Newly Published
Perioperative Medicine  |   February 2019
Nociception-guided versus Standard Care during Remifentanil–Propofol Anesthesia: A Randomized Controlled Trial
Author Notes
  • From the Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands.
  • The study was presented at the 38th anesthesia research conference at Leiden University Medical Center, Leiden, The Netherlands, on June 16, 2018, and at the American Society of Anesthesiologists annual meeting in San Francisco, California, October 13, 2018, Abstract No. BOC02 (Best of Abstracts: Clinical Science session).
    The study was presented at the 38th anesthesia research conference at Leiden University Medical Center, Leiden, The Netherlands, on June 16, 2018, and at the American Society of Anesthesiologists annual meeting in San Francisco, California, October 13, 2018, Abstract No. BOC02 (Best of Abstracts: Clinical Science session).×
  • Submitted for publication April 15, 2018. Accepted for publication December 31, 2018.
    Submitted for publication April 15, 2018. Accepted for publication December 31, 2018.×
  • Correspondence: Address correspondence to Dr. Dahan: Department of Anesthesiology, Leiden University Medical Center, H5-22, Albinusdreef 2, 2333 ZA Leiden, The Netherlands. a.dahan@lumc.nl. 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 / Quality Improvement / Opioid
Perioperative Medicine   |   February 2019
Nociception-guided versus Standard Care during Remifentanil–Propofol Anesthesia: A Randomized Controlled Trial
Anesthesiology Newly Published on February 26, 2019. doi:10.1097/ALN.0000000000002634
Anesthesiology Newly Published on February 26, 2019. doi:10.1097/ALN.0000000000002634
Abstract

Editor’s Perspective:

What We Already Know about This Topic:

  • The nociception level index (Medasense Biometrics Ltd., Ramat Gan, Israel), is a reliable measure of moderate to intense noxious stimulation during anesthesia and surgery

What This Article Tells Us That Is New:

  • In a randomized trial in patients having major abdominal surgery, compared to standard practice, nociception level-guided analgesia resulted in 30% less intraoperative remifentanil consumption

Background: The multidimensional index of nociception, the nociception level, outperforms blood pressure and heart rate in detection of nociceptive events during anesthesia. We hypothesized that nociception level–guided analgesia reduces opioid consumption and suboptimal anesthesia events such as low blood pressure and use of vasoactive medication.

Methods: In this single-blinded randomized study, 80 American Society of Anesthesiologists class I–III adult patients of either sex, scheduled for major abdominal procedures under remifentanil/propofol anesthesia by target-controlled infusion, were included. During the procedure nociception level, noninvasive blood pressure, and heart rate were monitored. Patients were randomized to receive standard clinical care or nociception level–guided analgesia. In the nociception level–guided group, remifentanil concentration was reduced when index values were less than 10 or increased when values were above 25 for at least 1 min, in steps of 0.5 to 1.0 ng/ml. Propofol was titrated to bispectral index values between 45 and 55. The primary outcomes of the study were remifentanil and propofol consumption and inadequate anesthesia events.

Results: Compared with standard care, remifentanil administration was reduced in nociception level–guided patients from (mean ± SD) 0.119 ± 0.033 to 0.086 ± 0.032 μg · kg-1 · min-1 (mean difference, 0.039 μg · kg-1 · min-1; 95% CI, 0.025–0.052 μg · kg-1 · min-1; P < 0.001). Among nociception level–guided patients, 2 of 40 (5%) experienced a hypotensive event (mean arterial pressure values less than 55 mm Hg) versus 11 of 40 (28%) patients in the control group (relative risk, 0.271; 95% CI, 0.08–0.77; P = 0.006). In the nociception level–guided group, 16 of 40 (40%) patients received vasoactive medication versus 25 of 40 (63%) patients in the standard care group (relative risk, 0.64; 95% CI, 0.40–0.99; P = 0.044).

Conclusions: Nociception level-guided analgesia during major abdominal surgery resulted in 30% less remifentanil consumption.