Skip to main content
SpringerLink
Log in

Foreseeing postoperative pain in neurosurgical patients: pupillometry predicts postoperative pain ratings—an observational study

  • Original Research
  • Published:
Journal of Clinical Monitoring and Computing Aims and scope Submit manuscript

Abstract

Pupillary reflex dilation (PRD) is triggered by noxious stimuli and diminished by opioid administration. In the postoperative period, PRD has been shown to be correlated with pain reporting and a useful tool to guide opioid administration. In this study we assessed whether pupillary measurements taken before extubation were related with the patient’s reported pain in the Post-Anesthesia Care Unit (PACU) using the Numerical Rating Scale (NRS). Our objective was to evaluate the correlation of PRD and pupillary variables measured intraoperatively with postoperative pain under the same opioid concentration. This was a prospective observational study of 26 neurosurgical patients undergoing general anesthesia exclusively with propofol and remifentanil. A portable infrared pupillometer was used to provide an objective measure of pupil size and PRD (using the Pupillary Pain Index) before extubation. Pain ratings were obtained from patients after recovery of consciousness, while remifentanil was maintained at 2 ng/mL. A significant correlation was observed between NRS scores and pre-extubation PPI (rS = 0.62; P = 0.002), as well as between NRS scores and pupil diameter before tetanic stimulation PPI (rS = 0.56, P = 0.006). We also found a negative correlation between pupil diameter and age (rS = − 0.42, P = 0.04). The statistically significant correlation between pre-extubation PPI scores and NRS scores, as well as between the pupillary diameter before tetanic stimulation and NRS scores suggest the possibility of titrating analgesia at the end of the intraoperative period based on individual responses. This could allow clinicians to identify the ideal remifentanil concentration for the postoperative period.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Rawal N. Current issues in postoperative pain management. Eur J Anaesthesiol. 2016;33(3):160–71. https://doi.org/10.1097/EJA.0000000000000366.

    Article  CAS  PubMed  Google Scholar 

  2. Larson MD, Sessler DI. Pupillometry to guide postoperative analgesia. Anesthesiology. 2012;116(5):980–2. https://doi.org/10.1097/ALN.0b013e318251d21b.

    Article  PubMed  Google Scholar 

  3. De Jonckheere J, Bonhomme V, Jeanne M, et al. Physiological signal processing for individualized anti-nociception management during general anesthesia: a review. Yearb Med Inform. 2015;10(1):95–101. https://doi.org/10.15265/IY-2015-004.

    Article  PubMed  Google Scholar 

  4. Cowen R, Stasiowska MK, Laycock H, Bantel C. Assessing pain objectively: the use of physiological markers. Anaesthesia. 2015;70(7):828–47. https://doi.org/10.1111/anae.13018.

    Article  CAS  PubMed  Google Scholar 

  5. Larson MD, Behrends M. Portable infrared pupillometry. Anesth Analg. 2015;120(6):1242–53. https://doi.org/10.1213/ANE.0000000000000314.

    Article  PubMed  Google Scholar 

  6. Larson MD, Kurz A, Sessler D. Alfentanil blocks reflex pupillary dilation in response to noxious stimulation but does not diminish the light reflex. Anesthesiology. 1997;87:849–55.

    Article  CAS  Google Scholar 

  7. Larson MD, Sessler DI, Washington DE, Merrifield BR, Hynson JA, McGuire J. Pupillary response to noxious stimulation during isoflurane and propofol anesthesia. Anesth Analg. 1993;76(5):1072–8. https://doi.org/10.1213/00000539-199305000-00028.

    Article  CAS  PubMed  Google Scholar 

  8. Barvais L, Engelman E, Eba JM, Coussaert E, Cantraine F, Kenny GN. Effect site concentrations of remifentanil and pupil response to noxious stimulation. Br J Anaesth. 2003;91(3):347–52. https://doi.org/10.1093/bja/aeg178.

    Article  CAS  PubMed  Google Scholar 

  9. Wildemeersch D, Peeters N, Saldien V, Vercauteren M, Hans G. Pain assessment by pupil dilation reflex in response to noxious stimulation in anaesthetized adults. Acta Anaesthesiol Scand. 2018;62(8):1050–6. https://doi.org/10.1111/aas.13129.

