Nociception index–monitored extubation is associated with improved hemodynamic stability and recovery efficiency in the post-anesthesia care unit: a single-center randomized controlled trial

Extubation in the post-anesthesia care unit (PACU) is a high-risk transition, frequently accompanied by hemodynamic fluctuations and respiratory events. Current practice relies mainly on subjective assessments and the bispectral index (BIS), which reflects cortical activity but not nociceptive responses. The electroencephalography-derived Nociception Index (NOX) may provide an objective measure of nociception–analgesia balance during extubation. This study aimed to evaluate whether NOX-monitored extubation improves hemodynamic stability and recovery efficiency in the PACU. In this single-center randomized controlled trial (July 2023–March 2025), 120 patients undergoing surgery with postoperative intubation were randomized to NOX-monitored extubation (n = 60) or standard monitoring (n = 60). Extubation criteria included consciousness, tidal volume ≥ 5 mL/kg, SpO₂ ≥90%, hemodynamic stability (SBP < 180 mmHg, HR < 100 bpm). Hemodynamic and respiratory parameters, extubation timing, PACU discharge time, and complications were compared between groups. Baseline characteristics were comparable except for higher hypertension prevalence in the NOX group (21.7% vs. 0%). At awakening, the NOX group showed attenuated blood-pressure responses (SBP − 7.3%, DBP − 9.0% vs. controls; both p < 0.05). PACU discharge was faster in the NOX group (median 27.5 vs. 50.5 min; p < 0.001; ≈42% reduction). However, greater heart-rate increases (+ 14.5 vs. + 7.4 bpm; p = 0.008) and oxygen desaturation (–2.28% vs. − 0.70%; p < 0.001) were observed. Complication rates were similar (11.7% vs. 18.3%; p = 0.306). NOX-monitored extubation improved hemodynamic stability and reduced PACU recovery time but was associated with paradoxical cardiorespiratory trade-offs. Larger multicenter trials are required to refine thresholds and validate its clinical utility. Clinical registration: The study was first posted on ChiCTR.org.cn on August 02, 2022, and the first research participant was enrolled on June 12, 2023.