Nociception level index monitoring in intensive care: pain awareness in pressure ulcer care in unconscious patients: a randomized controlled pilot study.

Abstract

Background: Pain management in intensive care is challenging due to multiple potential causes. The physiological consequences of uncontrolled pain can adversely affect treatment. Reliable, objective pain monitoring may therefore improve care.

Aims: To investigate the validity and clinical impact of the Nociception Level Index (NOL®) for guiding analgesia in intensive care patients.

Methods: This randomized, prospective, controlled study included 40 ICU patients assigned to either a control group or a NOL-guided group (n = 20 each). During daily pressure ulcer care, the NOL group received analgesia according to continuous nociception monitoring, while the control group was managed with fentanyl boluses (1 µg/kg) guided by the Critical Care Pain Observation Tool (CPOT). Hemodynamic variables and variability were also assessed.

Results: Total fentanyl use was significantly higher in the NOL group (67.5 ± 53.25 µg) than in the control group (37.5 ± 32.9 µg), with a mean difference of 30 µg (95% CI 1.7-58.3 µg, p = 0.04, Cohen's d = 0.68), corresponding to ~ 40% greater opioid use. At the start of care, systolic blood pressure (SBP) was higher in the control group (mean difference 12.5 mmHg, 95% CI 2.1-22.9 mmHg, p = 0.02, d = 0.62), while delta SBP was lower in the NOL group (mean difference -8 mmHg, 95% CI -15.2 to -0.8 mmHg, p = 0.03, d = 0.58).

Conclusion: NOL® monitoring may serve as an effective tool to guide analgesic needs in unconscious ICU patients, enabling objective pain assessment and contributing to hemodynamic stability.