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October 13, 2018
10/13/2018 1:15:00 PM - 10/13/2018 3:15:00 PM
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Nocicepion Level (NOL)-guided Analgesia: Influence on Opioid Consumption and Hypotensive Events During Propofol/Remifentanil Anesthesia
Albert Dahan, M.D.,Ph.D., Fleur S. Meijer, M.D., Suzanne Broens, M.D., Monique van Velzen, Ph.D., Christian Martini, M.D.,Ph.D.
LUMC, 1077 XD Amsterdam, Netherlands
Disclosures: A. Dahan: Funded Research; Self; Medasense, MSD, Medtronic, Eurocept. Consulting Fees; Self; Medasense, MSD, Medtronic, Eurocept. F.S. Meijer: None. S. Broens: None. M. van Velzen: None. C. Martini: Consulting Fees; Self; speaker fee from MSD.
Background. Various monitors of nociception are currently available. It is important to determine whether continuous monitoring of nociception coupled to nociception-guided administration of opioid analgesics during surgery will affect opioid use and patient

outcome. We assessed the effect of the Nociception Level Index (NOL, Medasense Biometrics Ltd., Israel) on opioid dose and hemodynamic stability in patients scheduled for

elective major surgery under total intravenous anesthesia. The NOL is a multiparameter

measure of nociception that ranges from 0 to 100.1 Acceptable values of nociception are

between 10 and 25.1 Values above 25 suggest increased nociception requiring supplemental

opioid administration, while values below 10 (during surgical stimuli) suggest opioid


Methods. ASA class I-III patients (aged 18 to 80 year) of either sex, scheduled major

abdominal surgical, urologic or gynecologic procedures under general anesthesia without

epidural analgesia, were recruited to participate in the study. All patients received

remifentanil/propofol anesthesia using a target controlled infusion (TCI) system, relaxation

with rocuronium and reversal with sugammadex. During the procedure the bispectral index

(BIS), NOL, non-invasive blood pressure (BP) and heart rate (HR) were monitored. Patients

were randomized to receive standard of care or NOL-guided analgesia. In case of NoL-

guided analgesia the remifentanil TCI was reduced when NOL values were below 10 or

increased when values were above 25 for at least 2 min, in steps of 0.5-1.0 ng/mL. In case of

standard of care, the TCI was left to the discretion of attending anesthesiologist. Propofol

was titrated to a BIS value of 50 ± 5. We here report on the effect of NOL-guided analgesia

on remifentanil dose and occurrence of mean arterial blood pressure values < 55 mmHg.

Results. Eighty patients participated in the study, 40 in each arm of the trial. See Table 1 for

patient characteristics. Intraoperative remifentanil consumption was less in the NOL-guided

group (0.08 μ, interquartile range (IQR) 0.10-0.65 μ versus standard

care (0.12 μ, IQR 0.09-0.15 μ; p < 0.0001). Propofol and rocuronium

consumption were not different between treatment arms. Hypotensive events (MAP < 55

Hg) occurred more frequently in the standard care group (n = 11 or 28% of patients)

compared to the NOL-guided group (n = 2 or 5% of patients, p = 0.01). BIS values were

comparable between treatment groups.

Conclusions. NOL-guided opioid administration had a significant impact on remifentanil

consumption and hemodynamic stability in patients undergoing elective major surgery.

Consequently we argue that opioid administration based on nociception monitoring is

clinically relevant and improves patient outcome.

1. Martini et al. Anesthesiology 2015; 123: 524-34

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