OR I G INA L A RT I C L E

Pain monitoring in intensive care: How does the

nociception level index affect treatment and prognosis?
A randomized, controlled, double-blind trial
Berna Çalışkan, Zeki Besir, Öznur Sen

Department of Anesthesiology and Reanimation, Haseki Training and Research Hospital, İstanbul-Türkiye

ABSTRACT
BACKGROUND: Effective pain management is vital in critical care settings, particularly post-surgery. Clinicians should maintain ob-
jective and efficient standards to assess pain in a patient-centered manner, in order to effectively manage this complex issue. A newer
technology, the nociception level (NOL) index, shows promise in achieving this task through its multi-parameter evaluation.
METHODS: This study was a prospective, controlled, randomized trial involving two groups of patients (n=30 each) in a diverse
intensive care unit. Participants were over 18 years old with American Society of Anesthesiology scores ranging from I to III and were
scheduled for critical care follow-up after general anesthesia. All subjects followed a standard analgesia protocol that included rescue
analgesia. Drug administration was guided by a numeric rating scale and the critical care pain observation tool in the Control Group,
while it was guided by nociception level index monitoring in the NOL Group.
RESULTS: Pain scores between the two groups did not significantly differ. However, within the NOL Group, pain scores and noci-
ception values displayed a strong positive correlation. Notably, total analgesic consumption was significantly lower in the NOL Group
(p=0.036).
CONCLUSION: Monitoring pain using the nociception level index is an effective method for detecting pain compared to standard
pain scores utilized in critical care. Its guidance facilitates personalized analgesic titration. Additionally, the potential of nociception
level index guidance to reduce the duration of intensive care and hospital stays may be linked to its effects on delirium, a connection
that awaits further exploration in future studies.
Keywords: Behavioral pain scores; delirium; nociception level index; pain monitoring; postoperative cognitive dysfunction; postopera-
tive pain.

INTRODUCTION significantly worsen clinical outcomes in the ICU. The exac-

erbation of pain can amplify the stress response, leading to
Patients in the intensive care unit (ICU) are frequently sub- hemodynamic and respiratory instability, which worsens the
jected to painful stimuli. Pain in the ICU can have multifocal underlying pathophysiology and negatively impacts mortality
causes, not only stemming from disease-related factors such and morbidity.[2] Furthermore, studies on the neuroimmune
as critical illness symptoms or postoperative surgical pain, but interaction of pain have demonstrated that while activated
also from treatments (e.g., endotracheal tube, drainage tubes, immunity can induce pain, pain itself can also cause immu-
catheters) and routine care procedures (e.g., blood collec- nosuppression.[3] Long-term effects of pain-related psycho-
tion, patient positioning).[1] Inadequate pain management can logical stress can include persistent pain, sleep disturbances,

Cite this article as: Çalışkan B, Besir Z, Sen O. Pain monitoring in intensive care: How does the nociception level index affect treatment and prognosis?
A randomized, controlled, double-blind trial. Ulus Travma Acil Cerrahi Derg 2024;30:415-422.
Address for correspondence: Berna Çalışkan
Haseki Training and Research Hospital, İstanbul, Türkiye
E-mail: [email protected]

Ulus Travma Acil Cerrahi Derg 2024;30(6):415-422 DOI: 10.14744/tjtes.2024.95533

Submitted: 11.10.2023 Revised: 25.04.2024 Accepted: 13.05.2024 Published: 11.06.2024
OPEN ACCESS This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).

