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The objective of this study is to investigate whether the use of surgical pleth index (SPI)-guided intraoperative analgesia can result in a reduction in opioid consumption, intraoperative circulatory fluctuations, and the incidence of postoperative adverse reactions when compared to conventional analgesia techniques. A comprehensive literature search was conducted in PubMed, Embase, Web of Science, and the Cochrane Library from the inception of these databases to November 2024. The objective was to identify randomized controlled trials that compared the use of SPI-guided analgesia with conventional analgesia practices in adult patients who underwent general anesthesia. The primary outcome was the intraoperative consumption of opioids, while intraoperative circulatory fluctuations, postoperative opioid consumption, pain scores, and adverse events served as secondary outcomes. Standardized mean differences (SMDs), weighted mean differences (WMDs) or pooled risk ratios (RRs) along with the corresponding 95 % confidence intervals (CIs) were employed for analysis. Fourteen studies were included in our meta-analysis. The pooled results indicated no significant difference in intraoperative opioid consumption between the SPI-guided analgesia group and the control group (SMD = 0.16, 95 % CI: −0.15 to 0.47, p = 0.33). However, SPI-guided analgesia was found to reduce intraoperative propofol dosage (SMD = −0.31, 95 % CI: −0.54 to −0.08, p = 0.008), prevent intraoperative tachycardia (RR = 0.50, 95 % CI: 0.30 to 0.85, p = 0.011), and significantly shorten the eye-opening time (WMD = −1.89, 95 % CI: −2.47 to −1.31, p < 0.001). No statistically significant differences were observed in extubation time, postoperative nausea and vomiting, pain scores, or postoperative opioid consumption. Compared to the conventional analgesia group, SPI-guided analgesia does not reduce intraoperative opioid consumption in adult patients undergoing general anesthesia. Trial registration: The protocol for this meta-analysis has been registered in PROSPERO (CRD42024611690). •Effective analgesia prevents intraoperative complications and enhances patient outcomes.•Opioids are essential intraoperative analgesics; their improper use can adversely affect surgical outcomes.•SPI provides guidance on pain management, minimizing the risks of overdose and inadequate analgesia.

Background Postoperative pain is common in children during early recovering from general anesthesia, especially for pediatric patients undergoing adenotonsillectomy surgery. There is no valid tool to predict postoperative pain at present. Methods One hundred and fifty patients aged 4–8 years, scheduled to undergo adenotonsillectomy surgery were enrolled in the clinical trial. All patients were given intravenous general anesthesia and endotracheal intubation by the same pediatric anesthesiologist. Surgical pleth index (SPI) monitoring for each patient was performed from the same shared SpO 2 measurement finger which was on the side opposite to the NIBP measurement through the CARESCAPE Monitor B650 (GE Healthcare, Helsinki, Finland). The SPI values, mean arterial pressure (MAP) and heart rate (HR) were recorded at each minute for five minutes immediately after surgery. The maximum values of SPI, MAP and HR (SPI max , MAP max and HR max respectively) were taken for analysis. Early postoperative pain was assessed for each patient using the modified Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) in postanesthesia care unit (PACU). Receiver-operating characteristics (ROC) curves and the associated areas under the curves (AUC) were computed to analyze the ability of SPI to predict early postoperative pain. Results One hundred and thirty-two patients were included and analyzed finally. The SPI max , MAP max and HR max of the patients whose CHEOPS scores less than 4 were 43 ± 6, 58 ± 9mmHg and 90 ± 12 beat/min while of the patients whose CHEOPS scores equal or greater than 4 were 54 ± 8, 67 ± 11mmHg and 96 ± 13 beat/min respectively. The SPI (AUC: 0.84, 95% CI: 0.74–0.92, P  < 0.001) had a good predictive value for postoperative moderate-to-severe pain compared with MAP (AUC: 0.53, 95% CI: 0.41–0.67, P  = 0.58) and HR (AUC: 0.62, 95% CI: 0.46–0.76, P  = 0.19). The best-fit (highest combined sensitivity and specificity ) cut-off values of SPI to distinguish mild pain from moderate-to-severe pain was 46 with the sensitivity of 79.4% and specificity of 87.8%. Conclusions SPI can effectively predict the occurrence of early postoperative moderate-to-severe pain in pediatric patients undergoing adenotonsillectomy surgery under general anesthesia. SPI might be one reliable pain assessment tool to guide pediatric anesthesiologists for timely identification and management of postoperative pain. Trial registration Chinese Clinical Trial Registry, identifier: ChiCTR2200058658 (13/04/2022).