    Article  CAS  PubMed Central  Google Scholar 

  10. Neice AE, Behrends M, Bokoch MP, Seligman KM, Conrad NM, Larson MD. Prediction of opioid analgesic efficacy by measurement of pupillary unrest. Anesth Analg. 2017;124(3):915–21. https://doi.org/10.1213/ANE.0000000000001728.

    Article  CAS  PubMed  Google Scholar 

  11. Sabourdin N, Barrois J, Louvet N, et al. Pupillometry-guided intraoperative remifentanil administration versus standard practice influences opioid use: a randomized study. Anesthesiology. 2017;127(2):284–92. https://doi.org/10.1097/ALN.0000000000001705.

    Article  CAS  PubMed  Google Scholar 

  12. Guglielminotti J, Grillot N, Paule M, et al. Prediction of movement to surgical stimulation by the pupillary dilatation reflex amplitude evoked by a standardized noxious test. Anesthesiology. 2015;122(5):985–93. https://doi.org/10.1097/ALN.0000000000000624.

    Article  PubMed  Google Scholar 

  13. Aissou M, Snauwaert A, Dupuis C, Atchabahian A, Aubrun F, Beaussier M. Objective assessment of the immediate postoperative analgesia using pupillary reflex measurement: a prospective and observational study. Anesthesiology. 2012;116(5):1006–122. https://doi.org/10.1097/ALN.0b013e318251d1fb.

    Article  CAS  PubMed  Google Scholar 

  14. Jakuscheit A, Weth J, Lichtner G, Jurth C, Rehberg B, Von Dincklage F. Intraoperative monitoring of analgesia using nociceptive reflexes correlates with delayed extubation and immediate postoperative pain: a prospective observational study. Eur J Anaesthesiol. 2017;34(5):297–305. https://doi.org/10.1097/EJA.0000000000000597.

    Article  PubMed  Google Scholar 

  15. Ly-Liu D, Reinoso-Barbero F. Immediate postoperative pain can also be predicted by pupillary pain index in children. Br J Anaesth. 2015;114(2):345–6. https://doi.org/10.1093/bja/aeu473.

    Article  CAS  PubMed  Google Scholar 

  16. Vinclair M, Schilte C, Roudaud F, et al. Using pupillary pain index to assess nociception in sedated critically ill patients. Anesth Analg. 2019. https://doi.org/10.1213/ane.0000000000004173.

    Article  PubMed  Google Scholar 

  17. Vide S, Costa CM, Gambus PL, Amorim PP. Effects of ketamine on pupillary reflex dilation: a case report. A&A Pract. 2018;10(2):39–41. https://doi.org/10.1213/XAA.0000000000000633.

    Article  Google Scholar 

  18. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF). Arthritis Care Res. 2011;63(Suppl. 11):S240–S252252. https://doi.org/10.1002/acr.20543.

    Article  Google Scholar 

  19. Boselli E, Bouvet L, Bégou G, et al. Prediction of immediate postoperative pain using the analgesia/nociception index: a prospective observational study. Br J Anaesth. 2014;112(4):715–21. https://doi.org/10.1093/bja/aet407.

    Article  CAS  PubMed  Google Scholar 

  20. Ledowski T, Burke J, Hruby J. Surgical pleth index: prediction of postoperative pain and influence of arousal. Br J Anaesth. 2016;117(3):371–4. https://doi.org/10.1093/bja/aew226.

    Article  CAS  PubMed  Google Scholar 

  21. Ledowski T, Sommerfield D, Slevin L, Conrad J, von Ungern-Sternberg BS. Surgical pleth index: prediction of postoperative pain in children? Br J Anaesth. 2017;119(5):979–83. https://doi.org/10.1093/bja/aex300.

    Article  CAS  PubMed  Google Scholar 

  22. Sabourdin N, Peretout JB, Khalil E, Guye ML, Louvet N, Constant I. Influence of depth of hypnosis on pupillary reactivity to a standardized tetanic stimulus in patients under propofol-remifentanil target-controlled infusion: a crossover randomized pilot study. Anesth Analg. 2018;126(1):70–7. https://doi.org/10.1213/ANE.0000000000001802.

