PPI (Pupillary Pain Index) as an alternative to the QoR-40 Questionnaire in measuring recovery quality in postoperative patients

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Patient after surgery (Photo: mynurtsz.com)
Patient after surgery (Photo: mynurtsz.com)

Postoperative pain causes several effects greater patient’s pain, slower healing, and a higher risk of chronic pain. Several tools can be used to assess or measure postoperative pain such as the Numeric Rating System (NRS), Visual Analogue Scale (VAS), and questionnaires. One of the questionnaires that can be used is QoR-40 (The Recovery Quality Questionnaire) which measures the quality of postoperative patient recovery by asking 40 questions to the patient. Other tools that can be used to measure recovery quality is PPI ( Pupillary Pain Index)that take advantage of the body’s various responses to pain or discomfort. One of them is interpreting the response of pupil dilation to pain.

This research aims to find the corellation between the two tools, QoR-40 and PPI in measuring the quality of postoperative patient recovery. This research was conducted in the Recovery Room, the Integrated Central Surgery Building, Dr. Soetomo from September to October 2019. This research was conducted on 46 patients aged between 18-60 years who underwent elective surgery with general anesthesia and had PS-ASA values ​​1-2.

Measurement on the quality of recovery in patients was assessed at 12 and 24 hours postoperative with the two tools, QoR-40 and PPI, then tested for comparison and correlation. In the use of QoR-40 it was determined that the cut-off score points used were 142. If the QoR-40 score> 142 then the patient experienced a good quality of recovery. At 12 hours postoperative, it was found that out of 46 patients, 28 patients (60.8%) had a score <142 ( poor recovery ) and 18 patients (39.2%) had a score ≥142 ( good recovery ). Different results were obtained on measurements at 24 hours postoperative, as many as 37 patients (80.4%) had a score> 142 ( good recovery ) and 9 patients (19.6%) had a score <142 ( bad recovery). Several things can cause poor quality of patient recovery at 12 hours postoperative based on the QoR-40 questionnaire covering five dimensions, patient support, patient comfort, patient emotions, physical independence, and pain.

In the use of PPI, the score varies from 1 to 10, the higher the PPI score, the worse the patient’s recovery score (the patient still feels pain and discomfort), and on the other hand the lower the PPI score, the better the patient’s recovery. In measuring the quality of patient recovery ( Recovery quality ) 12 hours after surgery, the results showed that the mean PPI score was 4.39 ± 1.94, while in the first 24 hours the average PPI score was 2.82 ± 1.33. It means that the PPI score at 24 hours postoperative is better than the PPI score at 12 hours postoperative. A total of 36 patients (78.2%) had a decreased PPI score (improvement in quality of recovery), 7 patients (15.2%) had a fixed score, and 3 patients (6.6%) had an increase in their PPI score (decreased quality of recovery).

Based on the correlation test, significant results were obtained between QoR-40 and PPI at 12 hours postoperative (P <0.001 and R = -0.952) and QoR-40 and PPI at 24 hours postoperative (P <0.001 and R = -0.928). It means that PPI measurements can be used to replace the QoR-40 measurement to assess the quality of postoperative patient recovery. Clinically, the use of PPI is considered more practical and effective than QoR-40. PPI measurement using pupillometry is an objective measure of pain as well as biomarkers such as cortisol, IL-6, TNF-alpha and so on. PPI that take advantage of multiple body responses to pain or discomfort are rated as more practical, non-invasive, quick, inexpensive in evaluating objective pain parameters and their relationship to the quality of postoperative patient recovery.

Based on the explanation above, it can be concluded that the use of the Pupillary Pain Index is considered more practical and effective so that it can be used as an alternative to QoR-40 as an instrument to measure the quality of recovery of postoperative patients. (*)

Author: Dr. Arie Utariani, dr., SpAn., KAP

Details from this research can be viewed at:


Agastya WD, Utariani A, Susila D. The relationship between QoR-40 questionary value and pupillary pain index as assessment of recovery quality on post-operating patients treated by multimodal analgesia (Parasetamol + NSAID + PCA OPIOID). Indian J Forensic Med Toxicol. 2020;14(3):2222–7.

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