Intraoperative "analgesia nociception index"-guided fentanyl administration during sevoflurane anesthesia in lumbar discectomy and laminectomy: A randomized clinical trial

Background: The "Analgesia Nociception Index" (ANI; MetroDoloris Medical Systems, Lille, France) is a proposed noninvasive guide to analgesia derived from an electrocardiogram trace. ANI is scaled from 0 to 100; with previous studies suggesting that values ≥50 can indicate adequate analgesia. This clinical trial was designed to investigate the effect of intraoperative ANI-guided fentanyl administration on postoperative pain, under anesthetic conditions optimized for ANI functioning. Methods: Fifty patients aged 18 to 75 years undergoing lumbar discectomy or laminectomy were studied. Participants were randomly allocated to receive intraoperative fentanyl guided either by the anesthesiologist's standard clinical practice (control group) or by maintaining ANI ≥50 with boluses of fentanyl at 5-minute intervals (ANI group). A standardized anesthetic regimen (sevoflurane, rocuronium, and nonopioid analgesia) was utilized for both groups. The primary outcome was Numerical Rating Scale pain scores recorded from 0 to 90 minutes of recovery room stay. Secondary outcomes included those in the recovery room period (total fentanyl administration, nausea, vomiting, shivering, airway obstruction, respiratory depression, sedation, emergence time, and time spent in the recovery room) and in the intraoperative period (total fentanyl administration, intraoperative-predicted fentanyl effect-site concentrations over time [CeFent], the correlation between ANI and predicted CeFent and the incidence of movement). Statistical analysis was performed with 2-tailed Student t tests, χ tests, ordinal logistic generalized estimating equation models, and linear mixed-effects models. Bonferroni corrections for multiple comparisons were made for primary and secondary outcomes. Results: Over the recovery room period (0-90 minutes) Numerical Rating Scale pain scores were on average 1.3 units lower in ANI group compared to the control group (95% confidence interval [CI], -0.4 to 2.4; P= .01). Patients in the ANI group additionally had 64% lower recovery room total fentanyl administration (95% CI, -12% to 85%; P= .44, unadjusted P= .026), 82% lower nausea scores (95% CI, -19% to 96%; P= .43, unadjusted P= .03), and a reduced incidence of shivering (ANI 4%, control 27%, P= .80, unadjusted P= .047) compared to the control group. Intraoperatively, ANI group patients had on average 27% higher predicted CeFent levels during the highly nociceptive periods of intubation and first incision (5-30 minutes) compared with control group patients (95% CI, 3%-57%; P= .51, unadjusted P= .03). For a 1-unit decrease in ANI scores, predicted CeFent on average increased by an estimated 1.98% in the ANI group (95% CI, 1.7%-2.26%; P< .0001) and 1.08% in the control group (95% CI, 0.76%-1.39%; P< .0001). This correlation was significantly different between groups (0.9%, 95% CI, 0.5%-1.3%; P< .0001). Recovery room vomiting, airway obstruction, respiratory depression, sedation, emergence time, time spent in the recovery room as well as total intraoperative fentanyl administration, hypnotic parameters, and incidence of intraoperative movement were not different between groups. Conclusions: Patients receiving intraoperative ANI-guided fentanyl administration during sevoflurane anesthesia for lumbar discectomy and laminectomy demonstrated decreased pain in the recovery room, likely as a result of more objective intraoperative fentanyl administration.Henry D. Upton, Guy L. Ludbrook, Andrew Wing, and Jamie W. Sleig