Background/Objectives: Hemodynamic instability and inappropriate postoperative pain perception (IPPP) with their consequences constitute an anesthesiological challenge in patients undergoing primary elective open lumbar infrarenal aortic aneurysm repair (OLIAAR) under general anesthesia (GA), as suboptimal administration of intravenous rescue opioid analgesics (IROAs), whose titration is optimized by Adequacy of Anaesthesia (AoA) guidance, constitutes a risk of adverse events. Intravenous or thoracic epidural anesthesia (TEA) techniques of preventive analgesia have been added to GA to minimize these adverse events. Methods: Seventy-five patients undergoing OLIAAR were randomly assigned to receive TEA with 0.2% ropivacaine (RPV) with fentanyl (FNT) 2.5 μg/mL (RPV group) or 0.2% bupivacaine (BPV) with FNT 2.5 μg/mL (BPV group) or intravenous metamizole/tramadol (MT group). IROA using FNT during GA was administered under AoA guidance. Systemic morphine was administered as a rescue agent in all groups postoperatively in the case of IPPP, assessed using the Numeric Pain Rating Score > 3. The maximum score at admission and the minimum at discharge from the postoperative care unit to the Department of Vascular Surgery, perioperative hemodynamic stability, and demand for rescue opioid analgesia were analyzed. Results: Ultimately, 57 patients were analyzed. In 49% of patients undergoing OLIAAR, preventive analgesia did not prevent the incidence of IPPP, which was not statistically significant between groups. No case of acute postoperative pain perception was noted in the RPV group, but at the cost of statistically significant minimum mean arterial pressure values, reflecting hemodynamic instability, with clinical significance < 65mmHg. Demand for postoperative morphine was not statistically significantly different between groups, contrary to significantly lower doses of IROA using FNT in patients receiving TEA. Conclusions: AoA guidance for IROA administration with FNT blunted the preventive analgesia effect of TEA compared with intravenous MT that ensured proper perioperative hemodynamic stability along with adequate postoperative pain control with acceptable demand for postoperative morphine.

We evaluated the performance of the Surgical Plethysmographic Index (SPI) and the Analgesia Nociception Index (ANI) as surrogate pain measures and determined their respective cut-off values for detecting pain in conscious postoperative patients. In total, 192 patients after elective surgery were enrolled. Baseline SPI and ANI data were acquired for 10 min in the operating room prior to surgery when the patients rated their pain as 0 on the numerical rating scale (NRS). Upon arrival in the post-anaesthesia care unit (PACU) after surgery, SPI and ANI data were recorded for 10 min. The means of the recorded data at OR and PACU were defined as the values representing baseline and postoperative pain, respectively. SPI and ANI data obtained from 189 patients were analysed, who were anesthetized with propofol (n = 149) or sevoflurane (n = 40). Remifentanil was continuously infused intraoperatively in all patients. The values of SPI and ANI were significantly different in conscious patients without (NRS = 0) and with pain (NRS > 0). The areas under the receiver operating curves for SPI and ANI were 0.73 (P < 0.0001) and 0.67 (P < 0.0001), respectively. The cut-off values for SPI and ANI in predicting postoperative pain were 44 (sensitivity: 84%, specificity: 53%) and 63 (sensitivity: 52%, specificity: 82%), respectively, which are different from those suggested by their respective manufacturers for use in intraoperative state under general anaesthesia. The cut-off values of SPI and ANI for detecting pain were similar regardless of the type of anesthesia.

