Prediction of immediate postoperative pain using the analgesia/nociception index: a prospective observational study

Br J Anaesth. 2014 Apr;112(4):715-21. doi: 10.1093/bja/aet407. Epub 2013 Dec 8.


Background: The analgesia/nociception index (ANI) is derived from heart rate variability, ranging from 0 (maximal nociception) to 100 (maximal analgesia), to reflect the analgesia/nociception balance during general anaesthesia. This should be correlated with immediate postoperative pain in the post-anaesthesia care unit (PACU). The aim of this study was to evaluate the performance of ANI measured at arousal from general anaesthesia to predict immediate postoperative pain on arrival in PACU.

Methods: Two hundred patients undergoing ear, nose, and throat or lower limb orthopaedic surgery with general anaesthesia using an inhalational agent and remifentanil were included in this prospective observational study. The ANI was measured immediately before tracheal extubation and pain intensity was assessed within 10 min of arrival in PACU using a 0-10 numerical rating scale (NRS). The relationship between ANI and NRS was assessed using linear regression. A receiver-operating characteristic (ROC) curve was used to evaluate the performance of ANI to predict NRS>3.

Results: A negative linear relationship was observed between ANI immediately before extubation and NRS on arrival in PACU. Using a threshold of <50, the sensitivity and specificity of ANI to discriminate between patients with NRS≤3 and NRS>3 were both 86% with 92% negative predictive value, corresponding to an area under the ROC curve of 0.89.

Conclusions: The measurement of ANI immediately before extubation after inhalation-remifentanil anaesthesia was significantly associated with pain intensity on arrival in PACU. The performance of ANI for the prediction of immediate postoperative pain is good and may assist physicians in optimizing acute pain management.

Clinical trial registration: NCT01796249.

Keywords: anaesthesia, general; analgesia; nociception; pain measurement.

Publication types

  • Clinical Trial
  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Analgesia / methods*
  • Anesthesia Recovery Period
  • Anesthesia, General / methods
  • Female
  • Heart Rate / physiology
  • Humans
  • Male
  • Middle Aged
  • Nociception / physiology*
  • Pain Measurement / methods
  • Pain, Postoperative / diagnosis*
  • Postoperative Care / methods
  • Predictive Value of Tests
  • Prospective Studies
  • Sensitivity and Specificity

Associated data