Nociception level index: do intra-operative values allow the prediction of acute postoperative pain?


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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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).

Author information




All authors significantly contributed to both, study and manuscript (TL: study design, data analysis and manuscript preparation; PS: data collection, analysis and manuscript preparation; NH: data collection and manuscript preparation.

Corresponding author

Correspondence to Thomas Ledowski.

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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.

Ethical approval

This trial was approved by the Ethics Committee of the South Metropolitan Health Service, Murdoch, WA, on 25.10.2019 under file no. RGS3573.

Informed consent

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).

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  • Nociception
  • Nociception level index
  • Postoperative pain
  • Prediction