Elevated Surgical Pleth Index at the End of Surgery Is Associated with Postoperative Moderate-to-Severe Pain: A Systematic Review and Meta-Analysis

Kuo-Chuan Hung, Yen-Ta Huang, Jinn-Rung Kuo, Chih-Wei Hsu, Ming Yew, Jen-Yin Chen, Ming-Chung Lin, I-Wen Chen, Cheuk-Kwan Sun, Kuo-Chuan Hung, Yen-Ta Huang, Jinn-Rung Kuo, Chih-Wei Hsu, Ming Yew, Jen-Yin Chen, Ming-Chung Lin, I-Wen Chen, Cheuk-Kwan Sun

Abstract

Despite acceptance of the surgical pleth index (SPI) for monitoring the intraoperative balance between noxious stimulation and anti-nociception under general anesthesia, its efficacy for predicting postoperative moderate-to-severe pain remains unclear. We searched electronic databases (e.g., Google Scholar, MEDLINE, Cochrane Library, and EMBASE) to identify articles focusing on associations of SPI at the end of surgery with immediate moderate-to-severe pain in the postanesthesia care unit from inception to 7 July 2022. A total of six observational studies involving 756 adults published between 2016 and 2020 were eligible for quantitative syntheses. Pooled results revealed higher values of SPI in patients with moderate-to-severe pain than those without (mean difference: 7.82, 95% CI: 3.69 to 11.95, p = 0.002, I2 = 46%). In addition, an elevated SPI at the end of surgery was able to predict moderate-to-severe pain with a sensitivity of 0.71 (95% confidence interval (CI): 0.65-0.77; I2 = 29.01%) and a specificity of 0.58 (95% CI: 0.39-0.74; I2 = 79.31%). The overall accuracy based on the summary receiver operating characteristic (sROC) curve was 0.72. In conclusion, this meta-analysis highlighted the feasibility of the surgical pleth index to predict postoperative moderate-to-severe pain immediately after surgery. Our results from a limited number of studies warrant further investigations for verification.

Keywords: meta-analysis; pain; postanesthesia care unit; summary receiver operating characteristic; surgical pleth index.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Flow chart for exclusion and inclusion of studies [21,23,24,25,30,31].
Figure 2
Figure 2
Pooled incidence of moderate-to-severe pain among studies [21,23,24,25,30,31].
Figure 3
Figure 3
Risks of bias assessed according to the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) [21,23,24,25,30,31].
Figure 4
Figure 4
Forest plot comparing values of surgical pleth index (SPI) between patients with or without moderate-to-severe pain. IV: inverse variance; CI, confidence interval [21,24,25,31].
Figure 5
Figure 5
Forest plots comparing sensitivity/specificity and summarizing the pooled effects of the included studies [21,23,24,25,30,31].
Figure 6
Figure 6
Hierarchical summary receiver operating characteristic (hsROC) curves of using surgical pleth index (SPI) for the prediction of moderate-to-severe pain in surgical patients [21,23,24,25,30,31]. SROC: summary receiver operating characteristic; SENS: sensitivity; SPEC: specificity; AUC: area under the curve.
Figure 7
Figure 7
Deeks’ funnel plot asymmetry test for publication bias assessment across the included studies [21,23,24,25,30,31].
Figure 8
Figure 8
Fagan’s nomogram plot for evaluating clinical utility of surgical pleth index (SPI) for postoperative moderate-to-severe pain prediction in surgical patients [21,23,24,25,30,31]. LR: Likelihood ratio; Prob: probability; Pos: positive; Neg: negative.

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