Till Örebro universitet

PURPOSE: The purpose of this study was to describe the experiences of critical care nurses (CCNs) and registered nurse anesthetists (RNAs) when monitoring and observing infants and toddlers recovering from anesthesia. DESIGN: A qualitative design with a critical incident approach.

METHODS: Semistructured individual interviews were conducted with a purposeful sample of CCNs and RNAs (n = 17) from postanesthesia care units at two hospitals. The critical incident technique approach was used to guide the interviews, and data were analyzed inductively using thematic analysis.

FINDINGS: The main finding was the CCNs' and RNAs' description of how they "watch over the children and stay close" to provide emotional and physical safety. CCNs' and RNAs' experiences of observing and managing the children's small, immature airways were reflected in the theme "using situation awareness of the small, immature airways." The theme "understanding emergence agitation" describes the challenge that arises when children are anxious, feel insecure, and have pain, and the theme "having parents nearby" shows the necessity and value of involving parents in their children's care.

CONCLUSIONS: Findings from this study suggest that caring for infants and toddlers recovering from anesthesia requires experience and both technical and nontechnical skills. These are prerequisites for achieving readiness for planning, setting priorities, and adapting one's behavior if an adverse event occurs. Alertness and the ability to solve acute problems and make quick decisions are essential because of the risks associated with children's small, immature airways, as is the ability to understand and respond to emergence agitation. Having parents nearby is equally important for creating the conditions for compassionate child- and family-centered care.

OBJECTIVES: Transcutaneous electrical nerve stimulation (TENS) is a noninvasive adjunct to multimodal pain management for acute postoperative care across various surgeries. Despite extensive evidence supporting its efficacy, TENS remains underutilized in clinical practice. This study aimed to assess the knowledge, attitudes, and practices of healthcare professionals regarding TENS in perioperative settings to support its integration into routine clinical practice.

METHODS: A web-based questionnaire was distributed to anesthesiology department heads at all university hospitals (n = 7) in Sweden and three smaller, randomly selected hospitals across three geographical areas. Department heads forwarded the questionnaire to anesthesiologists, nurse anesthetists, critical care nurses, and registered nurses with basic education working in perioperative settings. The questionnaire included four sections: demographic information, general postoperative phase information, TENS use for postoperative pain relief, and open-ended questions.

RESULTS: The survey was sent to 870 respondents, yielding a response rate of 28% (n = 246). Among respondents, 69% reported lacking adequate knowledge to administer TENS, and 79% indicated they did not use TENS in their practice. Furthermore, 45% noted an absence of clinical guidelines supporting the use of TENS in their clinic, while 32% were unsure about the existence of guidelines. However, 60% expressed interest in developing theoretical knowledge and practical skills for TENS application.

CONCLUSIONS: This study highlights that substantial knowledge gaps and the lack of clear clinical guidelines limit the use of TENS for acute postoperative pain management. These deficiencies may lead to inadequate pain control, increased opioid use, and opioid-related adverse effects. We recommend that hospital leadership and professional bodies develop and implement comprehensive educational programs and establish clear, evidence-based clinical guidelines for TENS use in postoperative pain management. Addressing these gaps is essential for improving clinical practice and empowering patients through greater involvement and autonomy in pain management strategies.

BACKGROUND: The objective of this study was to evaluate anaesthesia care professionals' perceptions and attitudes regarding the implementation and advancement of digital solutions in perioperative care.

METHODS: Anaesthesia personnel working in public Swedish institutions where anaesthesia is administered were invited to respond to an online survey regarding their attitudes towards digitalization in the workplace and their perceptions of information provision and future digitalization within anaesthesia and surgical healthcare. Data were analyzed using descriptive statistics, independent-samples Kruskal-Wallis tests, and post-hoc pairwise comparisons.

RESULTS: The survey response rate was 64.0% (n = 627). Most respondents agreed/strongly agreed that digital solutions facilitate their work, the preoperative preparation, patient participation, and being involved in the patients' journeys throughout the perioperative care process. The majority also agreed/strongly agreed that digital solutions could make more patients adequately prepared before anaesthesia/surgery, reduce the number of non-optimized patients, and adapt the perioperative process to the patients' individual needs, as well as lead to reduced costs for the healthcare provider and reduced cancelled anaesthesia/surgeries. However, there were statistically significant differences between responses in relation to age groups, where the largest differences were observed between respondents in the age groups 20-30 and 61-70 years and in relation to what part of Sweden respondents worked in, with the largest differences between respondents working in Southern Sweden and the middle part of Sweden.

CONCLUSION: Swedish anaesthesia personnel are confident that digital solutions may enhance the efficiency of care within the anaesthesia setting. However, varying perceptions on the benefits and necessity of digital solutions are indicated.

