Snoek Merel A J, van den Berg Victor J, Dahan Albert, Boon Martijn
Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands.
Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands.
Br J Anaesth. 2025 Jan;134(1):180-191. doi: 10.1016/j.bja.2024.09.020. Epub 2024 Nov 28.
To avoid underdosing or overdosing of analgesic medications, a variety of nociception monitors that use distinct techniques have been developed to quantify nociception during general anaesthesia. Although prior meta-analyses have examined the behaviour of nociception monitors vs standard care protocols, they did not include the potentially valuable data for monitor-to-monitor comparisons. In order to capture these data fully and compare the behaviour of these monitors, we conducted a systematic search and network meta-analysis.
We performed a Bayesian network meta-analysis on data obtained from a systematic search within PubMed, Embase, Web of Science, Cochrane Library, and EmCare databases. The search was aimed to detect relevant RCTs on the use of nociception monitoring versus standard care or versus other nociception devices(s) during general anaesthesia in adult patients. The primary endpoint was intraoperative opioid consumption, for which we calculated the standardised mean difference (SMD) of morphine equivalents (MEs). Secondary endpoints included postoperative opioid consumption and nausea or vomiting, extubation time, postoperative pain score, and time to discharge readiness. The risk of bias was assessed using the revised Cochrane Risk of Bias tool for randomised trials (RoB 2.0).
Thirty-eight RCTs, including 3412 patients and studying five different types of nociception monitors, were included in the analyses: Nociception Level Monitor (NOL), Analgesia Nociception Index (ANI), Surgical Plethysmographic Index (SPI), Pupillometry (pupillary pain index [PPI] or pupil dilation reflex [PDR]), and the beat-by-beat cardiovascular depth of anaesthesia index (CARDEAN). Pupillometry showed a significant reduction in intraoperative opioid consumption compared with standard care (SMD -2.44 ME; 95% credible interval [CrI] -4.35 to -0.52), and compared with SPI (SMD -2.99 ME; 95% CrI -5.15 to -0.81). With respect to monitors other than pupillometry, no significant differences in opioid consumption were detected in comparison with standard care or other monitors. Pupillometry was associated with a longer time to discharge readiness from the PACU, whereas NOL was associated with shorter extubation times. No relevant differences in other secondary outcomes were found.
Apart from pupillometry, no monitors demonstrated a significant effect on intraoperative opioid consumption. Secondary outcomes indicate limited clinical benefit for patients when using these monitors.
为避免镇痛药物剂量不足或过量，已开发出多种采用不同技术的伤害感受监测仪，以量化全身麻醉期间的伤害感受。尽管先前的荟萃分析研究了伤害感受监测仪与标准护理方案的对比情况，但未纳入监测仪之间进行比较的潜在有价值的数据。为了全面获取这些数据并比较这些监测仪的表现，我们进行了一项系统检索和网状荟萃分析。
我们对通过在PubMed、Embase、Web of Science、Cochrane图书馆和EmCare数据库中进行系统检索获得的数据进行了贝叶斯网状荟萃分析。该检索旨在检测关于成年患者全身麻醉期间使用伤害感受监测与标准护理或与其他伤害感受监测设备对比的相关随机对照试验。主要终点是术中阿片类药物消耗量，我们计算了吗啡等效物（MEs）的标准化均值差（SMD）。次要终点包括术后阿片类药物消耗量、恶心或呕吐、拔管时间、术后疼痛评分以及准备出院时间。使用修订后的Cochrane随机试验偏倚风险工具（RoB 2.0）评估偏倚风险。
分析纳入了38项随机对照试验，包括3412名患者，研究了五种不同类型的伤害感受监测仪：伤害感受水平监测仪（NOL）、镇痛伤害感受指数（ANI）、手术体积描记指数（SPI）、瞳孔测量法（瞳孔疼痛指数[PPI]或瞳孔扩张反射[PDR]）以及逐搏心血管麻醉深度指数（CARDEAN）。与标准护理相比，瞳孔测量法显示术中阿片类药物消耗量显著减少（SMD -2.44 ME；95%可信区间[CrI] -4.35至-0.52），与SPI相比也是如此（SMD -2.99 ME；95% CrI -5.15至-0.81）。对于除瞳孔测量法之外的监测仪，与标准护理或其他监测仪相比，未检测到阿片类药物消耗量有显著差异。瞳孔测量法与从麻醉后恢复室准备出院的时间较长相关，而NOL与较短的拔管时间相关。在其他次要结局方面未发现相关差异。
除瞳孔测量法外，没有监测仪显示对术中阿片类药物消耗量有显著影响。次要结局表明使用这些监测仪对患者的临床益处有限。
