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Background  In response to noxious stimulation, pupillary dilation reflex ( PDR ) occurs even in anaesthetized patients. The aim of the study was to evaluate the ability of pupillometry with an automated increasing stimulus intensity to monitor intraoperative opioid administration.    Methods  Thirty‐four patients undergoing elective surgery were enrolled. Induction by propofol anaesthesia was increased progressively until the sedation depth criteria (SeD) were attained. Subsequently, a first dynamic pupil measurement was performed by applying standardized nociceptive stimulation ( SNS ). A second  PDR  evaluation was performed when remifentanil reached a target effect‐site concentration. Automated infrared pupillometry was used to determine  PDR  during nociceptive stimulations generating a unique pupillary pain index ( PPI ). Vital signs were measured.    Results  After opioid administration, anaesthetized patients required a higher stimulation intensity (57.43 mA vs 32.29 mA,  P  < .0005). Pupil variation in response to the nociceptive stimulations was significantly reduced after opioid administration (8 mm vs 28 mm,  P  < .0005). The  PPI  score decreased after analgesic treatment (8 vs 2,  P  < .0005), corresponding to a 30% decrease. The elicitation of  PDR  by nociceptive stimulation was performed without changes in vital signs before ( HR  76 vs 74/min,  P  = .09;  SBP  123 vs 113 mm Hg,  P  = .001) and after opioid administration ( HR  63 vs 62/min,  P  = .4;  SBP  98.66 vs 93.77 mm Hg,  P  = .032).    Conclusions  During propofol anaesthesia, pupillometry with the possibility of low‐intensity standardized noxious stimulation via  PPI  protocol can be used for  PDR  assessment in response to remifentanil administration.

Pain assessment by pupil dilation reflex in response to noxious stimulation in anaesthetized adults