Ulus Travma Acil Cerrahi Derg, June 2024, Vol. 30, No. 6 415
 Çalışkan et al. Nociception level index in ICU: impact on treatment & prognosis

delirium, and both acute or chronic cognitive impairments.[3,4] III. We excluded patients from the study for several reasons:
Effective pain management in the ICU is associated with bet- those who declined to participate; individuals with concur-
ter wound healing, shorter weaning times, reduced ICU stays, rent organ failures, particularly lung failure as indicated by a
and improved quality of care.[3] Although pain in the intensive partial pressure of oxygen/fraction of inspired oxygen (PaO2/
care unit is a multidimensional issue with significant conse- FiO2) ratio below 200; those with histories of allergies to the
quences, the subjective nature of the pain experienced by pa- drugs used in our study protocol; patients undergoing deep
tients makes it challenging to address with a single standard anesthesia, characterized by a Richmond Agitation-Sedation
approach.[5] Therefore, it is crucial to provide individualized Score (RASS) of -2, meaning they could not be awakened by
care and tailor pain monitoring strategies in intensive care. loud sounds; individuals expected to have a low postopera-
tive Glasgow Coma Score (GCS) due to head trauma; and
In standard ICU settings, pain management typically employs
patients experiencing surgical complications, arrhythmias, or
pain intensity scales (e.g., Numeric Rating Scale (NRS)) for pa-
sepsis during their hospital stay. We also excluded patients
tients who can self-report, and observational behavioral scales
(e.g., Critical Care Observation Pain Tool (CPOT)) for those who required procedures associated with high pain intensity,
who cannot.[6] However, for patients who are neither able to such as chest tube removal, wound drain removal, endotra-
self-report nor express behavioral signs of pain, such as those cheal suctioning, frequent repositioning, and blood sampling
who are deeply sedated or non-communicative, reliable moni- (1). This study adhered to the Declaration of Helsinki, and
toring methods are necessary. written informed consent was obtained from all participants
prior to surgery. The study was registered at ClinicalTrials.
Nociception monitors have been developed and are currently gov (NCT05762666). The progression of the study was illus-
utilized for this purpose.[6] The nociception level (NOL) index trated using the Consolidated Standards of Reporting Trials
represents a new generation of electrophysiological devices (CONSORT) flow diagram (Fig. 1).
designed to assess pain-related nociception, distinguishing it-
Randomization
self through its multi-parameter evaluation.[7] The NOL index
is derived from five parameters: heart rate, heart rate vari- Randomization was achieved through a computer-generated
ability, skin conductance level, photoplethysmography wave- algorithm at a 1:1 ratio, resulting in two groups: the NOL
form amplitude, and the number and time derivatives of skin Group and the Control Group (n=30 each). Each group’s al-
conductance fluctuations. Beyond pain monitoring, the NOL location was sealed in opaque envelopes. On the day of the
system can facilitate targeted analgesic titration in the ICU, as surgery, if the inclusion/exclusion criteria were satisfied, the
recommended by recent guidelines.[4] Thanks to its multi-pa- anesthetist in the operating room selected one envelope
rameter design, the NOL may also help differentiate individual to implement the designated protocol for each group. Data
perceptions of nociplastic pain.[3,7] Furthermore, contempo- collected during the clinical follow-up were recorded by in-
rary pain assessment technologies are advised to supplement formed nurses in the ICU and by an independent anesthesi-
subjective and behavioral pain scales in the ICU as a validated ologist who was blinded to the group assignments. This anes-
component of the ABCDEFGHI bundle for delirium protec- thesiologist also assessed all post-surgical evaluations in the
tion.[8] Based on these hypotheses, employing NOL guidance wards, focusing particularly on delirium and total analgesic
as a pain management tool could probably significantly impact use by the end of the ICU stay.
treatment outcomes and prognosis in ICU practice.
Thus, our study aims to evaluate pain management under
NOL guidance, focusing on the use of postoperative analge-
sics in intensive care follow-up and treatment, as well as the
length of stay in the intensive care unit. Additionally, we inves-
tigated the potential effects of NOL on delirium.

MATERIALS AND METHODS

Study Design and Setting
Following approval by our Institutional Ethics Committee
(dossier no: 212-2022), we conducted a double-blind pro-
spective study involving 60 patients (2 groups; 1:1 allocation;
n=30). Eligible patients were those who underwent general
anesthesia for major surgery and required postoperative fol-
low-up in the ICU for at least 24 hours as per our institutional
protocol, to manage potential surgery-related complications.
Inclusion criteria encompassed patients aged 18 and over Figure 1. Consolidated Standards of Reporting Trials (CONSORT)
with American Society of Anesthesiology (ASA) scores of I to flow diagram of the study.