Despite the possibility of postoperative pain occurrence, in some patients, vitreoretinal surgeries (VRSs) require performance of general anesthesia (GA). The administration of intraoperative intravenous rescue opioid analgesics (IROA) during GA constitutes a risk of perioperative adverse events. The Adequacy of Anesthesia (AoA) concept consists of an entropy electroencephalogram to guide the depth of GA and surgical pleth index (SPI) to optimize the titration of IROA. Preemptive analgesia (PA) using cyclooxygenase-3 (COX-3) inhibitors is added to GA to minimize the demand for IROA and reduce postoperative pain. The current analysis evaluated the advantage of PA using COX-3 inhibitors added to GA with AoA-guided administration of IROA on the rate of postoperative pain and hemodynamic stability in patients undergoing VRS. A total of 165 patients undergoing VRS were randomly allocated to receive either GA with AoA-guided IROA administration with intravenous paracetamol/metamizole or with preemptive paracetamol or metamizole. Preemptive paracetamol resulted in a reduction in the IROA requirement; both preemptive metamizole/paracetamol resulted in a reduced rate of postoperative pain as compared to metamizole alone. We recommend using intraoperative AOA-guided IROA administration during VRS to ensure hemodynamic stability alongside PA using both paracetamol/metamizole to reduce postoperative pain.

Postoperative nausea and vomiting (PONV) constitutes an adverse event after endoscopic sinus surgery (ESS) under general anesthesia (GA) with intravenous opioids, such as remifentanil (RMF). Monitoring the nociception/antinociception balance using the surgical pleth index (SPI) or pupillary dilatation reflex (PRD) helps guide intravenous RMF infusion. We aimed to investigate whether their employment could help reduce the incidence of PONV in patients undergoing ESS. The data of 30 patients from the GA group, 31 from the SPI group, and 28 from the PRD group were analyzed. The initial RMF infusion rate of 0.25 µg/kg body weight/minute was increased by 50% when the SPI, PRD, or Boezaart Bleeding Scale (BBS) were elevated by >15, >5%, or >2 points, respectively, until they normalized. PONV was present in 7/89 patients (7.9%): 2/31 patients (6.5%) of the SPI group, 1/30 patients (3.3%) of the GA group, and 4/28 patients (14.3%) of the PRD group. Neither PRD nor SPI guidance for RMF administration reduced the incidence of PONV compared to standard practice. Further studies are required in order to investigate the possibility of PONV eradication in patients undergoing ESS under GA when it is possibly combined with paracetamol/metamizole preventive analgesia, as well as those using antiemetic prophylaxis based on the Apfel Score and premedication with midazolam.

Recently a novel pain recognition indicator derived from electroencephalogram(EEG) signals, pain threshold index(PTI) has been developed. The aim of this study was to determine whether PTI can be used for prediction of postoperative acute pain while surgical pleth index(SPI) applied as control. Eighty patients undergoing laparoscopic urological surgery under general anesthesia were enrolled. Data of SPI, PTI and a sedative index-wavelet index(WLI) were recorded within last 10 min at the end of surgery. The postoperative pain scores (NRS, numerical rating scale) were obtained. The Bland–Altman analysis was used for evaluation of consistency between PTI and SPI, whereas receiver-operating characteristic (ROC) curves was used for the mean values of PTI, SPI, and WLI to distinguish between mild (NRS 0–3) and moderate-severe (NRS 4–10) pain, and calculate their “best-fit” cut-off values. Data from 76 patients were included for final analysis. There was a good agreement between SPI and PTI values at the end of surgery. The ROC analysis showed a cut-off PTI value of 53 to discriminate between mild and moderate-to-severe pain, while SPI is 44 for this discrimination. Further analysis indicated that PTI had a best predictive accuracy reflected by highest area under curve (AUC)(0.772, 95% CI: 0.661–0.860)with sensitivity(62.50%) and specificity(90.91%) and a best positive predictive value(83.3%,95% CI: 68.4–98.2%). PTI obtained at the end of surgery, which have better predictive accuracy for postoperative pain than SPI, could differentiate the patients with moderate-to-severe pain from those with mild pain after they awaken from anesthesia.Clinical trial registration Chinese Clinical Trials Registry: ChiCTR1900024789.

