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Acta Anaesthesiol Scand. 2008 Sep;52(8):1038-45. doi: 10.1111/j.1399-6576.2008.01687.x.

Surgical stress index as a measure of nociception/antinociception balance during general anesthesia.

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Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland.



No validated monitoring method is available for evaluating the nociception/antinociception balance. We assessed the surgical stress index (SSI), computed from finger photoplethysmographic waveform amplitudes and pulse-to-pulse intervals, in patients undergoing shoulder surgery under general anesthesia (GA) and interscalene plexus block and in patients with GA only.


In this prospective, randomized study in 26 patients, increased blood pressure (BP) or heart rate, movement, and coughing were considered to be signs of intraoperative nociception and were treated with alfentanil. GA was maintained with desflurane aiming at a State Entropy level of 50. Photoplethysmographic waveforms were collected from the contra-lateral arm to the surgery and SSI values from 0 (no surgical stress) to 100 (maximal surgical stress) were calculated off-line.


Two minutes after skin incision, SSI had not increased in the plexus group and was lower in the plexus group (38 +/- 13) compared with the controls (58 +/- 13, P<0.005). Among the controls, 1 min before alfentanil administration, the SSI value was higher than during periods of adequate antinociception, 59 +/- 11 vs. 39 +/- 12 (P<0.01). The total cumulative need for alfentanil was higher in controls (2.7 +/- 1.2 mg) compared with the plexus group (1.6 +/- 0.5 mg; P=0.008). Tetanic stimulation to the ulnar region of the hand increased SSI significantly only among the patients with plexus block not covering the site of the stimulation.


SSI values were lower in patients with plexus block covering the sites of nociceptive stimuli. In detecting nociceptive stimuli, SSI had better performance than heart rate, BP, or response entropy.

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