416 Ulus Travma Acil Cerrahi Derg, June 2024, Vol. 30, No. 6
Çalışkan et al. Nociception level index in ICU: impact on treatment & prognosis

Standardization ceeded 25 for at least one minute. Additional analgesia was

All patients adhered to a uniform intraoperative analgesia administered if NOL values were elevated outside these
plan, receiving 2 mcg/kg of fentanyl without any monitoring specified intervals.
of pain, and a standard postoperative analgesia regimen be- Primary Outcome
ginning immediately after surgery. This included 1 gram of The primary outcome was the total amount of analgesic con-
paracetamol every six hours (with a maximum of four doses sumption during the ICU stay, recorded before discharge.
daily) and rescue analgesia of 1 mg/kg tramadol, also limited to
four doses daily every six hours. If pain relief was inadequate, Secondary Outcomes
additional intervention of 0.05 mg/kg morphine intravenous The study investigated the correlation between reference
(IV) boluses were administered based on elevated pain scale pain assessment tools (NRS, CPOT) and NOL values. Ad-
readings (NRS>4; CPOT>2; NOL>25 over 1 minute) or at ditionally, delirium was assessed at the 24th hour before
the patient's request. ICU nurses evaluated pain using NRS discharge using the Confusion Assessment Method for the
and CPOT scales at 6, 8, 12, and 24 hours postoperatively, Intensive Care Unit (CAM-ICU) score and by the 4 'A's Test
correlating these with NOL values at specific time points. (4AT) at the surgical ward on the third postoperative day be-
The Control Group underwent standard monitoring, using fore hospital discharge. Additionally, to evaluate the potential
pain scales, and received rescue analgesia based on these as- secondary effects of NOL monitoring on patient prognosis,
sessments. we compared the length of stay in the intensive care unit and
Intervention the total hospital stay between the groups.

The experimental group (the NOL Group) was monitored Statistical Methods
postoperatively using only NOL values throughout their ICU The primary endpoint was the total analgesic consumption
stay, while also receiving rescue analgesia guided by these during the ICU stay. The study was powered to detect a dif-
NOL values alongside traditional pain scales. Trained nurses ference in this primary endpoint, but not in pain assessment
administered the analgesia protocol when NOL values ex- tools. The required sample size was calculated using the

Table 1. Demographic and medical data of the study population

Group NOL* (n=30) Group Control (n=30) p-value

Age (years) (median, range) 63.5 (20-80) 63.0 (24-84) 0.68

BMI (kg/cm2) (median, range) 26.8 (19.7-42.5) 27.27 (18-52.7) 0.71
ASA Status (I / II / III) (number) 4 / 13 / 12 10 / 14 / 7 0.11
Comorbidities** (number)
Hypertension 13 11
Diabetes Mellitus 4 10
Coronary Artery Disease 8 11
Cancer 1 8
Epilepsy 2 -
Respiratory Disease 9 6
Chronic Renal Failure 2 3
Type of Surgery (number) 0.28
Orthopedic 3 4
Neurosurgery 13 10
General Surgery 8 9
Urologic 1 3
Otorhinolaryngologic 5 4
Length of Surgery (minutes) (median, range) 120 (20-607) 240.5 (69-510) 0.001***
Length of Hospital Stay (days) (mean, standard deviation) 10.03 (5.49) 15.23 (14.37) 0.016***
Length of ICU Stay (days) (mean, standard deviation) 1.07 (0.25) 1.23 (0.43) 0.01***
APACHE II Scores 8.3 (8) 8.7 (8) 0.51

NOL: Nociception Level; **Comorbidites that were diagnosed and under treatment; ***p<0.05.
*

Ulus Travma Acil Cerrahi Derg, June 2024, Vol. 30, No. 6 417
 Çalışkan et al. Nociception level index in ICU: impact on treatment & prognosis

(a)

(b) Figure 3. Comparison of total tramadol and morphine consumption

between groups.