Objective To investigate whether S-ketamine affects the Surgical Pleth Index (SPI) during video-assisted thoracoscopic surgery. Methods Eighty-four patients undergoing video-assisted thoracoscopic lung lobectomy were enrolled. They were randomly assigned to an S-ketamine group (group S) and an equivalent normal saline group (group N). SPI values were recorded; and pain score on a numerical rating scale (NRS), the consumption of opioids, rescue analgesia, and post-operative nausea and vomiting (PONV) were evaluated. Results The SPI and heart rate of the S-ketamine group were significantly lower 30 minutes after the start of surgery and at the end. The NRS score was lower in the S-ketamine group 6 and 12 hours postoperatively, but there were no differences in mean blood pressure or the NRS score 24 and 48 hours postoperatively. Rescue analgesia was required less frequently by the S-ketamine group, but the incidence of PONV did not differ between the groups. Conclusions S-ketamine was associated with lower intraoperative SPI 30 minutes after the start and at the end of surgery. It also reduced opioid use intraoperatively and the NRS scores 6 and 12 hours postoperatively. Trial registration: Chinese Clinical Trial Registry (ChiCTR2000040012), 18/11/2020.

Background Caudal block is usually performed after general anesthesia in children, which makes it hard to assess the success of the block. The aim of this study was to determine whether the surgical pleth index can serve as an objective tool for assessing nociception and the success of caudal block in anesthetized children. Methodology Sixty-two children aged 1–6 years, with American Society of Anesthesiologists Physical Status I and II, undergoing elective infraumbilical surgery, were included. All patients received general anesthesia with i-gel and caudal analgesia. The surgical pleth index, heart rate, and mean blood pressure were recorded throughout the procedure. Caudal block was assessed postoperatively with a gentle pinch. Results The patients were divided into Group S (caudal success) and Group F (caudal failure). In both groups, the SPI decreased after induction to nearly < 50. It continued to gradually decrease to ≈30 in Group S, whereas it increased sharply with incision in Group F to ≈76. After additional analgesia with fentanyl, the surgical pleth index decreased in Group F, but the mean surgical pleth index was significantly greater than in Group S ( p  < 0.01). The intergroup difference in surgical pleth index persisted throughout the procedure. A receiver operating curve showed that a surgical pleth index of 43.5 before incision has a sensitivity of 83.3% and a specificity of 67.9% for predicting successful caudal block. Heart rate and blood pressure increased significantly with incision in Group F, unlike in Group S. The intergroup difference in hemodynamics disappeared after additional analgesia. Conclusion A surgical pleth index of ≤ 43.5 (which may be rounded to 40) can serve as a nociceptive index to predict the success of a caudal block in children. IEC registration number IEC2 549/2023 dated 19th March 2024. Clinical trials registration (CTRI/2024/12/078281) dated 18th December 2024.

Background During general anesthesia, the surgical pleth index (SPI) monitors nociception. The evidence of SPI in the elderly remains scarce. We aimed to investigate whether there is a difference in perioperative outcomes following intraoperative opioid administration according to the surgical pleth index (SPI) value versus hemodynamic parameters (heart rate or blood pressure) in elderly patients. Methods Patients aged 65–90 years who underwent laparoscopic colorectal cancer surgery under sevoflurane/remifentanil anesthesia were randomized to receive remifentanil guided by SPI (SPI group) or conventional clinical judgment based on hemodynamic parameters (conventional group). The primary endpoint was intraoperative remifentanil consumption. Secondary endpoints were intraoperative hemodynamic instability, pain score, fentanyl consumption and delirium in the post-anesthesia care unit (PACU), and perioperative changes in interleukin-6 and natural killer (NK) cell activity. Results Seventy-five patients (38, SPI; 37, conventional) were included in the study. The SPI group consumed significantly more remifentanil intraoperatively than the conventional group (mean ± SD, 0.13 ± 0.05 vs. 0.06 ± 0.04 μg/kg/min, P  < 0.001). Intraoperative hypertension and tachycardia were more common in the conventional group than in the SPI group. Pain score in the PACU ( P  = 0.013) and the incidence of delirium in the PACU were significantly lower in the SPI group than the conventional group (5.2% vs. 24.3%, P  = 0.02). There was no significant difference in NK cell activity and interleukin-6 level. Conclusions In the elderly patients, SPI-guided analgesia provided appropriate analgesia with sufficient intraoperative remifentanil consumption, lower incidence of hypertension/ tachycardia events, and a lower incidence of delirium in the PACU than the conventional analgesia. However, SPI-guided analgesia may not prevent perioperative immune system deterioration. Trial registration The randomized controlled trial was retrospectively registered in the UMIN Clinical Trials Registry (trial number: UMIN000048351; date of registration: 12/07/2022).