surgery were enrolled. NOL data were recorded from induction of anaesthesia until the end of surgery. After admission to the postoperative acute care unit (PACU), pain scores (numeric rating scale [NRS, 0–10] were obtained 5-minutely for 15 min. NOL data of 74 patients were analyzed. Receiver-operating curve (ROC) analysis identified the NOL reaction to the knife to skin incision (median NOL within 60 s post knife to skin) vs. the median NOL during surgery vs. NOL at the end of surgery to have the highest correlation coefficient (ρ = 0.3; P = 0.01) as well as the highest area under the ROC curve (AUC 0.68; P = 0.01) for the prediction of moderate-severe pain in PACU. A NOL > 20 after skin incision predicted moderate-severe postoperative pain with the highest combined sensitivity (73%) and specificity (58%). A NOL < 10 after skin incision excluded moderate-severe pain in PACU with a negative predictive value of 83%. The NOL reaction to skin incision, but not NOL during surgery appears to allow the exclusion and, to a lesser degree the prediction of moderate-severe pain in PACU. The results may also strengthen the manufacturers recommendation of an intraoperative NOL range of 10–25.
Australian New Zealand Clinical Trials Registry: ACTRN12619001596190.
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Ledowski T. Objective monitoring of nociception: a review of current commercial solutions. Br J Anaesth. 2019;123(2):e312–21. https://doi.org/10.1016/j.bja.2019.03.024.
Pogatzki-Zahn EM, Segelcke D, Schug SA. Postoperative pain-from mechanisms to treatment. Pain Rep. 2017;2(2):e588. https://doi.org/10.1097/PR9.0000000000000588.
Edry R, Recea V, Dikust Y, Sessler DI. Preliminary intraoperative validation of the nociception level index: a noninvasive nociception monitor. Anesthesiology. 2016;125(1):193–203. https://doi.org/10.1097/ALN.0000000000001130.
Martini CH, Boon M, Broens SJ, Hekkelman EF, Oudhoff LA, Buddeke AW, Dahan A. Ability of the nociception level, a multiparameter composite of autonomic signals, to detect noxious stimuli during propofol-remifentanil anesthesia. Anesthesiology. 2015;123(3):524–34. https://doi.org/10.1097/ALN.0000000000000757.
Stockle PA, Julien M, Issa R, Decary E, Brulotte V, Drolet P, Henri M, Poirier M, Latulippe JF, Dorais M, Verdonck O, Fortier LP, Richebe P. Validation of the PMD100TM and its NOLTM Index to detect nociception at different infusion regimen of remifentanil in patients under general anaesthesia. Minerva Anestesiol. 2018. https://doi.org/10.23736/S0375-9393.18.12720-9.
Renaud-Roy E, Stockle PA, Maximos S, Brulotte V, Sideris L, Dube P, Drolet P, Tanoubi I, Issa R, Verdonck O, Fortier LP, Richebe P. Correlation between incremental remifentanil doses and the Nociception Level (NOL) index response after intraoperative noxious stimuli. Can J Anaesth. 2019;66(9):1049–61. https://doi.org/10.1007/s12630-019-01372-1.
Bollag L, Jelacic S, Delgado Upegui C, Wu C, Richebe P. The nociception level index (NOL) response to intubation and incision in patients undergoing video-assisted thoracoscopic surgery (VATS) with and without thoracic epidural analgesia. A pilot study. F1000Res. 2018;7:875. https://doi.org/10.12688/f1000research.15279.1.
Meijer FS, Martini CH, Broens S, Boon M, Niesters M, Aarts L, Olofsen E, van Velzen M, Dahan A. Nociception-guided versus standard care during remifentanil-propofol anesthesia: a randomized controlled trial. Anesthesiology. 2019;130(5):745–55. https://doi.org/10.1097/ALN.0000000000002634.
Cividjian A, Petitjeans F, Liu N, Ghignone M, de Kock M, Quintin L. Do we feel pain during anesthesia? A critical review on surgery-evoked circulatory changes and pain perception. Best Pract Res Clin Anaesthesiol. 2017;31(4):445–67. https://doi.org/10.1016/j.bpa.2017.05.001.