4AT and CAM-ICU assessments) were analyzed using inde-

pendent sample T-tests. Correlations were examined using
Pearson’s tests for parametric variables such as CAM-ICU
and 4AT, and Spearman’s tests for nonparametric variables
such as NRS, CPOT, and NOL.

RESULTS
Characteristics of Study Subjects: The distribution of age,
BMI, ASA status, Acute Physiology and Chronic Health
Figure 2. (a) Comparison of Numeric Rating Scale (NRS) scores
Evaluation II (APACHE II) scores, and type of surgery were
between groups. (b) Comparison of Critical Care Observation Pain
consistent across all groups. Notably, the length of surgery
Tool (CPOT) scores between groups.
was significantly shorter in the NOL Group. Additionally, the
G*Power 3.1 analysis program, based on a study anticipating lengths of hospital and ICU stays were significantly reduced in
a 25% reduction in total analgesic consumption (8). The ef- the NOL Group (Table 1).
fect size was derived from preliminary clinical observations of Primary Outcome: No significant differences were observed
mean daily morphine consumption to alleviate postoperative in CPOT and NRS scores between the groups, except at the
pain, targeting a power of 90% and a significance level of 8%. 18th hour, where both CPOT and NRS showed significant
It was determined that a minimum of 24 patients per group differences (p=0.026 and p=0.027, respectively) (Fig. 2). Upon
was necessary to achieve statistical significance. To account examining the correlations between NRS and CPOT with
for potential dropouts, we included 60 patients in the study. NOL values within the NOL Group, a strong positive cor-
Statistical analyses were conducted using IBM SPSS (Statisti- relation was noted at each hour (Table 2).
cal Package for the Social Sciences) Statistics for Windows
(Version 26.0; IBM Corp., Armonk, NY, USA). Demographic However, as the primary outcome of the study, the total an-
variables such as age, Body Mass Index (BMI), ASA status, and algesic consumption during the ICU stay was found to be
significantly different between groups in terms of morphine
length of surgery were not normally distributed, as indicated
consumption (p=0.036). Tramadol consumption was lower in
by the Shapiro-Wilk Test (p<0.05) and kurtosis and skew-
the NOL Group (p=0.065) (Fig. 3).
ness indices exceeding ±2. Consequently, the Mann-Whitney
U test was employed for analysis. Comparisons of normally Secondary Outcome: There were no significant differences
distributed values (NRS, CPOT, and NOL; total tramadol and between groups concerning CAM-ICU and 4AT scores (p=1;
morphine consumption; lengths of hospital and ICU stays; p=0.138). Furthermore, correlations between NOL values

Table 2. Correlations between NRS and CPOT with NOL values

NOL 6th (r) NOL 12th (r) NOL 18th (r) NOL 24th (r)

CPOT 0.759 0.417 0.171 0.618

NRS 0.691 0.478 0.361 0.515

0.2˂r˂0.29: Weak relationship; 0.3˂r˂0.39: Moderate relationship; 0.4˂r˂0.69: Strong relationship; r>0.69: Very strong relationship.

418 Ulus Travma Acil Cerrahi Derg, June 2024, Vol. 30, No. 6
Çalışkan et al. Nociception level index in ICU: impact on treatment & prognosis

