Exactitud diagnóstica del índice de nocicepción analgesia para la evaluación del dolor en pacientes críticos / Diagnostic accuracy of analgesia nociception index for pain assessment in critically ill patients / Precisão diagnóstica do índice de analgesia nocicepção para avaliação da dor em pacientes críticos

Resumen: La evaluación de la presencia de dolor en el enfermo sometido a sedación profunda y ventilación mecánica es posible a través de escalas que se basan en datos clínicos indirectos. El índice de nocicepción analgesia (ANI) es utilizado en enfermos anestesiados en la sala quirúrgica. La información sobre su eficacia en los enfermos críticos es escasa. Este trabajo prospectivo, observacional y analítico evalúa el rendimiento diagnóstico de ANI para detectar dolor en los enfermos críticos en ventilación mecánica, sedados con RASS de -3 a -1. Como estándar se utilizaron dos escalas clínicas (BPS y CPOT) aplicadas por médicos y enfermeras de manera simultánea a la medición de ANI, en cuatro ocasiones durante un periodo de 12 minutos. En 23 enfermos y 224 mediciones, la capacidad discriminativa medida a través de áreas por debajo de curvas ROC osciló entre 0.779 y 0.817. El puntaje de ANI con mejor capacidad diagnóstica osciló entre 52 y 55. Utilizando el valor umbral de 50, la sensibilidad osciló entre 0.418 y 0.524, la especificidad entre 0.910 y 0.980. Se reportan los valores predictivos y las razones de verosimilitud. Los cambios en ANI y las escalas, originados por procedimientos durante la medición, tuvieron una concordancia que osciló entre 28 y 41%. Los resultados identifican una tecnología con potencial para su utilización en el enfermo crítico. Son necesarios más estudios que corroboren nuestros resultados.

Abstract: The assessment of pain in patients undergoing deep sedation and mechanical ventilation is possible through scales that are based on indirect clinical data. The Analgesia Nociception Index (ANI) is used in anesthetized patients in the operating room. Information on its efficacy in critically ill patients is scarce. This prospective, observational and analytical study evaluates the diagnostic performance of ANI to detect pain in critically ill patients on mechanical ventilation and sedated (RASS from -3 to -1). Two clinical scales (BPS and CPOT) were used as standard, applied by doctors and nurses simultaneously to the ANI measurement, on four occasions during a 12-minute period. In 23 patients and 224 measurements, the discriminative capacity measured through ROC curve areas ranged between 0.779 and 0.817. The ANI score with the best diagnostic capacity ranged between 52 and 55. Using the threshold value of 50, the sensitivity ranged between 0.418 and 0.524, the specificity between 0.910 and 0.980. Predictive values and likelihood ratios are reported. The changes in ANI and the scales, originated by procedures during the measurement, had a concordance that ranged between 28 and 41%. The results identify a technology with potential for use in the critically ill. More studies are needed to corroborate our results.

Resumo: A avaliação da presença de dor em pacientes submetidos à sedação profunda e ventilação mecânica é possível por meio de escalas baseadas em dados clínicos indiretos. O índice de analgesia nocicepção (ANI) é utilizado em pacientes anestesiados na sala de cirurgia. As informações sobre sua eficácia em pacientes críticos são escassas. Este estudo prospectivo, observacional e analítico avalia o desempenho diagnóstico do ANI para detectar dor em pacientes críticos em ventilação mecânica, sedados com RASS de -3 a -1. Como padrão, foram utilizadas duas escalas clínicas (BPS e CPOT) aplicadas por médicos e enfermeiros simultaneamente à medida do ANI, em quatro ocasiões durante um período de 12 minutos. Em 23 pacientes e 224 medidas, a capacidade discriminativa medida através das áreas sob as curvas ROC variou entre 0.779 e 0.817. O escore ANI com melhor capacidade diagnóstica variou entre 52 e 55. Utilizando o valor limite de 50, a sensibilidade variou entre 0.418 e 0.524, a especificidade entre 0.910 e 0.980. Relatam-se valores preditivos e razões de verossimilhança. As alterações no ANI e nas escalas, causadas por procedimentos durante a medição, tiveram uma concordância que variou entre 28 e 41%. Os resultados identificam uma tecnologia com potencial para uso em pacientes críticos. Mais estudos são necessários para corroborar nossos resultados.

Analgesia Nociception Index: assessment of acute postoperative pain / Índice de Analgesia/Nocicepção: avaliação da dor aguda pós-operatória

Abstract Background and objectives Patient self-rating based scales such as Numerical Rating Scale, Visual Analog Scale that is used for postoperative pain assessment may be problematic in geriatric or critically ill patients with communication problems. A method capable of the assessment of pain in objective manner has been searched for years. Analgesia nociception index, which is based on electrocardiographic data reflecting parasympathetic activity, has been proposed for this. In this study we aimed to investigate the effectiveness of analgesia nociception index as a tool for acute postoperative pain assessment. Our hypothesis was that analgesia nociception index may have good correlation with Numerical Rating Scale values. Methods A total of 120 patients of American Society of Anesthesiologists (ASA) physical status I and II undergoing any surgical procedure under halogenated-based anesthesia with fentanyl or remifentanil were enrolled for the study. At the 15th minute of arrival to the Postoperative Care Unit the patients' pain was rated on a 0-10 point Numerical Rating Scale. The patients' heart rate, blood pressure, and analgesia nociception index scores were simultaneously measured at that time. The correlation between analgesia nociception index, heart rate, blood pressure and Numerical Rating Scale was examined. Results The study was completed with 107 patients, of which 46 were males (43%). Mean (SD) analgesia nociception index values were significantly higher in patients with initial Numerical Rating Scale ≤3, compared with Numerical Rating Scale >3 (69.1 [13.4] vs. 58.1 [12.9] respectively, p < 0.001). A significant negative linear relationship (r 2 = -0.312, p = 0.001) was observed between analgesia nociception index and Numerical Rating Scale. Conclusion Analgesia nociception index measurements at postoperative period after volatile agent and opioid-based anesthesia correlate well with subjective Numerical Rating Scale scores.

