BJA Advance Access originally published online on January 23, 2006
British Journal of Anaesthesia 2006 96(3):367-376; doi:10.1093/bja/ael005
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Novel multiparameter approach for measurement of nociception at skin incision during general anaesthesia
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1 Department of Anaesthesia, Tampere University Hospital, PO Box 2000, FIN-33521 Tampere, Finland. 2 Medical School, University of Tampere, FIN-33014, Finland. 3 VTT Information Technology, PO Box 1206, FIN-33101 Tampere, Finland. 4 GE Healthcare Finland, PO Box 900, FIN-00031 GE, Finland. 5 Department of Anaesthesia and Intensive Care, Helsinki University Central Hospital, PO Box 340, FIN-00029 HUS, Finland
* Corresponding author. E-mail: arvi.yli-hankala{at}uta.fi
Background. Direct indicators for the evaluation of the nociceptive–anti-nociceptive balance during general anaesthesia do not exist. The aim of this study was to combine physiological parameters to obtain such an indicator.
Methods. Fifty-five females scheduled for surgery under general anaesthesia combining target-controlled infusions of propofol and remifentanil were studied. Propofol was given to maintain state entropy (SE) at 50 and remifentanil was targeted at 1, 3 or 5 ng ml–1. The patients' reactions and clinical signs of nociception, remifentanil levels and estimation of noxious intensity of incision were combined into a clinical score [Clinical Signs–Stimulus–Antinociception (CSSA)] to evaluate the nociceptive–anti-nociceptive balance. ECG, photoplethysmography (PPG), response entropy (RE) and SE were recorded from 60 s before to 120 s after skin incision. Differences between post- and pre-incision values of heart rate variability (HRV), PPG and pulse transition time related parameters were analysed off-line to evidence the best predictors of CSSA. Those best predictors of CSSA served to develop a response index of nociception (RN), scaled from 0 to 100. This index was further tested in 10 additional patients.
Results. HRV, RE, RE–SE and PPG variability were the best predictors of CSSA. The prediction probability of RN at predicting CSSA was 0.78. RN response was higher after larger incision, in movers and with lower remifentanil concentrations.
Conclusions. The empirically developed algorithm of RN leads to an index that seems to adequately estimate the nociceptive–anti-nociceptive balance at skin incision during general anaesthesia. In the future, CSSA may serve as a reference for studies investigating methods aimed at evaluating this pharmacodynamic component of anaesthesia.
Presented in part at the annual Euroanaesthesia meeting, Vienna, Austria, May 28–31, 2005.
Declaration of interest. Dr Rantanen has received two direct research grants from GE Healthcare, Finland. Dr Yli-Hankala is a paid medical advisor for GE Healthcare Finland, Helsinki, Finland. Dr Huiku, Mr Takala and Mr Kymäläinen are employees of GE Healthcare, Finland. Dr Seitsonen has received equipment and personnel support from Datex-Ohmeda for her previous adequacy of anaesthesia-related studies. Both Tampere University Hospital, Department of Anaesthesia, and VTT Information Technology have received funding for this particular study from GE Healthcare, Finland.
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