and both CAM-ICU and 4AT scores were found to be negli- positive correlation between pain scores and NOL values.
gible (0˂r˂0.2).
More importantly, while other devices like the Analgesia No-
ciception Index have been ineffective in guiding personalized
DISCUSSION opioid use, the potential of the NOL index in establishing
Our study demonstrates the effectiveness of NOL-guided opioid-free anesthesia and ICU management remains under-
pain management in intensive care, focusing on a population explored.[17] Our study has addressed a critical gap by demon-
specifically selected to minimize pain factors. This population strating reduced opioid consumption under NOL guidance,
excludes individuals with complex disease diagnoses like sep- contributing to the burgeoning field of personalized, opioid-
sis or procedures known to produce high pain intensity. It is free pain management in the ICU.
among the first studies to compare NOL guidance in the ICU Delirium presents a major concern in qualified ICU care and
with traditional pain scores such as NRS and CPOT. These represents a critical area for future improvements in ICU
tools have been standard for analgesic titration and are cru- design.[8] Over time, it has been recognized that delirium
cial in monitoring pain and stratifying risk for delirium and can adversely affect patient prognosis, leading to prolonged
cognitive dysfunction.[9,10] anxiety, depression, cognitive dysfunction, and even post-
While there were no significant differences in CPOT and NRS traumatic stress disorder. Moreover, delirium has been as-
scores between groups, a strong positive correlation was ob- sociated with increased mortality, particularly among frail
served between these pain scales and NOL values within the patients, and extended lengths of stay in both the intensive
NOL Group. Remarkably, total analgesic consumption var- care unit and the hospital overall.[18,19] Consequently, a bundle
ied between groups (Fig. 3). Given that NOL values primar- has been developed to support a delirium-free ICU, which
ily dictated analgesic administration in the NOL Group, this has improved the comprehensive A to F (A-F) bundle for
outcome underscores its effectiveness in reducing analgesic managing delirium risk factors in the ICU.[20,21] An aspect of
usage, even when traditional pain scores were similar. this bundle that requires further investigation is the assess-
ment and management of pain using subjective (NRS) and
The application of NOL-guided analgesia in anesthesia has re- behavioral tools (CPOT), complemented by innovative non-
cently been validated for perioperative use, demonstrating a invasive pain assessment technologies such as NOL.[8] This is-
reduction in analgesic consumption during major abdominal sue prompted our examination of the impact of NOL-guided
surgerie.[8] Moreover, when opioid administration is guided pain management on CAM-ICU and 4AT scores. Although
by intraoperative NOL values instead of blood pressure and no significant differences were found between groups regard-
heart rate, this approach has been shown to decrease post- ing CAM-ICU and 4AT scores, the lengths of hospital and
operative pain scores.[11] A similar challenge exists in the ICU stays were significantly shorter in the NOL Group (Table
ICU setting, where patients under deep sedation and neuro- 1). This outcome may be attributed to our study's focus on
muscular paralysis cannot self-report or express behaviors. an uncomplicated population that did not receive sedation
[6]
Although video pupillometry, which measures changes in and excluded patients with prolonged ICU stays beyond 48
pupillary dimensions to indicate sympathetic and parasympa- hours. Further research could be invaluable in exploring the
thetic responses, was explored for this purpose, it proved relationship between NOL-guided pain monitoring and the
unreliable.[12] Additionally, the Analgesia Nociception Index emerging concept of the new component in the bundle, G -
(ANI), based on heart rate variability, was found to be more gaining insight into patient needs for more personalized care
sensitive to emotional stimuli and less specific to pain.[13,14] in future ICU settings.[8]
As a result of these observations, the NOL index may prove Limitations
more effective due to its design, which incorporates five
Our study was aimed at demonstrating the comparison of
physiologic variables related to nociception. This makes it
NOL-guided pain management in the ICU. We designed a
particularly valuable as it has been shown to effectively dis-
standardized ICU environment where noxious stimuli were
criminate between noxious and non-noxious stimuli in a clini-
minimized. To confirm the effectiveness of the NOL index
cal setting.[15]
and its impact on analgesic titration in settings with more fre-
Despite the existing research on NOL-guided anesthesia, fur- quent and intense procedural pain, further research involving
ther studies are needed to explore its impact in the ICU en- more complex critical patient populations is necessary. The
vironment. Gélinas et al.[16] conducted a study validating the types of surgeries involved in our study varied; consequently,
NOL index but only in the Postoperative Anesthesia Care the difference in surgical times between the two groups was
Unit (PACU) population following cardiac surgery. Conse- unintentionally higher, with the control group experiencing
quently, we selected a more diverse ICU setting to determine longer surgery durations. To reduce ambiguity, conducting
if NOL values correlate with NRS and CPOT scores in pain another study focused on a single type of surgery would yield
detection. Although previous findings indicated only modest more precise results. Additionally, we selected patients who
performance in pain detection using NRS scores and no cor- were not sedated or mechanically ventilated; however, in-
relation with CPOT scores, our study observed a strong and vestigating the NOL index may be more effective in patients