Boselli E, Bouvet L, Begou G, Dabouz R, Davidson J, Deloste JY, Rahali N, Zadam A, Allaouchiche B. Prediction of immediate postoperative pain using the analgesia/nociception index: a prospective observational study. Br J Anaesth. 2014;112(4):715–21. https://doi.org/10.1093/bja/aet407.
Ledowski T, Schmitz-Rode I. Predicting acute postoperative pain by the Qnox score at the end of surgery: a prospective observational study. Br J Anaesth. 2020;124(2):222–6. https://doi.org/10.1016/j.bja.2019.09.041.
Ledowski T, Schneider M, Gruenewald M, Goyal RK, Teo SR, Hruby J. Surgical pleth index: prospective validation of the score to predict moderate-to-severe postoperative pain. Br J Anaesth. 2019;123(2):e328–32. https://doi.org/10.1016/j.bja.2018.10.066.
Persson AK, Pettersson FD, Dyrehag LE, Akeson J. Prediction of postoperative pain from assessment of pain induced by venous cannulation and propofol infusion. Acta Anaesthesiol Scand. 2016;60(2):166–76. https://doi.org/10.1111/aas.12634.
Werner MU, Duun P, Kehlet H. Prediction of postoperative pain by preoperative nociceptive responses to heat stimulation. Anesthesiology. 2004;100(1):115–9 (discussion 115A).
Stepanova Ia V, Shchelkova O, Lebedinskii KM, Mazurok VA. Prediction of postoperative pain on the basis of the psychological characteristics of patients and standard pain stimuli. Anesteziol Reanimatol. 2013;3:58–63.
Nielsen PR, Norgaard L, Rasmussen LS, Kehlet H. Prediction of post-operative pain by an electrical pain stimulus. Acta Anaesthesiol Scand. 2007;51(5):582–6. https://doi.org/10.1111/j.1399-6576.2007.01271.x.
Haghverdian BA, Wright DJ, Schwarzkopf R. Pressure pain threshold as a predictor of acute postoperative pain following total joint arthroplasty. Surg Technol Int. 2016;29:320–7.
McKay RE, Neice AE, Larson MD. Pupillary unrest in ambient light and prediction of opioid responsiveness: case report on its utility in the management of 2 patients with challenging acute pain conditions. A A Pract. 2018;10(10):279–82. https://doi.org/10.1213/XAA.0000000000000710.
Neice AE, Behrends M, Bokoch MP, Seligman KM, Conrad NM, Larson MD. Prediction of opioid analgesic efficacy by measurement of pupillary unrest. Anesth Analg. 2017;124(3):915–21. https://doi.org/10.1213/ANE.0000000000001728.
Jakuscheit A, Weth J, Lichtner G, Jurth C, Rehberg B, von Dincklage F. Intraoperative monitoring of analgesia using nociceptive reflexes correlates with delayed extubation and immediate postoperative pain: a prospective observational study. Eur J Anaesthesiol. 2017;34(5):297–305. https://doi.org/10.1097/EJA.0000000000000597.
The authors would like to thank the team from Medasense for their help with components of the data analysis (TWA analysis).
This study was funded by the investigators via an unrestricted research grant by the Royal Perth Hospital Dept. of Anaesthesia and Pain Medicine. Medasense provided in kind support with a section of the data analysis (see details in methods).
Conflict of interest
The authors do not declare a conflict of interest. The team from Medasense who helped analyzing the NOL TWA data were always blinded to the outcome parameters investigated in this study and had no influence on the manuscript preparation.
This trial was approved by the Ethics Committee of the South Metropolitan Health Service, Murdoch, WA, on 25.10.2019 under file no. RGS3573.
Written informed consent was obtained from all participants in this trial.
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Ledowski, T., Schlueter, P. & Hall, N. Nociception level index: do intra-operative values allow the prediction of acute postoperative pain?. J Clin Monit Comput (2021). https://doi.org/10.1007/s10877-021-00654-8
- Nociception level index
- Postoperative pain