Nociception monitoring tools using autonomic tone changes for intraoperative analgesic guidance in pediatric patients

Abstract

Nociception monitoring devices using changes in autonomic nervous system activity have been developed in numerous ways. Although there have been few studies conducted on children, compared to the relatively higher number of studies on adults, most of the nociception monitors in children, as in adults, appear to be more useful than the standard clinical practice that uses hemodynamic parameters in the evaluation and treatment of intraoperative nociception (pain) during general anesthesia. Particularly, when monitoring the surgical pleth index (SPI) in anesthetized children, the application of a new target range of SPI values (≤ 40) to the SPI monitoring criteria seems to be necessary for providing a more proper intraoperative analgesia. The analgesia nociception index (ANI) shows promising results in anesthetized adults, and recently, positive results along with cardiorespiratory coherence have been reported in pediatric patients. Newborn infant parasympathetic evaluation (NIPE) could be useful for providing adequate analgesia in newborns, infants, and children under 2 years of age in anesthetized or awake states. In cases of skin conductance and pupillometry, further studies are needed. Understanding the pros, cons, and limitations of these nociception monitoring tools will provide more effective and safe intraoperative analgesia to pediatric patients undergoing general anesthesia, and it may also help to plan and conduct promising research on the use of perioperative nociception monitoring in pediatric patients in the future.

Cholinesterase activity in serum during general anesthesia in patients with or without vascular disease

“…A current review of the anesthesia literature suggests that heart rate variability (HRV) tracking can be used as a surrogate marker for sympathetic response and for analgesic management in clinical practice 21 . A recent study by Wujtewicz et al used an HRV method to evaluate the relationship between the baseline autonomic tone and the vagotonic effect of a bolus dose of remifentanil 22 .…”

Surgical pleth index monitoring in perioperative pain management: usefulness and limitations

“…Moreover, SPI monitoring in the elderly can detect nociceptor stimulation masked by hypotension due to decreased myocardial contractility, decreased vascular elasticity, and decreased β--adrenergic response, providing appropriate analgesia with sufficient intraoperative analgesic consumption [15]. However, several studies evaluating SPI-guided intraoperative analgesic administration in children have yielded conflicting results that do not seem to provide adequate analgesia within a target range of 20-50 SPI values [10,18,31]. Since children usually have higher blood vessel distensibility and baseline heart rates than adults [10] and autonomic control of cardiac chronotropic function is strongly influenced by age [32,33], the SPI value can be less valid in children than in adults [18].…”

“…However, several studies evaluating SPI-guided intraoperative analgesic administration in children have yielded conflicting results that do not seem to provide adequate analgesia within a target range of 20-50 SPI values [10,18,31]. Since children usually have higher blood vessel distensibility and baseline heart rates than adults [10] and autonomic control of cardiac chronotropic function is strongly influenced by age [32,33], the SPI value can be less valid in children than in adults [18]. This suggests that clinicians should be cautious when considering the use of SPI in pediatric practice.…”

“…However, some studies with conflicting results have reported that SPIguided analgesia alone does not reduce intraoperative opioid consumption [14] or that SPI-guided analgesia provides appropriate analgesia with sufficient (compared to control which was insufficient) intraoperative remifentanil consumption [15]. Moreover, several studies have shown that SPI monitoring has various limitations because the two parameters that determine SPI, HBI and PPGA, can be influenced by not only surgical stress but also other confounding factors or different characteristics such as vasoactive drugs, population age, and cardiac arrhythmia [16][17][18][19][20].…”

Evaluation of Nociception during Pediatric Surgery: A Topical Review

“…As a result, a SPI of 40 or lower may be a better cut-off in this population [ 58 ]. In a study involving children >4 years of age [ 59 ], the median SPI (named SSI in the study) was higher than baseline and above 50 (range 31.7–60.1) during intubation and surgical stimulation, but the SPI variability was high (ΔSPI range −9.9 to 37.5 after intubation and −7.2 to 16.9 after the beginning of surgery). Although the SPI increase was statistically significant, baseline SPI could be as low as 22.6 and as high as 58.0 and the study did not consider the dependency between observations.…”