Anesth Pain Med.  2019 Oct;14(4):380-392. 10.17085/apm.2019.14.4.380.

Nociception monitoring tools using autonomic tone changes for intraoperative analgesic guidance in pediatric patients

• Lim BG

• KMID: 2465334
• DOI: http://doi.org/10.17085/apm.2019.14.4.380

Abstract

Nociception monitoring devices using changes in autonomic nervous system activity have been developed in numerous ways. Although there have been few studies conducted on children, compared to the relatively higher number of studies on adults, most of the nociception monitors in children, as in adults, appear to be more useful than the standard clinical practice that uses hemodynamic parameters in the evaluation and treatment of intraoperative nociception (pain) during general anesthesia. Particularly, when monitoring the surgical pleth index (SPI) in anesthetized children, the application of a new target range of SPI values (≤ 40) to the SPI monitoring criteria seems to be necessary for providing a more proper intraoperative analgesia. The analgesia nociception index (ANI) shows promising results in anesthetized adults, and recently, positive results along with cardiorespiratory coherence have been reported in pediatric patients. Newborn infant parasympathetic evaluation (NIPE) could be useful for providing adequate analgesia in newborns, infants, and children under 2 years of age in anesthetized or awake states. In cases of skin conductance and pupillometry, further studies are needed. Understanding the pros, cons, and limitations of these nociception monitoring tools will provide more effective and safe intraoperative analgesia to pediatric patients undergoing general anesthesia, and it may also help to plan and conduct promising research on the use of perioperative nociception monitoring in pediatric patients in the future.

Keyword

Analgesia; Anesthesia, general; Autonomic nervous system; Children; Monitoring, intraoperative; Nociception test; Pain measurement

MeSH Terms

Adult
Analgesia
Anesthesia, General
Autonomic Nervous System
Child
Hemodynamics
Humans
Infant
Infant, Newborn
Monitoring, Intraoperative
Nociception*
Pain Measurement
Skin

Figure

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  Fig. 1 Flow diagram for article search and inclusion criteria in the review.

• 

  Fig. 2 Comparison of photoplethysmographic (PPG) responses between adults and children for nociception during anesthesia. The schematic diagram shows the difference between adults and children on the change of the PPG signal during endotracheal intubation at anesthesia induction. The changes (decrease) of the photoplethysmographic amplitude (PPGA) and area under the curve (AUC) are smaller in children, and the resulting changes (increase) of the surgical pleth index (SPI) values are also smaller in children (refer [SPI ∞ 1/AUC]). That is, this difference in PPG responses for nociception may cause a difference in SPI values between adults and children. (A) PPG waveforms in adults. With an assumption that heartbeat interval (HBI) equals to PPGA (HBI = PPGA = α) and the data of SPI and heart rate in the reference (Mustola et al. Anesthesiol Res Pract 2010; 2010: 810721 [30]), the following equations can be established and thus the values of the variables can be assumed: α’ = α – 6.2 = 55.8 – 6.2 = 49.6; β = α – 22.8 = 55.8 – 22.8 = 33.0. (B) PPG waveforms in children. With an assumption that HBI equals to PPGA (HBI = PPGA = γ) and the data of SPI and heart rate in the reference (Kallio et al. Br J Anaesth 2008; 101: 383–9 [31]), the following equations can be established and thus the values of the variables can be assumed: γ’= γ – 8.2 = 60.8 – 8.2 = 52.6; δ = γ – 17.5 = 60.8 – 17.5 = 43.3. This figure is newly drawn based on the data of the two studies [30,31] that reported changes in SPI, heart rate, and PPGA during endotracheal intubation.

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