    Article  PubMed  Google Scholar 

  23. Birren JE, Casperson RC, Botwinick J. Age changes in pupil size. J Gerontol. 1950;5(3):216–21. https://doi.org/10.1093/geronj/5.3.216.

    Article  CAS  PubMed  Google Scholar 

  24. Larson MD. Pupillary effects of general anesthesia. Anesthesiol Rev. 1986;XII(1):28.

    Google Scholar 

  25. Aubrun F, Mazoit J-X, Riou B. Postoperative intravenous morphine titration. Br J Anaesth. 2012;108(2):193–201. https://doi.org/10.1093/bja/aer458.

    Article  CAS  PubMed  Google Scholar 

  26. Abou Hammoud H, Simon N, Urien S, Riou B, Lechat P, Aubrun F. Intravenous morphine titration in immediate postoperative pain management: population kinetic-pharmacodynamic and logistic regression analysis. Pain. 2009;144(1–2):139–46. https://doi.org/10.1016/j.pain.2009.03.029.

    Article  CAS  PubMed  Google Scholar 

  27. Larson MD, Berry PD, May J, Bjorksten A, Sessler DI. Latency of pupillary reflex dilation during general anesthesia. J Appl Physiol. 2004;97(2):725–30. https://doi.org/10.1152/japplphysiol.00098.2004.

    Article  PubMed  Google Scholar 

  28. Pogatzki-Zahn EM, Segelcke D, Schug SA. Postoperative pain—from mechanisms to treatment. Pain Rep. 2017. https://doi.org/10.1097/PR9.0000000000000588.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Charier D, Vogler MC, Zantour D, et al. Assessing pain in the postoperative period: Analgesia Nociception IndexTM versus pupillometry. Br J Anaesth. 2019;123(2):e322–e327327. https://doi.org/10.1016/j.bja.2018.09.031.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Funding

None.

Author information

Authors and Affiliations

  1. Department of Anesthesia, Unidade Local de Saúde de Matosinhos – Hospital Pedro Hispano, R. de Dr. Eduardo Torres, 4464-513, Matosinhos, Portugal

    Sérgio Vide

  2. Department of Anesthesiology, Center for Clinical Research in Anesthesia, Centro Hospitalar do Porto, Porto, Portugal

    Sérgio Vide, Rui Correia, Catarina S Nunes & Pedro Amorim

  3. Systems Pharmacology Effect Control & Modeling (SPEC-M) Research Group, Anesthesiology Department, Hospital CLINIC de Barcelona, Barcelona, Spain

    Sérgio Vide & Pedro Gambús

  4. Hospital Santa Maria Maior, Barcelos, Portugal

    Ana Castro MD, PhD

  5. Department of Anesthesia, Hospital Divino Espírito Santo, Ponta Delgada, Portugal

    Tiago Cabral

  6. Faculdade de Medicina da Universidade do Porto, Porto, Portugal

    Deolinda Lima

  7. Department of Sciences and Technology, Universidade Aberta, Porto, Portugal

    Catarina S Nunes

  8. Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), NeuroImmunology Research Group, Barcelona, Spain

    Pedro Gambús

Authors
  1. Sérgio Vide
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ana Castro MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Rui Correia
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Tiago Cabral
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Deolinda Lima
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Catarina S Nunes
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Pedro Gambús
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Pedro Amorim
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

SV: This author helped design and conduct the study; collect, analyze, and interpret the data; and write the manuscript. AC: This author helped analyze and interpret the data; and write the manuscript. RC: This author helped analyze and interpret the data. TC: This author helped conduct the study; collect and interpret the data. DL: This author helped interpret the data and revise the manuscript. CN: This author helped interpret the data. PG: This author helped analyze and interpret the data; and write the manuscript. PA: This author helped design and conduct the study; collect, analyze, and interpret the data; and revise the manuscript.

Corresponding author

Correspondence to Sérgio Vide.

Ethics declarations

Conflict of interest

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Vide, S., Castro, A., Correia, R. et al. Foreseeing postoperative pain in neurosurgical patients: pupillometry predicts postoperative pain ratings—an observational study. J Clin Monit Comput 35, 1111–1118 (2021). https://doi.org/10.1007/s10877-020-00570-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10877-020-00570-3

Keywords

Search

Navigation