Nociception monitors vs. standard practice for titration of opioid administration in general anesthesia: A meta-analysis of randomized controlled trials

Dandan Ma, Jiahui Ma, Huayong Chen, Dongliang Mu, Hao Kong, Lingzhi Yu, Dandan Ma, Jiahui Ma, Huayong Chen, Dongliang Mu, Hao Kong, Lingzhi Yu

Abstract

Background: Nociception monitors are being increasingly used during surgery, but their effectiveness in guiding intraoperative opioid administration is still uncertain. This meta-analysis of randomized controlled trials (RCTs) aimed to compare the effectiveness of nociception monitors vs. standard practice for opioid administration titration during general anesthesia.

Methods: We searched the electronic databases of PubMed, EMBASE, Cochrane Library, Clinical Trial, and Web of Science from inception up to August 1, 2021, to identify relevant articles, and extracted the relevant data. Intraoperative opioid administration, extubation time, postoperative pain score, postoperative opioid consumption and postoperative nausea and vomiting (PONV) were compared between patients receiving nociception monitoring guidance and patients receiving standard management. The standardized mean difference (SMD), with 95% confidence interval (CI), was used to assess the significance of differences. The risk ratio (RR), with 95% CI, was used to assess the difference in incidence of PONV. Heterogeneity among the included trials was evaluated by the I 2 test. RevMan 5.3 software was used for statistical analysis.

Results: A total of 21 RCTs (with 1957 patients) were included in the meta-analysis. Intraoperative opioid administration was significantly lower in patients receiving nociception monitor-guided analgesia than in patients receiving standard management (SMD, -0.71; 95% CI, -1.07 to -0.36; P < 0.001). However, pain scores and postoperative opioid consumption were not significantly higher in the former group. Considerable heterogeneity was found among the studies (92%). Extubation time was significantly shorter (SMD, -0.22; 95% CI, -0.41 to -0.03; P = 0.02) and the incidence of PONV significantly lower (RR, 0.78; 95% CI, 0.61 to 1.00; P = 0.05) in patients receiving nociception monitoring guidance.

Conclusions: Intraoperative nociception monitoring guidance may reduce intraoperative opioid administration and appears to be a viable strategy for intraoperative titration of opioids.

Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=273619, identifier: CRD42019129776.

Keywords: analgesia nociception index; general anesthesia; nociception; nociception monitors; opioid.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 Ma, Ma, Chen, Mu, Kong and Yu.

Figures

Figure 1
Figure 1
Flowchart showing the selection of studies.
Figure 2
Figure 2
Assessment of risk of bias. “+” = low risk of bias; “?” = unclear risk of bias; and “–” = high risk of bias; # and * represent different interventions in the same study.
Figure 3
Figure 3
Forest plot showing the effects of intervention (nociception monitoring guidance/standard practice) on intraoperative opioid administration.
Figure 4
Figure 4
Forest plot showing the effects of intervention (nociception monitoring guidance/standard practice) on extubation time.
Figure 5
Figure 5
Forest plot showing the effects of intervention (nociception monitoring guidance/standard practice) on postoperative pain scores.
Figure 6
Figure 6
Forest plot showing the effects of intervention (nociception monitoring guidance/standard practice) on postoperative opioid consumption.
Figure 7
Figure 7
Forest plot showing the effects of intervention (nociception monitoring guidance/standard practice) on the incidence PONV.
Figure 8
Figure 8
Subgroup analysis according to different nociception monitors.
Figure 9
Figure 9
Subgroup analysis according to different classification of surgeries.
Figure 10
Figure 10
Subgroup analysis according to different ages.
Figure 11
Figure 11
Subgroup analysis according to different kinds of intraoperative opioids.
Figure 12
Figure 12
Subgroup analysis according to different anesthesia methods.
Figure 13
Figure 13
Funnel plot evaluating publication bias.

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