Newly Published
Perioperative Medicine  |   May 2017
Validation of Innovative Techniques for Monitoring Nociception during General Anesthesia: A Clinical Study Using Tetanic and Intracutaneous Electrical Stimulation
Author Notes
  • From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine (S.F., S.S., B.S., K.B., D.A.R., R.N.), and Institute of Medical Biometry and Epidemiology (H.O.P.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Submitted for publication November 7, 2016. Accepted for publication April 5, 2017.
    Submitted for publication November 7, 2016. Accepted for publication April 5, 2017.×
  • Acknowledgments: The authors thank Sebastian A. Haas, M.D., and Franziska von Breunig, M.D., Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Germany, for their help in conducting the experiments. We further thank all faculty members of the Martini-Klinik, University Medical Center Hamburg-Eppendorf, Germany, for their assistance with patient recruitment. Additionally, the authors thank Dennis Jordan, M.D., Department of Anesthesiology, Klinikum rechts der Isar, Technical University Munich, Germany, for the assignment of the Windows-based program “PK Tool” for computing prediction probability (PK). Finally, we thank Nadine Funcke, Ph.D., Rotterdam School of Management, Erasmus University, Rotterdam, The Netherlands, for her critical review of the draft.
    Acknowledgments: The authors thank Sebastian A. Haas, M.D., and Franziska von Breunig, M.D., Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Germany, for their help in conducting the experiments. We further thank all faculty members of the Martini-Klinik, University Medical Center Hamburg-Eppendorf, Germany, for their assistance with patient recruitment. Additionally, the authors thank Dennis Jordan, M.D., Department of Anesthesiology, Klinikum rechts der Isar, Technical University Munich, Germany, for the assignment of the Windows-based program “PK Tool” for computing prediction probability (PK). Finally, we thank Nadine Funcke, Ph.D., Rotterdam School of Management, Erasmus University, Rotterdam, The Netherlands, for her critical review of the draft.×
  • Research Support: This is an investigator-initiated trial and was supported by departmental funds only. The three monitoring devices used were loaned by the companies mentioned throughout the text.
    Research Support: This is an investigator-initiated trial and was supported by departmental funds only. The three monitoring devices used were loaned by the companies mentioned throughout the text.×
  • Competing Interests: The authors declare no competing interests.
    Competing Interests: The authors declare no competing interests.×
  • Reproducible Science: Full protocol available from: s.funcke@uke.de. Raw data available from: s.funcke@uke.de.
    Reproducible Science: Full protocol available from: s.funcke@uke.de. Raw data available from: s.funcke@uke.de.×
  • Correspondence: Address correspondence to Dr. Funcke: Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany. s.funcke@uke.de.Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Perioperative Medicine / Pain Medicine
Perioperative Medicine   |   May 2017
Validation of Innovative Techniques for Monitoring Nociception during General Anesthesia: A Clinical Study Using Tetanic and Intracutaneous Electrical Stimulation
Anesthesiology Newly Published on May 18, 2017. doi:10.1097/ALN.0000000000001670
Anesthesiology Newly Published on May 18, 2017. doi:10.1097/ALN.0000000000001670
Abstract

Background: This study compares the analgesic indices Analgesia Nociception Index (heart rate variability), Surgical Pleth Index (photoplethysmography), and pupillary dilatation, to heart rate, mean arterial pressure, and bispectral index, with regard to diagnostic accuracy and prediction probability for nociceptive response. The primary endpoint was the correlation between Δ values and the remifentanil dose administered.

Methods: We anesthetized 38 patients with propofol and increasing doses of remifentanil and applied standardized tetanic and intracutaneous electrical painful stimulations on each analgesic level. Baseline and Δ values of the Analgesia Nociception Index, the Surgical Pleth Index, pupillary dilatation, heart rate, mean arterial pressure, and bispectral index and their relation to remifentanil doses were analyzed by receiver operating characteristic curves, prediction probability (PK), and mixed-model analysis.

Results: Under propofol sedation, sensitivity and specificity of the Analgesia Nociception Index (PK = 0.98), the Surgical Pleth Index (PK = 0.87), and pupillary dilatation (PK = 0.98) for detecting both painful stimulations were high compared to heart rate (PK = 0.74), mean arterial pressure (PK = 0.75), and bispectral index (PK = 0.55). Baseline values had limited prediction probability toward the nociceptive response (Analgesia Nociception Index: PK = 0.7; Surgical Pleth Index: PK = 0.63; pupillary dilatation: PK = 0.67; and bispectral index: PK = 0.67). The remifentanil dose had an effect (P < 0.001) on all parameters except for bispectral index (P = 0.216).

Conclusions: The Analgesia Nociception Index, the Surgical Pleth Index, and pupillary dilatation are superior in detecting painful stimulations compared to heart rate and mean arterial pressure but had limited predictive value. These effects are attenuated by increasing dosages of remifentanil. Our data confirm that bispectral index is not a marker of analgesia.