Journal of Clinical Monitoring and Computing

, Volume 31, Issue 5, pp 961–965 | Cite as

Evaluation of perfusion index as a tool for pain assessment in critically ill patients

  • Ahmed HasaninEmail author
  • Sabah Abdel Raouf Mohamed
  • Akram El-adawy
Original Research


Pain is a common and undertreated problem in critically ill patients. Pain assessment in critically ill patients is challenging and relies on complex scoring systems. The aim of this work was to find out the possible role of the perfusion index (PI) measured by a pulse oximeter (Masimo Radical 7; Masimo Corp., Irvine, CA, USA) in pain assessment in critically ill patients. A prospective observational study was carried out on 87 sedated non-intubated patients in a surgical intensive care unit. In addition to routine monitoring, a Masimo pulse oximeter probe was used for PI measurement. The sedation level of the patients was assessed by using the Richmond Agitation-Sedation Scale (RASS). The pain intensity was determined by applying the behavioral pain scale for non-intubated (BPS-NI) patients. The PI, arterial blood pressure, heart rate, RASS, and BPS-NI values before and after the application of a standard painful stimulus (changing the patient position) were reported. Correlation between the PI and other variables was carried out at the two measurements. Correlation between changes in the PI (delta PI) and in the hemodynamic variables, RASS, and BPS-NI was also done. Changing the patient position resulted in a significant increase in SBP (128 ± 20 vs 120.4 ± 20.6, P = 0.009), DBP (71.3 ± 11.2 vs 68.7 ± 11.3, P = 0.021), heart rate (99.5 ± 19 vs 92.7 ± 18.2, P = 0.013), and BPS-NI (7[6–8] vs 3[3–3], P < 0.001) values and a significant decrease in the PI (1[0.5–1.9] vs 2.2[0.97–3.6], P < 0.001) value compared to the baseline readings. There was no correlation between the values of the PI and the ABP, BPS-NI, and RASS at the two measurements. A good correlation was found between the delta PI and delta BPS-NI (r = −0.616, P < 0.001). A weak correlation was observed between the PI and heart rate after the patient positioning (r = −0.249, P < 0.02). In surgical critically ill non-intubated patients, the application of a painful stimulus was associated with decreased PI. There was a good correlation between the change in the PI and the change in BPS-NI values after the application of painful stimulus.