BACKGROUND: Inadequate or excessive nociceptive control during general anesthesia can result in significant adverse outcomes. Using traditional clinical variables, such as heart rate, systolic blood pressure, and respiratory rate, to assess and manage nociceptive responses is often insufficient and could lead to overtreatment with both anesthetics and opioids. This study evaluated the feasibility and effectiveness of three nociception monitoring techniques Nociception Level Index (NOL), Skin Conductance Algesimeter (SCA) and heart rate monitoring in patients undergoing image-guided, minimally invasive abdominal interventions under general anesthesia.

METHOD: This prospective observational study collected data from 2022 to 2024. All patients were anesthetized according to the department's routine, and predetermined events were recorded. Two commercially available nociception monitors, the PMD-200 from Medasense (NOL) and PainSensor from MedStorm (SCA), were used, and their data were collected along with various hemodynamic parameters. The three nociception monitoring techniques were compared during predetermined events.

RESULT: A total of 49 patients were included in this study. NOL and SCA demonstrated higher responsiveness than HR for all events except for skin incision. The comparison of the values above and below the threshold for each nociceptive stimulus showed significance for all measurements using the SCA and NOL. However, using HR as a surrogate for nociception with a threshold of a 10% increase from baseline, the difference was significant only at skin incision. There was no variation in the peak values attributable to differences in patients' age. Weight was a significant predictor of the peak NOL values.

CONCLUSION: NOL and SCA demonstrated superior sensitivity and responsiveness to nociceptive stimuli compared to HR, effectively detecting significant changes in nociceptive thresholds across various stimuli, although responses during skin incision showed no such advantage.

TRIAL REGISTRATION: Clinical trial - NCT05218551.

INTRODUCTION: The primary objective was to map the impact on confidence and performance on radiographic examinations among undergraduate radiography students utilizing virtual reality (VR). The secondary objective was to identify potential pitfalls to avoid in future VR implementation.

METHODS: A systematic review was conducted, which included comprehensive search in nine databases. The software Covidence was used for screening. Nine studies were included after quality assurance using the Critical Appraisal Skills Programme (CASP). Data extraction consisted of participant characteristics, study design, relevant statistical results, study limitations, and conclusions. Key findings were summarized in a systematic synthesis.

RESULTS: VR compared to traditional skills training provides an advantage in students' assessed performance in both equipment and patient positioning, as well as self-reported confidence within equipment positioning, selection of exposure parameters, and radiation safety. For successful outcome, factors to consider were the size of the VR room, VR tutorials, the length of the VR-session, a realistic VR environment, feedback from the VR system, and the opportunity to interact with patients, both verbally and palpatory.

CONCLUSION: VR is a feasible tool, providing students with a safe, engaging, and controlled environment. Students may apply their theoretical knowledge into real-life scenarios, which develop students' clinical skills, critical thinking, and decision-making abilities.

IMPLICATIONS FOR PRACTICE: Although VR has shown positive effects, VR alone does not guarantee increased performance and confidence in students. Research within this field is deficient, hence further research is needed to confirm the effect of VR, preferably case-control or randomized studies.

OBJECTIVE: This systematic scoping review aimed to map the literature on the use of various nudging strategies to influence prescriber behavior toward reducing opioid prescriptions across diverse healthcare settings.

METHODS: A systematic database search was conducted using seven electronic databases. Only articles published in English were included. A total of 2234 articles were identified, 35 of which met the inclusion criteria. Two independent dimensions were used to describe nudging strategies according to user action and the timing of their implementation.

RESULTS: Six nudging strategies were identified. The most common strategy was default choices, followed by increasing salience of information or incentives and providing feedback. Moreover, 32 studies used the electronic health record as an implementation method, and 29 reported significant results. Most of the effective interventions were multicomponent interventions (i.e., combining nudge strategies and non-nudge components).

CONCLUSIONS: Most nudging strategies used a passive approach, such as defaulting prescriptions to generics and requiring no action from the prescriber. Although reported as effective, this approach often operates under the prescriber's radar. Future research should explore the ethical implications of nudging strategies.

INPLASY registration number: 202420082.

BACKGROUND: Despite recent evidence supporting the adoption of opioid-free anaesthetic and analgesic alternatives in the perioperative context, opioid-based regimens remain standard of care. There is limited knowledge about the patients' perioperative experiences of bariatric surgery, with no study yet investigating their experiences within an opioid-free care pathway.

OBJECTIVE: We aimed to describe similarities and differences in patients' perioperative experiences of undergoing bariatric surgery with either an opioid-free or opioid-based care pathway.

DESIGN: A qualitative interview study.

SETTING: A strategic sample of patients enrolled in an ongoing randomized controlled trial investigating the effects of opioid-free anaesthesia for bariatric surgery were recruited. In the randomized controlled trial, participants were randomized to either opioid-based anaesthesia or opioid-free anaesthesia, including transcutaneous electrical nerve stimulation as primary postoperative pain management.

