Ability of the Nociception Level, a Multiparameter Composite of Autonomic Signals, to Detect Noxious Stimuli during Propofol–Remifentanil Anesthesia

Martini, C.H.; Boon, Martijn; Broens, Suzanne; Hekkelman, Evelien F.; Oudhoff, Lisanne A.; Buddeke, Anna Willemijn; Dahan, Albert

doi:10.1097/aln.0000000000000757

Cited by 122 publications

(88 citation statements)

References 32 publications

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“…In our study, the dose of remifentanil was not particularly high and yet the attenuation of pain response was quite marked. Although both tolerance and hyperalgesia can occur with remifentanil, it is not clinically manifested with average doses around 3–6 ng.ml −1 (0.15–0.35 μg.kg.min −1 ) and it would be unusual for patients to require higher doses than this during surgery .…”

Section: Discussionmentioning

confidence: 99%

The effect of remifentanil on propofol requirements to achieve loss of response to command vs. loss of response to pain

et al. 2017

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SummaryWhen providing total intravenous anaesthesia, careful selection of end-points is required in titrating dose to effect during induction. Although propofol and remifentanil have predominantly different pharmacodynamic effects, they are seen to interact in achieving loss of consciousness and analgesia. To highlight these differences, we performed a double-blind, randomised controlled trial, comparing one group of patients receiving propofol alone (n = 42) with another group receiving remifentanil plus propofol (n = 46) as a target-controlled infusion of remifentanil (Minto; 3 ng.ml À1 ). Propofol was also titrated using a target-controlled infusion (Marsh effect model) to produce loss of response to tactile and vocal stimuli, and subsequently to loss of response to pain. The effect-site concentration of propofol at which 50% of patients lost tactile/verbal response was 2.9 lg.ml À1 in the propofol only group and 2.4 lg.ml À1 in the remifentanil with propofol group. In contrast, loss of pain response occurred at 4.4 lg.ml À1 in the propofol group, and 2.7 lg.ml À1 in the remifentanil with propofol group, with correspondingly lower bispectral index values. Judicious use of analgesia in total intravenous anaesthesia can have a propofol-sparing effect and potentially minimise the suppression of brain electrical activity.

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Section: Discussionmentioning

confidence: 99%

The effect of remifentanil on propofol requirements to achieve loss of response to command vs. loss of response to pain

et al. 2017

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“…Using a target controlled infusion (TCI), a dose range of 3–7 ng.ml −1 is usual. Boluses of 1 μg.kg −1 or TCI up to around 12 ng.ml −1 can be used in healthy patients to attenuate the short‐term stress of particularly noxious stimuli such as tracheal intubation .…”

Section: Clinical Importance Of Remifentanilmentioning

confidence: 99%

Remifentanil tolerance and hyperalgesia: short‐term gain, long‐term pain?

et al. 2016

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SummaryThe unique pharmacology of remifentanil makes it a popular intra-operative analgesic. Short-acting opioids like remifentanil have been associated with acute opioid tolerance and/or opioid-induced hyperalgesia, two phenomena which have different mechanisms and are pharmacologically distinct. Clinical studies show heterogeneity of remifentanil infusion regimens, durations of infusion, maintenance of anaesthesia, cumulative dose of remifentanil and pain measures, which makes it difficult to draw conclusions about the incidence of acute tolerance or hyperalgesia. However, it appears that intra-operative remifentanil infusion rates of above 0.25 lg.kg À1.min À1 are associated with higher postoperative opioid consumption, suggesting tolerance. Infusion rates greater than 0.2 lg.kg À1.min À1 are characterised by lower mechanical/pressure/cold/pain thresholds, which suggests hyperalgesia. The use of concurrent multimodal analgesia, especially N-methyl-D-aspartate receptor antagonists, may be an effective preventive strategy.The clinical significance and long-term consequences of these entities is still uncertain.

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“…hypertension and hypotension), reliable nociception monitors may help optimize anesthetic management. Evidence from preclinical validation studies show that these monitors distinguish noxious and non-noxious events far better than hemodynamic responses [2][3][4][5][6].…”

Section: Introductionmentioning

confidence: 99%

Does nociception monitor-guided anesthesia affect opioid consumption? A systematic review of randomized controlled trials

Meijer

Niesters

Velzen

et al. 2019

J Clin Monit Comput

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Monitors that estimate nociception during anesthesia may be used to guide opioid and other analgesics administration to optimize anesthesia care and possibly outcome. We reviewed the literature to evaluate current evidence of the effect of nociception-guided management over standard anesthesia practice during surgery. A systematic review of the literature on the effect of nociception monitoring on anesthesia practice was conducted. Reports were eligible if they compared nociception-guided anesthesia to standard practice during surgery. Primary endpoint of this review is intraoperative opioid consumption. Secondary endpoints included hemodynamic control, postoperative pain and pain treatment. We identified 12 randomized controlled trials that compared one of five different nociception monitoring techniques to standard anesthesia care. Most studies were single center studies of small sample size. Six studies reported intraoperative opioid consumption as primary outcome. There was considerable variability with respect to surgical procedure and anesthesia technique. For nociception monitors that were investigated by more than one study, analysis of the pooled data was performed. The surgical plethysmographic index was the only monitor for which an intra operative opioid sparing effect was found. For the other monitors, either no effect was detected, or pooled analysis could not be performed due to paucity of study data. On secondary outcomes, no consistent effect of nociception-guided anesthesia could be established. Although some nociception monitors show promising results, no definitive conclusions regarding the effect of nociception monitoring on intraoperative opioid consumption or other anesthesia related outcome can be drawn. Clinical trial number PROSPERO ID 102913.

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Ability of the Nociception Level, a Multiparameter Composite of Autonomic Signals, to Detect Noxious Stimuli during Propofol–Remifentanil Anesthesia

Abstract: The NoL is a reliable measure of moderate and intense noxious stimulation and outperforms HR and MAP in differentiating noxious from nonnoxious stimuli. In contrast to HR and MAP, the NoL was not affected by hemodynamic effects of remifentanil.

Cited by 122 publications

References 32 publications

The effect of remifentanil on propofol requirements to achieve loss of response to command vs. loss of response to pain

The effect of remifentanil on propofol requirements to achieve loss of response to command vs. loss of response to pain

Remifentanil tolerance and hyperalgesia: short‐term gain, long‐term pain?

Does nociception monitor-guided anesthesia affect opioid consumption? A systematic review of randomized controlled trials

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