Intra-operative nociceptive responses and postoperative major complications after gastrointestinal surgery under general anaesthesia

Abstract

BACKGROUND Surgical procedures stimulate nociception and induce physiological responses according to the balance between nociception and antinociception. The severity of surgical stimuli is associated with major postoperative complications. Although an intra-operative quantitative index representing surgical invasiveness would be useful for anaesthetic management to predict and prevent major complications, no such index is available. OBJECTIVES To identify associations between major complications after gastrointestinal surgery and intra-operative quantitative values from intra-operative nociception monitoring. DESIGN A multi-institutional observational study. SETTING Two university hospitals. PATIENTS Consecutive adult patients undergoing gastrointestinal surgery under general anaesthesia. MAIN OUTCOME MEASURES Averaged values of nociceptive response index from start to end of surgery (mean NR index) and risk scores of the Surgical Mortality Probability Model (S-MPM) were calculated. Pre and postoperative serum C-reactive protein (CRP) levels were obtained. After receiver-operating characteristic (ROC) curve analysis, all patients were divided into groups with high and low mean nociceptive response index. Associations between mean nociceptive response index and postoperative major complications, defined as Clavien-Dindo grade at least IIIa, were examined using logistic regression analysis. RESULTS ROC curve analysis showed a nociceptive response index cut-off value for major complications of 0.83, and we divided patients into two groups with mean nociceptive response index less than 0.83 and at least 0.83. The incidence of major complications was significantly higher in patients with mean nociceptive response index at least 0.83 (23.1%; n = 346) than in patients with mean nociceptive response index less than 0.83 (7.7%; n = 443; P < 0.001). Multivariate analysis revealed emergency surgery, S-MPM risk score, mean nociceptive response index and postoperative CRP levels as independent risk factors for major complications. CONCLUSION Mean nociceptive response index during surgery likely correlates with major complications after gastrointestinal surgery. TRIAL REGISTRATION The current observational study had no intervention, and was therefore, not registered.

Association between thoracic epidural block and major complications after pleurectomy/decortication for malignant pleural mesothelioma under general anesthesia

“…Our previous study showed that a higher degree of surgical invasiveness increases mean NR index during surgery, associating with a higher incidence of postoperative morbidity 19 24. In the present study, however, mean NR≥0.83 was not selected as independent risk factors for major complications after P/D for MPM in the present study.…”

“…On the other hand, we previously reported that mean NR index during laparoscopic gastrointestinal surgery was 0.815±0.053, and the incidence of major complications was 8.2% 25. Moreover, after we recalculated mean NR index using our previous data, mean NR values were 0.817±0.057 during gastrointestinal surgery including laparotomy and laparoscopic surgery and 0.818±0.056 during total shoulder arthroplasty, and the incidences of major postoperative complications were 14.5% and 1.2%, respectively 19 26. Since mean NR index during P/D corresponds to the highest level of surgical severity even in patients with epidural block,24 it might be plausible that multivariable logistic regression analyses did not select mean NR≥0.83 as independent risk factors for major complications in the present study.…”

“…We performed multivariable logistic regression analyses to determine the association between epidural block and major complications. Since no multicollinearity existed between candidate variables, eight variables of age≥70 years, male sex, BMI≥25 kg·m −2 , ASA-PS≥III, preoperative CRP levels≥1.00 mg·dL −1 ,18 epidural block, mean NR≥0.83,19 and RBC transfusion volume≥1200 mL7 were selected as candidate variables. Multivariable logistic regression revealed that the absence of epidural analgesia was an independent risk factor for major complications (table 2).…”

Intraoperative Assessment of Surgical Stress Response Using Nociception Monitor under General Anesthesia and Postoperative Complications: A Narrative Review

“…Results from nociception monitors combining these autonomic responses are thus also expected to be associated with postoperative complications. Higher values of NR averaged from the start to the end of surgery (mean NR), which are calculated using heart rate, systolic blood pressure, and peripheral perfusion index, were reportedly associated with a higher incidence of major postoperative complications, defined as a Clavien–Dindo Class ≥ IIIa, after gastrointestinal surgery ( Table 1 ) [ 44 ]. Mean NR values also increased in the order of severity of postoperative complications in patients undergoing total shoulder arthroplasty, gastrointestinal surgery, and thoracic surgery ( Figure 2 ) [ 44 , 45 , 46 , 84 , 85 ].…”

“…Gray circles show individual data points. Data in this graph were obtained from [ 44 , 45 , 46 , 84 , 85 ]. Significant differences are defined at * p < 0.001 vs. no complications, and # p < 0.001 vs. minor complications.…”