Novel multiparameter approach for measurement of nociception at skin incision during general anaesthesia

M. Rantanen, A. Yli-Hankala (Corresponding Author), Mark van Gils, Heidi Yppärilä-Wolters, P. Takala, M. Huiku, M. Kymäläinen, E. Seitsonen, Ilkka Korhonen

    Research output: Contribution to journalArticleScientificpeer-review

    79 Citations (Scopus)


    Background: Direct indicators for the evaluation of the nociceptive–anti-nociceptive balance during general anaesthesia do not exist. The aim of this study was to combine physiological parameters to obtain such an indicator.

    Methods: Fifty-five females scheduled for surgery under general anaesthesia combining target-controlled infusions of propofol and remifentanil were studied. Propofol was given to maintain state entropy (SE) at 50 and remifentanil was targeted at 1, 3 or 5 ng ml−1. The patients’ reactions and clinical signs of nociception, remifentanil levels and estimation of noxious intensity of incision were combined into a clinical score [Clinical Signs–Stimulus–Antinociception (CSSA)] to evaluate the nociceptive–anti-nociceptive balance. ECG, photoplethysmography (PPG), response entropy (RE) and SE were recorded from 60 s before to 120 s after skin incision. Differences between post- and pre-incision values of heart rate variability (HRV), PPG and pulse transition time related parameters were analysed off-line to evidence the best predictors of CSSA. Those best predictors of CSSA served to develop a response index of nociception (RN), scaled from 0 to 100. This index was further tested in 10 additional patients.

    Results: HRV, RE, RE–SE and PPG variability were the best predictors of CSSA. The prediction probability of RN at predicting CSSA was 0.78. RN response was higher after larger incision, in movers and with lower remifentanil concentrations.

    Conclusions: The empirically developed algorithm of RN leads to an index that seems to adequately estimate the nociceptive–anti-nociceptive balance at skin incision during general anaesthesia. In the future, CSSA may serve as a reference for studies investigating methods aimed at evaluating this pharmacodynamic component of anaesthesia.
    Original languageEnglish
    Pages (from-to)367-376
    JournalBritish Journal of Anaesthesia
    Issue number3
    Publication statusPublished - 2006
    MoE publication typeA1 Journal article-refereed


    • anaesthesia
    • depth of anaesthesia


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