Pain measurement in mechanically ventilated patients with traumatic brain injury: Behavioral pain tools versus analgesia nociception index

Abstract

Introduction:Pain is highly prevalent in critically ill trauma patients, especially those with a traumatic brain injury (TBI). Behavioral pain tools such as the behavioral pain scale (BPS) and critical-care pain observation tool are recommended for sedated noncommunicative patients. Analysis of heart rate variability (HRV) is a noninvasive method to evaluate autonomic nervous system activity. The analgesia nociception index (ANI) device (Physiodoloris®, MDoloris Medical Systems, Loos, France) allows noninvasive HRV analysis. The ANI assesses the relative parasympathetic tone as a surrogate for antinociception/nociception balance in sedated patients. The primary aim of our study was to evaluate the effectiveness of ANI in detecting pain in TBI patients. The secondary aim was to evaluate the impact of norepinephrine use on ANI effectiveness and to determine the correlation between ANI and BPS.Methods:We performed a prospective observational study in 21 deeply sedated TBI patients. Exclusion criteria were nonsinus cardiac rhythm; presence of pacemaker; atropine or isoprenaline treatment; neuromuscular blocking agents; and major cognitive impairment. Heart rate, blood pressure, and ANI were continuously recorded using the Physiodoloris® device at rest (T1), during (T2), and after the end (T3) of the painful stimulus (tracheal suctioning).Results:In total, 100 observations were scored. ANI was significantly lower at T2 (Median [min – max] 54.5 [22–100]) compared with T1 (90.5 [50–100], P < 0.0001) and T3 (82 [36–100], P < 0.0001). Similar results were found in the subgroups of patients with (65 measurements) or without (35) norepinephrine. During procedure, a negative linear relationship was observed between ANI and BPS (r2 = −0.469, P < 0.001). At the threshold of 50, the sensitivity and specificity of ANI to detect patients with BPS ≥ 5 were 73% and 62%, respectively, with a negative predictive value of 86%.Discussion:Our results suggest that ANI is effective in detecting pain in ventilated sedated TBI patients, including those patients treated with norepinephrine.

ANI and BIS variations in supine and prone position during closed-tracheal suction in sedated and myorelaxed ICU patients with severe COVID-19: A retrospective study

“…However, the role of norepinephrine on ANI values in ICU patients is still to be determined, and the quite small number of patients included in the current study may prevent any interpretation of this discrepancy. Indeed, another study has shown decreased median [min-max] ANIi (55 [22-100]) and ANIm (69 [32-100]) during tracheal suctioning with traumatic brain injury, which is similar to the current study [15]. However, no clear difference could be observed without or with epinephrine: median [ Our study presents certain limitations, in particular because of its retrospective design.…”

“…To date, four studies have reported the use of ANI monitoring in ICU patients [12][13][14][15]. In the first study performed in conscious burn patients, the performance of ANI to detect pain during dressing changes procedures was studied, with an area under the receiver-operating characteristics curve (ROC AUC) of 0.76 [95% CI 0.75-0.76] [12].…”

Is the heart rate variability monitoring using the analgesia nociception index a predictor of illness severity and mortality in critically ill patients with COVID-19? A pilot study

“…Thus, the autonomic nervous system (ANS) is responsible for the regulation of this inflammatory reflex, and its balance is essential to the maintenance of the body's homeostasis [9,10]. A physiological metric for the measurement of the ANS is the analysis of heart rate variability (HRV) and, more specifically, the analgesia nociception index (ANI) monitor has proven to be a crucial tool for the measurement of the ANS and nociception in both surgical and critically ill patients [11][12][13][14][15].…”

Pain measurement techniques: spotlight on mechanically ventilated patients

“…BPS is the second most used pain scale in ICUs. It evaluates three behavioral domains (facial expressions, movement of upper limbs, and compliance with ventilation) 64 and it is valid in different languages 53 , 58 , 64 – 74 and samples 35 , 75 – 78 ( Table 1 ). Psychometric properties, as internal consistency (Cronbach α coefficient ranged from 0.63 to 0.72, 65 , 74 , 79 , 80 ) interrater reliability (Kappa coefficient ranged from 0.67–0.83 64 , 79 , 81 and ICC of 0.95, 65 ) sensitivity, specificity, criterion and discriminant validity (significant increases of 2–3 points in BPS scores following nociceptive procedures 64 , 65 , 69 , 74 , 79 , 80 ) were supported previously and confirm the advantages of BPS use, including frequency of pain assessments and patient’s positive outcomes.…”