Resumo Justificativa e objetivo As escalas baseadas na autoavaliação de pacientes, como a Escala Visual Numérica e a Escala Visual Analógica, que são usadas para avaliar a dor pós-operatória podem ser problemáticas em pacientes geriátricos ou em estado crítico com problemas de comunicação. Portanto, um método capaz de avaliar a dor de maneira objetiva vem sendo pesquisado há anos. O índice de analgesia/nocicepção, baseado em dados eletrocardiográficos que refletem a atividade parassimpática, tem sido proposto para tal avaliação. Neste estudo, objetivamos investigar a eficácia do índice de analgesia/nocicepção como uma ferramenta para a avaliação da dor pós-operatória aguda. Nossa hipótese foi que o índice de analgesia/nocicepção pode ter boa correlação com os valores da Escala de Classificação Numérica. Métodos Um total de 120 pacientes com estado físico ASA I e II, submetidos a qualquer procedimento cirúrgico com o uso de anestésicos halogenados associados a fentanil ou remifentanil, foi incluído no estudo. No 15º minuto após a chegada à sala de recuperação pós-anestesia, a dor dos pacientes foi avaliada em uma escala numérica de 0-10 pontos. Os escores de frequência cardíaca, pressão arterial e o índice de analgesia/nocicepção dos pacientes foram medidos simultaneamente naquele momento. A correlação entre o índice de analgesia/nocicepção, frequência cardíaca, pressão arterial e a Escala Visual Numérica foi avaliada. Resultados O estudo foi concluído com 107 pacientes, dos quais 46 eram do sexo masculino (43%). Os valores da média (DP) do índice de analgesia/nocicepção foram significativamente maiores nos pacientes com valor inicial na Escala Visual Numérica ≤ 3, em comparação com valor na mesma escala > 3 (69,1 [13,4] vs. 58,1 [12,9], respectivamente, p < 0,001). Uma relação linear negativa significativa (r2 = -0,312, p = 0,001) foi observada entre o índice de analgesia/nocicepção e a Escala Visual Numérica. Conclusão As mensurações do índice de analgesia/nocicepção no pós-operatório após anestesia com agentes halogenados e opioides mostraram boa correlação com os escores subjetivos da Escala Visual Numérica.

Effectiveness of analgesia nociception index on pain assessment in laparoscopic surgery under total intravenous anesthesia / 实用医学杂志

Objective To observe the correlation between analgesia nociception index (ANI) and hemodynamic changes during laparoscopic surgery after tracheal intubation andto assess the effectiveness of ANI.Methods A multicenter, prospective clinical study was conducted and 284 patients underwent laparoscopic surgery were enrolled. Patients were monitored after entering the operating room. Endotracheal intubation was completed by anesthesia induction with target controlled remifentanil and propofol, after arterial and central venous catheterization were improved. Anesthesia was maintainedby continued propofol and remifentanil target controlled infusion.The ANI value, systolic pressure, heart rate of 5 minutes after completion of the entry, completion of the first trocar and completion of all the trocars were recorded. The ANI values and the changes in the vital signs (systolicblood pressure and heart rate) were observed during the laparoscopic operation, and the effectiveness of the ANI index to assess the pain caused by the insertion of a laparoscope trocar was evaluated. Results (1) The area under the ANI curve was positively correlated with the one under thesystolic blood pressure and the heart rate curve during the period from cutting the skin to 5 mins after completing all the trocars (P < 0.05). (2) ANI was negatively correlated with SBP and HR when skin incision and the first trocar were completed (P < 0.001). Conclusions The changes in ANI were in accordance with the balance between analgesic and noxious stimuli, and negatively correlated with the changes insystolic blood pressure and heart rate. ANI could accurately evaluate the pain situation when the card was inserted.

Analgesia nociception index guides remifentanil administration during general anesthesia in posterior lumbar spinal surgery / 基础医学与临床

Objective_To evaluate the clinical profile of ANI-guided remifentanil administration during posterior lumbar spinal surgery.Methods_Sixty patients undergoing selective posterior lumbar decompression laminectomy and internal fixation were randomized into two groups, ANI-guided analgesia group ( ANI group) and another group which was blinded to ANI ( control group) .In both groups, combined propofol-remifentanil target control infusion ( TCI) was performed, In ANI group, the concentration of remifentanil was adjusted to maintain ANI values be-tween 50 and 70, however, in the control group, remifentanil target concentration was adapted corresponding to HR or BP values.Anesthetics consumption, incidence of unwanted events, interventions, time of open-eyes and extu-bation, VAS0h and VAS1/2h, complementary analgesics, intraoperative awareness, PONV and other symptoms were recorded.Results_Remifentanil consumption was lower in ANI group than that in control group ( P between two groups.Conclusions_ANI-guided remifentanil infusion resulted in application of lower remifentanil administered dose with more stable hemodynamics in posterior lumbar spinal surgery.