Ulus Travma Acil Cerrahi Derg, June 2024, Vol. 30, No. 6 419
 Çalışkan et al. Nociception level index in ICU: impact on treatment & prognosis

experiencing deep sedation and paralysis, where other pain detection. Although previous findings indicated only modest
scores prove ineffective. Conducting a multicenter study with performance in pain detection using NRS scores and no cor-
a larger and more diverse population could better demon- relation with CPOT scores, our study observed a strong and
strate the significant benefits of NOL monitoring in standard positive correlation between pain scores and NOL values.
care within intensive care units.
More importantly, while other devices like the Analgesia No-
CONCLUSION ciception Index have been ineffective in guiding personalized
opioid use, the potential of the NOL index in establishing
Our study demonstrates the effectiveness of NOL-guided opioid-free anesthesia and ICU management remains under-
pain management in intensive care, focusing on a population explored.[17] Our study has addressed a critical gap by demon-
specifically selected to minimize pain factors. This population strating reduced opioid consumption under NOL guidance,
excludes individuals with complex disease diagnoses like sep- contributing to the burgeoning field of personalized, opioid-
sis or procedures known to produce high pain intensity. It is free pain management in the ICU.
among the first studies to compare NOL guidance in the ICU
Delirium presents a major concern in qualified ICU care and
with traditional pain scores such as NRS and CPOT. These represents a critical area for future improvements in ICU
tools have been standard for analgesic titration and are cru- design.[8] Over time, it has been recognized that delirium
cial in monitoring pain and stratifying risk for delirium and can adversely affect patient prognosis, leading to prolonged
cognitive dysfunction.[9,10] anxiety, depression, cognitive dysfunction, and even post-
While there were no significant differences in CPOT and NRS traumatic stress disorder. Moreover, delirium has been as-
scores between groups, a strong positive correlation was ob- sociated with increased mortality, particularly among frail
served between these pain scales and NOL values within the patients, and extended lengths of stay in both the intensive
NOL Group. Remarkably, total analgesic consumption var- care unit and the hospital overall.[18,19] Consequently, a bundle
ied between groups (Fig. 3). Given that NOL values primar- has been developed to support a delirium-free ICU, which
ily dictated analgesic administration in the NOL Group, this has improved the comprehensive A to F (A-F) bundle for
outcome underscores its effectiveness in reducing analgesic managing delirium risk factors in the ICU.[20,21] An aspect of
usage, even when traditional pain scores were similar. this bundle that requires further investigation is the assess-
ment and management of pain using subjective (NRS) and
The application of NOL-guided analgesia in anesthesia has re- behavioral tools (CPOT), complemented by innovative non-
cently been validated for perioperative use, demonstrating a invasive pain assessment technologies such as NOL.[8] This is-
reduction in analgesic consumption during major abdominal sue prompted our examination of the impact of NOL-guided
surgeries.[8] Moreover, when opioid administration is guided pain management on CAM-ICU and 4AT scores. Although
by intraoperative NOL values instead of blood pressure and no significant differences were found between groups regard-
heart rate, this approach has been shown to decrease post- ing CAM-ICU and 4AT scores, the lengths of hospital and
operative pain scores.[11] A similar challenge exists in the ICU stays were significantly shorter in the NOL Group (Table
ICU setting, where patients under deep sedation and neuro- 1). This outcome may be attributed to our study's focus on
muscular paralysis cannot self-report or express behaviors. an uncomplicated population that did not receive sedation
[6]
Although video pupillometry, which measures changes in and excluded patients with prolonged ICU stays beyond 48
pupillary dimensions to indicate sympathetic and parasympa- hours. Further research could be invaluable in exploring the
thetic responses, was explored for this purpose, it proved relationship between NOL-guided pain monitoring and the
unreliable.[12] Additionally, the Analgesia Nociception Index emerging concept of the new component in the bundle, G -
(ANI), based on heart rate variability, was found to be more gaining insight into patient needs for more personalized care
sensitive to emotional stimuli and less specific to pain.[13,14] in future ICU settings.[8]
As a result of these observations, the NOL index may prove Limitations
more effective due to its design, which incorporates five
Our study was aimed at demonstrating the comparison of
physiologic variables related to nociception. This makes it
NOL-guided pain management in the ICU. We designed a
particularly valuable as it has been shown to effectively dis-
standardized ICU environment where noxious stimuli were
criminate between noxious and non-noxious stimuli in a clini-
minimized. To confirm the effectiveness of the NOL index
cal setting.[15]
and its impact on analgesic titration in settings with more fre-
Despite the existing research on NOL-guided anesthesia, fur- quent and intense procedural pain, further research involving
ther studies are needed to explore its impact in the ICU en- more complex critical patient populations is necessary. The
vironment. Gélinas et al.[16] conducted a study validating the types of surgeries involved in our study varied; consequently,
NOL index but only in the Postoperative Anesthesia Care the difference in surgical times between the two groups was
Unit (PACU) population following cardiac surgery. Conse- unintentionally higher, with the control group experiencing
quently, we selected a more diverse ICU setting to determine longer surgery durations. To reduce ambiguity, conducting
if NOL values correlate with NRS and CPOT scores in pain another study focused on a single type of surgery would yield

