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Description of the validity of the Analgesia Nociception Index (ANI) and Nociception Level Index (NOL) for nociception assessment in anesthetized patients undergoing surgery: a systematized review

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Abstract

Maintaining optimum analgesia in anesthetized patients is challenging due to the inability to self-report pain or exhibit pain-related behaviours. The Analgesia Nociception Index (ANI) (based on heart rate variability [HRV]) and the Nociception Level Index (NOL) (based on HRV, photoplethysmography, skin conductance, and temperature) both include HRV and provide continuous index monitoring for nociception assessment. The research question was: “What are the validation strategies of the NOL and ANI for nociception assessment in anesthetized patients?”. The objectives were to describe and analyze the validation strategies and results. A systematized review was conducted using a comprehensive search with keywords under three concepts (nociception/pain, ANI/NOL, and validity) in four databases. A quality assessment using an adapted GRADE approach for measurement tools, and a risk of bias assessment using QUADAS-2 tool were performed by two reviewers. Out of 525 results, 15 validation studies were included. Strategies included hypothesis testing, discriminative, and criterion validation. Significant changes in ANI/NOL values were found in response to nociceptive stimuli at different opioid concentrations (hypothesis testing). Higher ANI/NOL values were observed during nociceptive stimuli (discriminative). AUCs ranging from 0.83 to 0.99 were obtained to detect nociceptive stimuli (criterion). Both technologies performed superiorly in detecting nociceptive stimuli compared to individual monitoring of HR and blood pressure. Although the aforementioned validation strategies are deemed appropriate, in the absence of a gold standard, criterion validation findings should be interpreted with caution. Moreover, reliability could be examined using test–retest with consistent ANI/NOL values during a stable time-interval.

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Acknowledgements

The authors would like to thank the dedicated librarians, Alexandre Amar-Zifkin, MLIS, and Taline Ekmekjian, MLIS, at McGill University Health Centre Medical Libraries (Montreal, Quebec, Canada) for their help with the literature search process.

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This project was not funded by any funding agencies and it is considered as the authors own work.

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Authors and Affiliations

  1. Ingram School of Nursing, McGill University, Montréal, Canada

    T. Shiva Shahiri, Melissa Richard-Lalonde & Céline Gélinas

  2. Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital - CIUSSS West-Central Montréal, Montréal, Canada

    T. Shiva Shahiri, Melissa Richard-Lalonde & Céline Gélinas

  3. Department of Anesthesiology and Pain Medicine, University of Montréal, Hôpital Maisonneuve-Rosemont - CIUSSS Est-de-lÏle-de-Montréal, Montréal, Canada

    Philippe Richebé

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Contributions

Conception and design: SST, CG. Data acquisition: SST, PR. Data analysis: SST, MRL, CG. Data interpretation: SST, PR, MRL, CG. Drafting and revision of the manuscript: SST, CG. Critical revision of the manuscript for important intellectual content: SST, PR, MRL, CG.

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Correspondence to Céline Gélinas.

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SST, MRL, CG declare no conflict of interest. PR has received honorarium for lectures and consultations from Medasense Ltd.

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Shahiri, T.S., Richebé, P., Richard-Lalonde, M. et al. Description of the validity of the Analgesia Nociception Index (ANI) and Nociception Level Index (NOL) for nociception assessment in anesthetized patients undergoing surgery: a systematized review. J Clin Monit Comput 36, 623–635 (2022). https://doi.org/10.1007/s10877-021-00772-3

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