Perfusion index Pain Critically ill patients 



This work was funded by Cairo University.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Chanques G, Sebbane M, Barbotte E, Viel E, Eledjam J-J, Jaber S. A prospective study of pain at rest: incidence and characteristics of an unrecognized symptom in surgical and trauma versus medical intensive care unit patients. Anesthesiology. 2007;107(5):858–60.CrossRefPubMedGoogle Scholar
  2. 2.
    Puntillo KA, Wild LR, Morris AB, Stanik-Hutt J, Thompson CL, White C. Practices and predictors of analgesic interventions for adults undergoing painful procedures. Am J Crit Care. 2002;11:415–29. quiz 430–431.PubMedGoogle Scholar
  3. 3.
    Sigakis MJG, Bittner EA. Ten myths and misconceptions regarding pain management in the ICU. Crit Care Med. 2015;43:2468–78.CrossRefPubMedGoogle Scholar
  4. 4.
    Puntillo KA, Morris AB, Thompson CL, Stanik-Hutt J, White CA, Wild LR. Pain behaviors observed during six common procedures: results from Thunder Project II. Crit Care Med. 2004;32:421–7.CrossRefPubMedGoogle Scholar
  5. 5.
    Grosclaude C, Asehnoune K, Demeure D, Millet S, Champin P, Naux E, Malinge MLC. Opinion of different professional categories about the intensity of procedural pain in adult intensive care units. Ann Fr Anesth Reanim. 2010;29:884–8.CrossRefPubMedGoogle Scholar
  6. 6.
    Payen JF, Bru O, Bosson JL, Lagrasta A, Novel E, Deschaux I, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med. 2001;29:2258–63.CrossRefPubMedGoogle Scholar
  7. 7.
    Aïssaoui Y, Zeggwagh AA, Zekraoui A, Abidi K, Abouqal R. Validation of a behavioral pain scale in critically ill, sedated, and mechanically ventilated patients. Anesth Analg. 2005;101:1470–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Chanques G, Payen J-F, Mercier G, de Lattre S, Viel E, Jung B, et al. Assessing pain in non-intubated critically ill patients unable to self report: an adaptation of the Behavioral Pain Scale. Intensive Care Med. 2009;35:2060–7.CrossRefPubMedGoogle Scholar
  9. 9.
    Lima A, Bakker J. Noninvasive monitoring of peripheral perfusion. Intensive Care Med. 2005;31:1316–26.CrossRefPubMedGoogle Scholar
  10. 10.
    Korhonen I, Yli-Hankala A. Photoplethysmography and nociception. Acta Anaesthesiol Scand. 2009;53:975–85.CrossRefPubMedGoogle Scholar
  11. 11.
    Hamunen K, Kontinen V, Hakala E, Talke P, Paloheimo M, Kalso E. Effect of pain on autonomic nervous system indices derived from photoplethysmography in healthy volunteers. Br J Anaesth. 2012;108:838–44.CrossRefPubMedGoogle Scholar
  12. 12.
    Galvin EM, Niehof S, Verbrugge SJ, Maissan I, Jahn A, Klein J, et al. Peripheral flow index is a reliable and early indicator of regional block success. Anesth Analg. 2006;103:239–43.CrossRefPubMedGoogle Scholar
  13. 13.
    Sebastiani A, Philippi L, Boehme S, Closhen D, Schmidtmann I, Scherhag A, et al. Perfusion index and plethysmographic variability index in patients with interscalene nerve catheters. Can J Anaesth. 2012;59:1095–101.CrossRefPubMedGoogle Scholar
  14. 14.
    Yamazaki H, Nishiyama J, Suzuki T. Use of perfusion index from pulse oximetry to determine efficacy of stellate ganglion block. Local Reg Anesth. 2012;5:9–14.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Franck LS, Greenberg CS, Stevens B. Pain assessment in infants and children. Pediatr Clin North Am. 2000;47:487–512.CrossRefPubMedGoogle Scholar
  16. 16.
    Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane KA, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166:1338–44.CrossRefPubMedGoogle Scholar
  17. 17.
    Atef HM, Fattah SA, Gaffer MEA, Al Rahman AA. Perfusion index versus non-invasive hemodynamic parameters during insertion of i-gel, classic laryngeal mask airway and endotracheal tube. Indian J Anaesth. 2013;57:156–62.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Nishimura T, Nakae A, Shibata M, Mashimo T, Fujino Y. Age-related and sex-related changes in perfusion index in response to noxious electrical stimulation in healthy subjects. J Pain Res. 2014;7:91–7.PubMedPubMedCentralGoogle Scholar
  19. 19.
    Høiseth LØ, Hisdal J, Hoff IE, Hagen OA, Landsverk SA, Kirkebøen KA. Tissue oxygen saturation and finger perfusion index in central hypovolemia: influence of pain. Crit Care Med. 2015;43:747–56.CrossRefPubMedGoogle Scholar
  20. 20.
    Park SG, Lee OH, Park Y-H, Shin HY, Kang H, Baek CW, et al. The changes of non-invasive hemoglobin and perfusion index of Pulse CO-Oximetry during induction of general anesthesia. Korean J Anesthesiol. 2015;68:352–7.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Kus A, Gurkan Y, Gormus SK, Solak M, Toker K. Usefulness of perfusion index to detect the effect of brachial plexus block. J Clin Monit Comput. 2013;27:325–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Ginosar Y, Weiniger CF, Meroz Y, Kurz V, Bdolah-Abram T, Babchenko A, et al. Pulse oximeter perfusion index as an early indicator of sympathectomy after epidural anesthesia. Acta Anaesthesiol Scand. 2009;53:1018–26.CrossRefPubMedGoogle Scholar
  23. 23.
    Ginosar Y, Weiniger CF, Kurz V, Babchenko A, Nitzan M, Davidson E. Sympathectomy-mediated vasodilatation: a randomized concentration ranging study of epidural bupivacaine. Can J Anaesth. 2009;56:213–21.CrossRefPubMedGoogle Scholar
  24. 24.
    Klodell CT, Lobato EB, Willert JL, Gravenstein N. Oximetry-derived perfusion index for intraoperative identification of successful thoracic sympathectomy. Ann Thorac Surg. 2005;80:467–70.CrossRefPubMedGoogle Scholar
  25. 25.
    Rasmy I, Mohamed H, Nabil N, Abdalah S, Hasanin A, Eladawy A, et al. Evaluation of perfusion index as a predictor of vasopressor requirement in patients with severe sepsis. Shock. 2015;44:554–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Lima AP, Beelen P, Bakker J. Use of a peripheral perfusion index derived from the pulse oximetry signal as a noninvasive indicator of perfusion. Crit Care Med. 2002;30:1210–3.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2016

Authors and Affiliations

  • Ahmed Hasanin
    • 1
    Email author
  • Sabah Abdel Raouf Mohamed
    • 1
  • Akram El-adawy
    • 1
  1. 1.Department of Anesthesia and Critical Care MedicineCairo UniversityCairoEgypt

Personalised recommendations