420 Ulus Travma Acil Cerrahi Derg, June 2024, Vol. 30, No. 6
Çalışkan et al. Nociception level index in ICU: impact on treatment & prognosis

more precise results. Additionally, we selected patients who patients. Intensive Care Med 2018;44:1493–501. [CrossRef ]
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scores prove ineffective. Conducting a multicenter study with M, et al. Exploration of a multi-parameter technology for pain assessment
in postoperative patients after cardiac surgery in the intensive care unit:
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8. Meijer FS, Martini CH, Broens S, Boon M, Niesters M, Aarts L, et al.
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NOL index monitoring correlates well with more traditional 9. Kotfis K, van Diem-Zaal I, Williams Roberson S, Sietnicki M, van den
methods of detecting pain, such as the NRS and CPOT scales. Boogaard M, Shehabi Y, et al. The future of intensive care: delirium
NOL offers a superior, objective, and efficient technology for should no longer be an issue. Crit Care 2022;26:200.Erratum in: Crit
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ther subjective (NRS) or behavioral (CPOT) pain scales. Fur- 10. Mäkinen OJ, Bäcklund ME, Liisanantti J, Peltomaa M, Karlsson S, Kal-
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opioid use by facilitating personalized, opioid-free analgesia view. Br J Anaesth 2020;125:149–58. [CrossRef ]
in critical care. 11. Fuica R, Krochek C, Weissbrod R, Greenman D, Freundlich A, Gozal
Y. Reduced postoperative pain in patients receiving nociception monitor
Ethics Committee Approval: This study was approved by guided analgesia during elective major abdominal surgery: a randomised,
the Haseki Training and Research Hospital Ethics Committee controlled trial. J Clin Monit Comput 2023;37:481–91. [CrossRef ]
(Date: 30.11.2022, Decision No: 212-2022). 12. Bernard C, Delmas V, Duflos C, Molinari N, Garnier O, Chalard K, et al.
Assessing pain in critically ill brain-injured patients: a psychometric com-
Peer-review: Externally peer-reviewed.
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Authorship Contributions: Concept: B.C.; Design: B.C.; 13. Chanques G, Tarri T, Ride A, Prades A, De Jong A, Carr J, et al. Analgesia
Supervision: B.C., Z.B.; Resource: O.S.; Materials: B.C., Z.B.; nociception index for the assessment of pain in critically ill patients: a
Data collection and/or processing: B.C., Z.B.; Analysis and/or diagnostic accuracy study. Br J Anaesth 2017;119:812–20. [CrossRef ]
interpretation: B.C.; Literature search: B.C.; Writing: B.C.; 14. Yoshida K, Obara S, Inoue S. Analgesia nociception index and high-fre-
Critical review: B.C. quency variability index: promising indicators of relative parasympathetic
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Conflict of Interest: None declared.
15. Edry R, Recea V, Dikust Y, Sessler DI. Preliminary intraoperative valida-
Use of AI for Writing Assistance: Not declared. tion of the nociception level index: a non-invasive nociception monitor.
Financial Disclosure: The author declared that this study Anesthesiology 2016;125:193–203. [CrossRef ]
has received no financial support. 16. Gélinas C, Shahiri T S, Richard-Lalonde M, Laporta D, Morin JF, Boitor
M, et al. Exploration of a multi-parameter technology for pain assessment
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 Çalışkan et al. Nociception level index in ICU: impact on treatment & prognosis