PARTICIPANTS: Twenty patients were interviewed 3 months after surgery: 10 participants in the opioid-free group versus 10 in the opioid-based group.

METHODS: Semi-structured interviews were conducted between December 2020 and February 2022 and analysed with qualitative content analysis.

RESULTS: The analysis yielded four categories and 12 subcategories. In Category 1, participants shared diverse emotions before surgery, including anticipation of a healthier life, but also apprehensions and feelings of failure. In Category 2, describing liminality of general anaesthesia, there were similar descriptions of struggling to remember the anaesthesia induction and struggling to surface when recovering from anaesthesia. However, some participants in the opioid-free group shared descriptions of struggling to keep control, describing accentuated memories of the anaesthesia induction. Category 3, managing your pain, showed similar experiences and strategies but different narrations of pain management, with the opioid-free group stating that transcutaneous electrical nerve stimulation works but not when it really hurts, and the opioid-based group describing confidence in but awareness of opioids. Throughout the overall perioperative time period, participants acknowledged Category 4, a patient-professional presence, stating that preparations boost the feeling of confidence before surgery and that they felt confidence in a vulnerable situation although vulnerability challenges communication.

CONCLUSIONS: We highlighted the overall similarities in perioperative experiences of patients undergoing bariatric surgery. However, the differences in experiences during opioid-free anaesthesia induction need to be addressed in further implementation and research studies investigating strategies to reduce the sense of loss of control. More research is needed to facilitate the implementation of opioid-free treatment strategies into clinical practice and improve the patient care experience.

BACKGROUND: Measuring and interpreting vital signs in pediatric patients recovering from anaesthesia, particularly those up to 36 months old, is challenging. Nurses' decision-making regarding the level of monitoring must balance patient safety with individualized care. This study aimed to explore the perceptions of critical care nurses and registered nurse anesthetists regarding their experiences and actions when making decisions about vital sign monitoring for children in post-anesthesia care units (PACUs).

METHODS: A qualitative study utilizing the critical incident technique was conducted. Interviews were performed with a purposeful sample of 17 critical care nurses and registered nurse anaesthetists from two hospitals.

RESULTS: Nurses reported that the rationale for decisions concerning the need for vital sign monitoring in children was both adequate and inadequate. Actions were taken to adjust the monitoring of vital signs, optimizing conditions for assessment and ensuring the child's safe recovery.

CONCLUSIONS: The complexity of accurately monitoring children makes it challenging for nurses in the PACU to adhere to guidelines. Evidence-based care and safety are compromised when technology has limitations and is not adapted for paediatric use, leading to a greater reliance on experience and clinical assessment. This reliance on experience is crucial for reliable assessment but also entails accepting greater risks.

Red hair has been linked to altered sensitivity to pain, analgesics, and hypnotics. This alteration may be impacted by variants in the melanocortin-1 receptor (MC1R) gene, which are mainly found in redheads. The aim of this narrative review was to explore and present the current state of knowledge on red hair and its plausible associations with altered responsiveness to pain, analgesics, and hypnotics. Structured searches in the PubMed, CINAHL Complete, and Scopus electronic databases were conducted. Evidence suggests that women with red hair have an increased sensitivity to pain. Conversely, data also indicate a higher pain tolerance in homozygous carriers of MC1R variant alleles. Varied responses to analgesia have been reported, with both increased analgesic responsiveness in homozygous carriers of MC1R variant alleles and less analgesia in redheads. Data indicate an increased need for hypnotics in redheads. However, failed attempts to find statistical associations between red hair and altered responsiveness to hypnotics are also evident. Even though there seems to be an association between red hair and an altered responsiveness to pain, analgesics, and/or hypnotics, the results of this narrative review are inconclusive. Further research studies with larger populations and MC1R testing are needed.

PURPOSE: The purpose of this study was to investigate how Registered Nurse Anesthetists (RNAs) who have been working for nongovernmental organizations in low- and middle-income countries perceive their role in global health.

DESIGN: A qualitative design was used in this study.

METHODS: Data were collected by means of semistructured interviews with 11 participants who met the inclusion criteria, and qualitative analysis of the interview content was performed.

FINDINGS: The analysis resulted in three categories and six subcategories. Of the categories, "Using skills" includes the respondents' varying levels of responsibility, tasks, and perceptions of how far they are applying their expertise. "Encountering new cultures" is about adapting to new cultural norms in nursing, education, and cooperation in the international team. "Promoting change through volunteerism" comprises personal and professional development, and impact - both local and potentially global.

CONCLUSIONS: This study highlights the relevance of RNAs in global health and emphasizes the cultural encounters, exchanges, and challenges associated with volunteer medical missions. RNAs' knowledge of, and humble approach to the host country's culture are essential for their ability to provide nursing care, engage in cooperation and training, and promote global health in a high-quality, sustainable and effective way.