1 Introduction
Monitor | Manufacturer | Autonomic input variables | Index | Optimal range/cut off |
---|---|---|---|---|
SPI | GE Healthcare | Pulse beat interval Pulse wave amplitude | 0–100 | 20–50 |
ANI | MDoloris Medical Systems | Heart rate variability | 0–100 | 50 |
NOL | Medasense | Heart rate and heart rate variability Pulse wave amplitude Skin conductance | 0–100 | 10–25 |
CARDEAN | Alpha-2 | Blood pressure Heart rate | 0–100 | 60 |
Algiscan | ID Med | Pupil diameter | NA | Pupil diameter increase > 30% |
2 Materials and methods
2.1 Identification of relevant studies
2.2 Data extraction
2.3 Bias assessment
2.4 Data analysis
3 Results
3.1 Study selection
3.2 Study characteristics
First author | Year | Nociception monitor (target for intervention groupa) | Number of patients (intervention/control) | Surgery | Anesthesia technique | Hypnosis monitor (target for all patients) | Patients (ASA, age) | Primary outcome | Comments |
---|---|---|---|---|---|---|---|---|---|
Won [21] | 2016 | SPI (20–50) | 23/22 | Thyroid resection | – Sevoflurane – Oxycodone – Rocuronium | BIS (40–60) | ASA 1–2, 20–65 years. | Intraoperative oxycodone consumption | Single center study. Rescue medication (thiopental) in case of somatic movement despite SPI and BIS values within target boundaries |
Bergmann [17] | 2013 | SPI (20–50 and Δ < 10) | 76/75 | Orthopedic surgery in a supine or beach-chair position | – Propofol – Remifentanil – Mivacurium | SE (40–60) | ASA 1–3, 18–75 years | Propofol (1) and remifentanil (2) consumption. Recovery time (3) | Single center study. There was maximum remifentanil infusion rate. No difference in postoperative pain |
Chen [18] | 2010 | SPIb (20–50) | 40/40 | ENT surgery | – Propofol TCI – Remifentanil TCI – Rocuronium | BIS (40–60) | ASA 1–2, 18–70 years | Number of episodes with inadequate anesthesiad | Single center study. No difference in postoperative pain |
Colombo [19] | 2015 | SPI (< 50) | 30/30 | Laparoscopic chole-cystectomy | – Propofol TCI – Remifentanil TCI – Cis-atracurium | SE (40–60) | ASA 1–2, 18–50 years | Sympathetic modulation | Single center study |
Gruenewald [20] | 2014 | SPI (< 50) | 42/40 | Gynecological or orthopedic surgery | – Sevoflurane – Sufentanil – Rocuronium | BIS (40–60) | ASA 1–2, 18–65 years | Incidence of unwanted somatic events | Single center study |
Jain [16] | 2019 | SPI (20–50) | 70/70 | Laparoscopic cholecystectomy | – Sevoflurane – Fentanyl | BIS (40–60) | ASA 1–2, 18–65 years | Intraoperative fentanyl consumption | Single center study |
Dundar [22] | 2018 | ANI (50–70) | 22/22 | Breast surgery | – Sevoflurane – Remifentanil – Thoracic para-vertebral block | BIS (40–60) | ASA 1–2, females, 18–65 years | Total remifentanil consumption (mentioned in “Discussion”) | Study sites not specified. All patients received a thoracic paravertebral block |
Upton [24] | 2017 | ANI (≥ 50) | 24/26 | Lumbar discectomy or laminectomy | – Sevoflurane – Fentanyl and non-opioid analgesia – Rocuronium | BIS (40–60) | ASA 1–2, 18–75 years | Postoperative NRS | Single center study |
Szental [23] | 2015 | ANI (> 50) | 59/60 | Laparoscopic cholecystectomy | – Sevoflurane or desflurane –Fentanyl, morphine and non-opioid analgesia –Neuromuscular blocker | BIS depth not specified | ASA –, 18–75 years | VAS > 50 mm in first postoperative hour | Study performed in two centers |
Meijer [15] | 2018 | Nociception level (10–25) | 40/40 | Major abdominal surgery: urology (48%), abdominal surgery (39%), gynecology (14%) | – Propofol TCI – Remifentanil TCI – Rocuronium | BIS (45–55) | ASA 1–3, 18–80 years | Propofol (1) and remifentanil (2) consumption. Incidence of inadequate anesthesia events (3) | Single center study |
Martinez [25] | 2010 | Beat-to-beat cardiovascular indexc (< 60 and absence of conventional signs of nociception) | 71/75 | Gastroscopy and/or colonoscopy | – Propofol TCI – Alfentanil | BIS (40–60) | ASA 1–2, 20–75 years | Reduction in unwanted movements | Single center study. Beat-to-beat blood pressure was measured using the Finapress™ device using a finger cuff. |
