• Fleur Meijer, Maarten Honing, Tessa Roor, Samantha Toet, Paul Calis, Erik Olofsen, Chris Martini, Monique van Velzen, Leon Aarts, Marieke Niesters, Martijn Boon, and Albert Dahan.
• Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands.
• Br J Anaesth. 2020 Dec 1; 125 (6): 1070-1078.

BackgroundThe majority of postoperative patients report moderate to severe pain, possibly related to opioid underdosing or overdosing during surgery. Objective guidance of opioid dosing using the Nociception Level (NOL) index, a multiparameter artificial intelligence-driven index designed to monitor nociception during surgery, may lead to a more appropriate analgesic regimen, with effects beyond surgery. We tested whether NOL-guided opioid dosing during general anaesthesia results in less postoperative pain.MethodsIn this two-centre RCT, 50 patients undergoing abdominal surgery under fentanyl/sevoflurane anaesthesia were randomised to NOL-guided fentanyl dosing or standard care in which fentanyl dosing was based on haemodynamics. The primary endpoint of the study was postoperative pain assessed in the PACU.ResultsMedian postoperative pain scores were 3.2 (inter-quartile range 1.3-4.3) and 4.8 (3.0-5.3) in NOL-guided and standard care groups, respectively (P=0.006). Postoperative morphine consumption (standard deviation) was 0.06 (0.07) mg kg-1 (NOL-guided group) and 0.09 (0.09) mg kg-1 (control group; P=0.204). During surgery, fentanyl dosing was not different between groups (NOL-guided group: 6.4 [4.2] μg kg-1vs standard care: 6.0 [2.2] μg kg-1, P=0.749), although the variation between patients was greater in the NOL-guided group (% coefficient of variation 66% in the NOL-guided group vs 37% in the standard care group).ConclusionsDespite absence of differences in fentanyl and morphine consumption during and after surgery, a 1.6-point improvement in postoperative pain scores was observed in the NOL-guided group. We attribute this to NOL-driven rather than BP- and HR-driven fentanyl dosing during anaesthesia.Clinical Trial Registrationwww.trialregister.nl under identifier NL7845.Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.

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