ORİJİNAL ÇALIŞMA - ÖZ

Yoğun bakımda ağrı takibi: Nosisepsiyon düzeyi indeksi tedavi ve prognozu nasıl etkiler?
Randomize kontrollü, çift kör bir çalışma
Berna Çalışkan, Zeki Besir, Oznur Sen
Haseki Eğitim ve Araştırma Hastanesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, İstanbul, Türkiye
AMAÇ: Özellikle ameliyat sonrası yoğun bakımda ağrı yönetimi önemlidir. Bu çok boyutlu sorunu yönetmek için klinisyenlerin ağrıyı hasta bazlı bir
şekilde tespit etmeye yönelik objektif ve etkili standartlar sağlamaları gerekir. Yeni bir teknoloji olan nosisepsiyon düzeyi indeksi, çok parametreli
değerlendirmesiyle bu görevi başarmak için umut verici bir adaydır.
GEREÇ VE YÖNTEM: Heterojen yoğun bakım ünitesindeki iki grubu (n=30) karşılaştırmak için prospektif, kontrollü, randomize bir çalışma tasar-
landı. Genel anestezi sonrası yoğun bakım takibi için 18 yaş üstü ve Amerikan Anesteziyoloji Derneği skoru I-III olan hastalar seçildi. Tüm hastalara,
kurtarma analjezisini de içeren standart analjezi protokolü verildi ve ilaç uygulaması, Grup NOL'de nosisepsiyon düzeyi indeksi monitörizasyonu
tarafından yönlendirilirken Grup Kontrol'de sayısal bir derecelendirme ölçeği ve kritik bakım ağrı gözlem aracı tarafından yönlendirildi.
BULGULAR: Ağrı skorları açısından gruplar arasında anlamlı fark yoktu. NOL Grubu içindeki ağrı skorları ve nosisepsiyon değerleri güçlü bir pozitif
korelasyon gösterdi. Toplam analjezik tüketimi NOL grubunda anlamlı derecede düşüktü (p=0.036).
SONUÇ: Ağrı için nosisepsiyon düzeyi indeksinin izlenmesi, yoğun bakımda kullanılan standart ağrı skorlarıyla karşılaştırıldığında ağrıyı tespit etme-
nin etkili bir yoludur. Rehberliğinde kişiselleştirilmiş analjezik titrasyonuna yardımcı olur. Nosisepsiyon düzeyi indeksinin yoğun bakım ve hastanede
kalış süresini azaltma üzerindeki etkisi, daha fazla çalışma ile ortaya çıkarılmayı bekleyen deliryum üzerindeki etkisiyle bağlantılı olabilir.
Anahtar sözcükler: Ağrı takibi; davranışsal ağrı skorları; deliryum; nosisepsiyon düzeyi indeksi; postoperatif bilişsel işlev bozukluğu; postoperatif ağrı.

Ulus Travma Acil Cerrahi Derg 2024;30(6):415-422 DOI: 10.14744/tjtes.2024.95533

422 Ulus Travma Acil Cerrahi Derg, June 2024, Vol. 30, No. 6