Sabourdin [26] | 2017 | Pupillometry (pupil diameter 5–30% of baseline) | 25/30 | Gynecological surgery | – Propofol TCI – Remifentanil TCI – Atracurium | BIS (40–60) | ASA 1–2, females, 18–60 years | Remifentanil consumption | Single center study. In case of large hemodynamic changes remifentanil TCI could be changed and/or vasoactive medication or fluids could be given |
Author | Monitor | Effect on opioid consumption during anesthesia | Absolute difference in opioid consumption (converted to morphine equivalents) | Hemodynamic variables | Efficiency variables (i.e. time to extubation) | Postoperative pain and opioid consumption | Other |
---|---|---|---|---|---|---|---|
Won [21] | SPI | 30% Reduction in oxycodone consumption in the SPI group (p = 0.012) | 2.8 mg | No significant differences | Extubation time 3.4 min shorter with SPI (p = 0.03) | No significant differences | |
Bergmann [17] | SPI | 25% Reduction in remifentanil consumption in SPI group (p < 0.05) | 0.12 mg kg−1 h−1 | No differences in mean HD variables (apart from intubation: Δ MAP 9 mmHg, p < 0.005) | Recovery times were reduced by 3–4 min in the SPI group (p < 0.05) | No significant differences | |
Chen [18] | SPI | 23% Reduction in remifentanil consumption in the SPI group (p < 0.05) | 0.3 mg kg−1 h−1 | No significant difference in mean values Number of episodes with hypertension, hypotension or bradycardia significantly reduced (p < 0.01) | No significant differences | No significant differences | |
Colombo [19] | SPI | No significant differences | NA | There was less sympathetic modulation as measured by heart rate variability indices in the SPI group (p < 0.01) | No significant differences | No significant differences | |
Gruenewald [20] | SPI | No significant differences | NA | No differences in mean values or number of episodes | No significant differences | No significant differences | |
Jain [16] | SPI | 12% Increase in fentanyl consumption in the SPI group (p = 0.017) | 0.024 mg kg−1 h−1 | No significant differences | Duration of surgery was 9.8 min reduced in SPI group (p = 0.03) | Fentanyl consumption was 7 μg less in SPI group (p = 0.01) and VAS was 0.6 points lower in SPI group (p = 0.04) | |
Dundar [22] | ANI | 30% Reduction in remifentanil consumption in the ANI group (p = 0.027) | 33.5 mg | No significant differences | No significant differences | No significant differences | |
Upton [24] | ANI | No significant differences | No significant differences | No significant differences (only total surgery time reported) | No significant differences | Pain scores in the first 90 min of PACU stay were on average 1.3 units lower pain scores in the ANI group (p = 0.01) | |
Szental [23] | ANI | No significant differences | No significant differences | No significant differences | No significant differences | No significant differences | |
Meijer [15] | NOL | 28% Reduction in remifentanil consumption in the NOL group (p < 0.001) | 0.18 mg kg−1 h−1 | No significant differences | Reversal to extubation time was 2 min shorter in NOL group (p = 0.03) | No significant differences | |
Martinez [25] | CARDEAN | No significant difference in alfentanil consumption (dose corrected for duration) Increased number of patients in the CARDEAN group received alfentanil (83% vs. 61%; p = 0.003) | NA | No significant differences | No significant differences | No significant differences | There was a 50% reduction in unwanted movements with CARDEAN monitoring at BIS values < 60 (p = 0.001) |
Sabourdin [26] | Pupillometry | 48% Reduction in remifentanil consumption in pupillometry group (p < 0.001) | 0.42 mg kg−1 h−1 | More patients required nicardipine in pupillometry group (42.3% vs. 0%; p < 0.001) | No significant differences | Reduced morphine consumption 0–12 h (mean difference 0.1 mg kg−1) No difference in pain scores | Significant correlation between remifentanil consumption and postoperative morphine requirements |