Background & Aims
Opioids have been the mainstay of balanced anesthesia (OBA). Dexmedetomidine, the most commonly used drug for opioid free anesthesia (OFA) causes a decrease in heart rate (HR), increase in root mean square of the successive differences (RMSSD) and increase in the high frequency (HF) component of HR variability. Analgesia Nociception Index (ANI) monitor measures nociception by analysing the influence of respiration on the HF component of HRV. Therefore, the reliability of ANI may vary with OFA. Surgical Pleth Index (SPI), is derived from combined measurement of heart-beat interval and plethysmographic pulse wave amplitude which is modified by the sympathetic tone. There are a few studies which observed that SPI performs equally for monitoring nociception during OBA and dexmedetomidine-based OFA. This study aimed at comparing the performances of ANI, SPI and hemodynamics (HR and mean arterial pressure [MAP]) during OBA and OFA.
Methods
In this open label active-controlled randomized trial, patients undergoing elective supratentorial surgery under general anesthesia were randomized to receive either OBA with fentanyl (2µg/kg over 10 min followed by an infusion of 1 µg/kg/hour) or OFA with dexmedetomidine (1µg/kg over 10 minutes followed by 0.5µg/kg/hour infusion). Following the bolus dose of analgesic, general anesthesia was induced. ANI (instantaneous and mean), SPI and HR and MAP were compared before and after noxious stimuli (intubation, skull pin insertion, skin incision and craniotomy) with respect to magnitude of maximum change in the variable and response time. The magnitude of change for ANI was defined as the difference between the lowest value after stimulation and the highest value before the noxious stimulus and the reverse for SPI and HR/MAP. Response time was defined as the time taken for the parameter to change maximally due to noxious stimuli, from the pre-stimuli value.
Results
A total of 58 patients, 29 in each group were recruited into the study. The most common surgical diagnoses in both the groups were meningioma and glioma. At intubation, SPI changed significantly more in the OBA group compared to OFA (37 versus 20 units, p=0.007). The response time of SPI was found to be longer in OBA group, with the difference trending towards statistical significance (p=0.066). The magnitude of change in ANIi and ANIm was more in patients receiving OFA compared to patients receiving OBA, with a difference of 15 and 7 units between the groups respectively (p=0.024 and 0.009) at skull pin insertion. Also, the time taken for ANIm to change maximally was more in OFA group as compared to OBA (p=0.039). There was no difference in the magnitude of maximal change or in the response time of ANI, SPI, HR and MAP between the 2 groups at skin incision/craniotomy.
Conclusions
With intubation as the noxious stimulus, SPI had a greater magnitude of change and the time to maximal change was longer when fentanyl rather than dexmedetomidine was used as the analgesic This suggests that when using OBA for anti-nociception, SPI might be a better choice as a nociception monitor at intubation. At skull pin insertion, ANIi and ANIm had a higher degree of change with significantly greater response time in the OFA group. This emphasizes that when OFA is used, ANI might be a superior choice as it appears to be more sensitive. No difference was observed between the objective monitors or hemodynamic parameters in response to skin incision or craniotomy. This could be explained by the fact that the application of skull pin holder is highly painful as pins enter through the scalp and the periosteum into the external layer of skull. Similarly, tracheal intubation is considered a very potent noxious stimulus as compared to skin incision.
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Presenting Author
Sonia Bansal
Poster Authors
Sonia Bansal
MD
National Institute of Mental Health and Neurosciences, Bengaluru
Lead Author
Dr Rakesh TL
National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, INDIA
Lead Author
Dr Shwethashri KR
National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, INDIA
Lead Author
Dr Dhritiman Chakrabarti
National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, INDIA
Lead Author
Dr Sriganesh Kamath
National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, INDIA
Lead Author
Topics
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