Utility of Nociceptive Flexion Reflex Threshold, Bispectral Index, Composite Variability Index and Noxious Stimulation Response Index as measures for nociception during general anaesthesia

Abstract

SummaryMovement and haemodynamic responses to noxious stimuli during general anaesthesia are regarded as signs of nociception. We compared the Nociceptive Flexion Reflex Threshold (NFRT), Bispectral Index (BIS), Composite Variability Index (CVI), Noxious Stimulation Response Index (NSRI) and the calculated propofol ⁄ remifentanil effectcompartment concentrations (Ce) as predictors for such responses in 50 female subjects at laryngeal mask airway insertion and skin incision. Although the cerebral effect of hypnotics may be monitored using processed electroencephalography, no comparable monitor exists to measure nociception during general anaesthesia. In clinical practice, opioids are administered according to haemodynamic and movement responses to noxious stimuli [1].The correlation of such responses with the hypnotic depth as measured by the bispectral index (BIS) is relatively poor [2,3]. The composite variability index (CVI), which is derived from the BIS, may provide a better correlation and whereas promising results are presented in abstract form [4,5], no full research paper has yet been published.The nociceptive flexion reflex (NFR) is a polysynaptic spinal withdrawal reflex, which can be assessed by electromyography of the biceps femoris muscle

Assessing pain objectively: the use of physiological markers

“…When looking at other potential tools, the nociceptive flexion reflex threshold appears a better predictor of movement and heart rate responses to noxious stimuli under general anaesthesia than either the noxious stimulation response index or propofol–remifentanil effect‐site concentrations . However, it has been criticised as being more specific for muscular activity, rather than detecting pain due to measuring a muscular reflex.…”

Higher doses of intraoperative analgesia are associated with lower levels of persistent pain and less analgesic consumption six months after total hip arthroplasty

“…Currently, a variety of different tools to measure intraoperative nociception and/or analgesia are under investigation in clinical studies. These are based on a wide range of physiological mechanisms including skin conductance (Storm, ), haemodynamics (Wennervirta et al., ; Rossi et al., ; Gruenewald et al., , ), electroencephalogram (Haenggi et al., ; Sahinovic et al., ) and a variety of nociceptive reflexes (von Dincklage et al., , , ; Paulus et al., ; Guglielminotti et al., ; Ly‐Liu and Reinoso‐Barbero, ; Jakuscheit et al., ). Currently, however, none of the tools have been shown to have enough specificity/sensitivity to outweigh the effort and cost of their routine clinical application (Gruenewald and Ilies, ; von Dincklage, ).…”

EEG Based Monitoring of General Anesthesia: Taking the Next Steps

“…But these observations have not been used for current monitors of nociception. These devices use processed EEG like the BIS as subparameters (Ellerkmann et al, 2013; Castro et al, 2016), a wide range of spectral band power (Jensen et al, 2014), or non EEG information from heart rate variability (Ledowski et al, 2013), modeled drug and opioid concentrations (Luginbühl et al, 2010), or the polysynaptic spinal withdrawal reflex (Von Dincklage et al, 2012). One exception is the BAR.…”