Comparison of Pupillometry With Surgical Pleth Index Monitoring on Perioperative Opioid Consumption and Nociception During Propofol–Remifentanil Anesthesia: A Prospective Randomized Controlled Trial

Abstract

BACKGROUND: Intraoperative monitoring with pupillometry has shown promising results for nociception/antinociception balance monitoring. However, its benefits in clinical practice remain unproven. The aim of this study was to evaluate the efficacy of intraoperative pupillometry monitoring on intraoperative opioid consumption and postoperative pain compared to surgical pleth index (SPI), another widely investigated monitoring. METHODS: American Society of Anesthesiologists (ASA) I–II patients scheduled for elective laparoscopic cholecystectomy were included. This prospective, parallel-arm, single-center study was conducted in 2 steps. First, we evaluated the feasibility of using pupillometry and SPI monitoring compared with conventional hemodynamic monitoring. Next, a parallel-arm, double-blind randomized study compared the peak postoperative pain measured with numerical rating scale (NRS) from 0 (no pain) to 10 (extreme pain) as a primary outcome between pupillometry (pupillometry group, n = 43) and SPI monitoring (SPI group, n = 43) using Mann-Whitney U test. Secondary outcomes included intraoperative remifentanil consumption, postoperative opioid responsiveness (a decrease in NRS by ≥1 after fentanyl administrations), number of analgesic administrations, and opioid-related complications. RESULTS: In the preliminary study (n = 50), remifentanil consumption was less under pupillometry monitoring compared to SPI monitoring, and peak postoperative pain was lower under pupillometry compared to conventional monitoring. In the main study (n = 86), peak postoperative pain and intraoperative remifentanil consumption were lower in the pupillometry group (median [first to third quartile], 5 [4–6]; mean ± standard deviation [SD], 0.078 ± 0.019 μg·kg−1·minute−1) compared to the SPI group (7 [5–8] and 0.0130 ± 0.051 μg·kg−1·minute−1; P < .001), with the median difference in peak postoperative pain of −1 and its 95% confidence interval between −2 and −0.5. The pupillometry group had better responsiveness to fentanyl (84.6% vs 61.0%; P = .005) and lower number of analgesic administrations (2 [1–2] vs 2 [1–3]; P = .048) compared to the SPI group. CONCLUSIONS: Intraoperative pupillometry monitoring reduced intraoperative remifentanil consumption and postoperative pain. It may be an alternative option for intraoperative opioid control under general anesthesia in adult patients.

Adequacy of Anesthesia Guidance for Colonoscopy Procedures

“…Different methods of instrumental evaluation of the efficacy of nociception/antinociception balance and OA titration to alleviate the IPP during anesthesia are gaining popularity [ 24 , 33 ]. Soral et al [ 33 ] compared the effects of analgesia management with ANI-guided analgesia versus analgesia guided with conventional methods induced with propofol and ketamine and continued using infusion of propofol and remifentanil in patients undergoing a CP.…”

“…The most widely used are the Bispectral Index (BIS) and a State and Response Entropy EEG (SE & RE EEG) [ 17 , 18 , 19 , 20 ]. In recent years, the Surgical Pleth Index (SPI), a new method of objective assessment of nociception/antinociception balance, has been added to RE and SE order to serve together as the Adequacy of Anesthesia (AoA) concept, a new tool (SPI; GE Healthcare, Helsinki, Finland) that, with different success rates, has been proven useful to guide adequate anesthetic dosages for hypnosis as well as opioids for analgesia [ 21 , 22 , 23 ], aiming to reduce the occurrence of unwelcome adverse events [ 24 , 25 , 26 ].…”

Multiparametric Monitoring of Hypnosis and Nociception-Antinociception Balance During General Anesthesia - A New Era in Patient Safety Standards and Healthcare Management

“…The conclusion was that dose reduction and shorter recovery times can be achieved by adapting general anaesthesia based on the SPI [10]. Huiku et al confirmed in a similar study that SPI monitoring has a beneficial impact on anesthetic drugs used doses, increasing patient safety and the quality of the medical services [67].…”

“…Table 2 summarizes a series of studies regarding the impact of monitoring techniques on the nociception-antinociception balance and on the clinical outcome of patients. Numerous studies have shown that opioid overdose during anesthesia is responsible for a series of adverse effects, such as increased recovery times and opioid induced hyperalgesia, and they also lead to hypotension, having a major impact on perioperative hemodynamic stability [66][67][68][69][70][71]. Won et al, have reported that using SPI monitoring during general anesthesia reduces opioid consumption, improves hemodynamic stability, and reduced postoperative recovery times [71].…”

Multiparametric Monitoring of Hypnosis and Nociception-Antinociception Balance During General Anesthesia - A New Era in Patient Safety Standards and Healthcare Management

“…Figure 1. Technologies/parameters used for monitoring the nociception-antinociception balance [59][60][61][62][63][64][65][66] One of the most widely studied technologies is the analysis of hemodynamic changes and includes the evaluation of the normalized heart beat intervals (HBIs) and of the amplitude of the plethysmographic waves, both correlating with sympathetic and parasympathetic tones. A higher sympathetic tone correlates with the intensity of the surgical stimuli and results in a suppressed plethysmographic amplitude (PPGA).…”