Effect of surgical pleth index-guided analgesia versus conventional analgesia techniques on fentanyl consumption under multimodal analgesia in laparoscopic cholecystectomy: a prospective, randomized and controlled study

Abstract

Background The Surgical Pleth Index (SPI) is an objective tool that can reflect nociception-antinociception balance and guide the use of intraoperative analgesics. Multimodal analgesia has been neglected in many previous studies. The aim of this study was to compare fentanyl consumption using SPI-guided analgesia versus conventional analgesia techniques under multimodal analgesia in laparoscopic cholecystectomy. Methods A total of 80 patients aged 18–65 years with American Society of Anaesthesiologists (ASA) grade I-II and a body mass index (BMI) of 18.5 to 30 kg/m2 who were scheduled for laparoscopic cholecystectomy under total intravenous anaesthesia from March 2020 to September 2020 were selected. Multimodal analgesia, including local infiltration of the surgical incision, nonsteroidal anti-inflammatory drugs and opioids, was adopted perioperatively. Fentanyl boluses of 1.0 µg/kg were administered to maintain the SPI value between 20 and 50 in the SPI group. By contrast, fentanyl boluses of 1.0 µg/kg were administered whenever the heart rate (HR) or mean arterial pressure (MAP) increased to 20 % above baseline or when the HR was greater than 90 beats per minute (bpm) in the control group. Preoperative and postoperative blood glucose, plasma cortisol and interleukin-6 (IL-6) levels were evaluated. Intraoperative haemodynamic events and propofol and fentanyl doses were noted. The extubation time, postoperative visual analogue scale (VAS) score, use of remedial analgesics and opioid-related adverse reactions were recorded. Results In total, 18 of 80 patients withdrew for various reasons, and data from 62 patients were finally analysed. Intraoperative fentanyl consumption was significantly lower in the SPI group than in the control group (177.1 ± 65.9 vs. 213.5 ± 47.5, P = 0.016). The postoperative extubation time was shorter in the SPI group than in the control group (16.1 ± 5.2 vs. 22.1 ± 6.3, P < 0.001). Preoperative and postoperative blood glucose, plasma cortisol and IL-6 levels, intraoperative haemodynamic changes, postoperative VAS scores, remedial analgesic consumption and opioid-related adverse reactions were comparable in the two groups. Conclusions Lower doses of fentanyl are required intraoperatively with shorter extubation times when SPI is used to guide intraoperative analgesia compared to conventional analgesia techniques under multimodal analgesia in laparoscopic cholecystectomy. Trial registration Chictr.org.cn ChiCTR2000030145. Retrospectively Registered (Date of registration: February 24, 2020).

Does surgical plethysmographic index-guided analgesia affect opioid requirement and extubation time? A systematic review and meta-analysis

“…The age of the participants ranged from 3 to 74 years. They had an American Society of Anesthesiologists physical status classification of I–III, and underwent elective surgery including orthopedic surgery [ 25 – 27 ], ear–nose–throat surgery [ 11 , 27 , 28 ], laparoscopic cholecystectomy [ 19 , 21 , 29 , 30 ], radical retropubic prostatectomy [ 20 , 22 ], gynecological surgery [ 26 , 27 ], thyroidectomy [ 12 ], adenotonsillectomy [ 31 ], maxillofacial, and trauma surgery [ 27 ].…”

“…General anesthesia was maintained by using inhalation anesthesia with sevoflurane in five studies [ 12 , 19 , 20 , 26 , 31 ] or by intravenous anesthesia with propofol in eight studies [ 11 , 21 , 22 , 25 , 27 – 30 ]. Intraoperative analgesia was administered with continuous remifentanil infusion in seven studies [ 11 , 21 , 22 , 25 , 27 – 29 ], intravenous anesthesia with fentanyl in three studies [ 19 , 30 , 31 ], sufentanil in two studies [ 20 , 26 ], or oxycodone in one study [ 12 ]. Participants received hypnosis monitoring with bispectral index (BIS) in five studies [ 11 , 12 , 19 , 26 , 30 ] or entropy in six studies [ 21 , 25 , 27 – 29 , 31 ], or did not receive hypnosis monitoring in two studies [ 20 , 22 ].…”

“…Emergence time after anesthesia was reported with extubation time in eight studies [ 12 , 20 – 22 , 25 , 26 , 30 , 31 ] or eye-opening time in six studies [ 11 , 19 , 21 , 25 , 27 , 31 ]. Postoperative pain was measured by using the numerical rating scale in seven studies [ 12 , 20 – 22 , 25 , 26 , 29 ], visual analog scale in four studies [ 11 , 19 , 27 , 30 ], or Children’s Hospital of Eastern Ontario Pain Scale in one study [ 31 ]. PONV was reported in eight studies [ 11 , 12 , 19 , 22 , 25 , 27 , 30 , 31 ], and six studies reported the requirements of analgesia in the PACU [ 12 , 19 , 20 , 22 , 26 , 31 ].…”

“…This study focused on whether the use of SPI to guide opioid administration reduced opioid requirement and effectively accelerated recovery after surgery, in line with ERAS. In comparison with the number of RCTs included in the previous meta-analyses [ 15 – 18 ], we included seven more RCTs [ 19 – 22 , 27 , 28 , 30 ]. Our meta-analysis, including 13 RCTs, revealed no significant decrease in intraoperative opioid consumption, but effectively demonstrated shortened extubation and eye-opening times in the SPI-guided group.…”

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

“…In the initial period of SPI-associated studies, studies were conducted to investigate the correlation of SPI with the nociception-antinociception balance and with changes in stress hormones during the perioperative period [3,8]. Following these studies, randomized controlled trials (RCTs) comparing SPI-guided analgesia and conventional analgesia (hemodynamic parameter-guided analgesia) were mainly conducted [9][10][11][12]. Various opioids, such as remifentanil, This article is protected by copyright of Korean Journal of Anesthesiology.…”