Till Örebro universitet

BACKGROUND: Seizure duration during electroconvulsive therapy (ECT) correlates with treatment efficacy and may be influenced by depth of anaesthesia. The Patient State Index (PSi), derived from processed EEG, offers a potential method to monitor depth of anaesthesia during ECT. This study examined the correlation between pre-ictal PSi and EEG-seizure duration.

METHODS: In this prospective observational study, adult patients undergoing routine ECT at a Swedish university hospital were monitored using the SedLine pEEG system. Anaesthetic care followed standard protocols and the clinical team was blinded to PSi values. Pre-ictal PSi was defined as the final value prior to the ECT stimulus. EEG-seizure duration and relevant clinical variables were extracted from health records. The primary outcome was the association between pre-ictal PSi and EEG-seizure duration, analysed using a linear mixed-effects model adjusting for age and use of benzodiazepines or anticonvulsants. Secondary analyses explored sex and age effects on PSi over time and differences between baseline and pre-ictal PSi.

RESULTS: Eighty-seven ECT sessions in 37 patients were analysed. Median baseline PSi was 94 (IQR 4) and pre-ictal PSi was 38 (IQR 31; p < 0.001). No correlation was found between pre-ictal PSi and EEG-seizure duration. There were no significant effects of age or sex on pre-ictal PSi while there was a significant difference between sexes on baseline PSi. Artefact and EMG activity in the EEG signal were minimal.

CONCLUSION: Pre-ictal PSi was not associated with EEG-seizure duration.

EDITORIAL COMMENT: This study found no evidence to support a correlation between pre-ictal Patient State index and seizure duration, thereby challenging any clinical utility for guiding ECT administration.

OBJECTIVES: Nociception monitoring during general anesthesia is evolving to improve intraoperative management and postoperative outcomes. While opioid-based anesthesia (OBA) remains widely used for its strong antinociceptive effects, concerns about opioid-induced adverse effects have fueled interest in opioid-free anesthesia (OFA) approaches. This study aimed to compare perioperative and postoperative hemodynamic parameters, nociceptive dynamics, and depth of consciousness between OFA and OBA.

METHODS: This secondary analysis used data from the multicenter cohort study Opioid-Sparing Person- Centered Care study, a prospective, multicenter randomized controlled trial (ClinicalTrials.gov number: NCT03756961), including 79 patients undergoing bariatric surgery with OFA or OBA. Hemodynamic parameters, depth of consciousness, and nociception level (NOL) index was collected during anesthesia induction, surgery and in post-anesthesia care unit (PACU), while postoperative pain scores, measured with the Numbers Rating Scale (NRS), were recorded only in the PACU. NOL index values were blinded to clinicians throughout the procedure.

RESULTS: During anesthesia induction, the OFA group exhibited significantly higher hemodynamic and nociceptive responses compared to the OBA group. NOL index values were elevated in the OFA group, indicating increased nociceptive activity. In contrast, the OBA group showed slightly higher NOL index values in the PACU. Bispectral index monitoring demonstrated a lighter depth of anesthesia in the OFA group compared with the OBA group, although both groups remained within an adequate anesthesia range. OFA regime was identified as a strong predictor of lower postoperative NOL index values. However, the OBA group also included a higher proportion of patients that scored postoperative pain with NRS ≥4 compared with the OFA group.

CONCLUSIONS: Intraoperative monitoring revealed distinct patterns in nociceptive dynamics and their coupling with anesthetic depth between OFA and OBA techniques. OBA showed a tighter coupling between nociception and anesthetic depth, whereas both approaches appeared suboptimal for postoperative pain control. Despite these intraoperative variations, the overall impact on early postoperative recovery was limited. Larger, prospective studies are warranted to assess how nociception-guided anesthesia strategies and time within specific NOL intervals influence postoperative pain and long-term outcomes.

PURPOSE: Despite increased interest in opioid-free strategies, their clinical uptake remains limited. This study explores Swedish perioperative healthcare professional's (HCPs) knowledge, attitudes, and practices regarding opioid and nonopioid analgesia across intraoperative and postoperative contexts.

DESIGN: A national web-based survey was conducted among perioperative HCPs across Sweden between October 2023 and January 2024. METHODS: The questionnaire, based on the Knowledge, Attitudes, Practices (KAP) model, included closed- and open-ended items addressing intra and postoperative pain management. Quantitative data were analyzed using nonparametric statistics, and qualitative responses were examined using deductive thematic analysis aligned with the KAP model.

RESULTS: Knowledge gaps predominated: 39% of all respondents were unsure of intraoperative opioid-free evidence, and 37% of postoperative anesthesiologists scored lower than nurse anesthetists and critical-care nurses (p < .01). Attitudes were pragmatic but opioid-centric: 89% were satisfied with current practice, and 87% deemed opioids essential, though most favored dose reduction over elimination, citing vague opioid-free anesthesia (OFA) definitions and case-specific risk. Practice mirrored attitudes: 68% did not primarily use opioid-free medications intraoperatively, blocks were common yet rarely audited. Nonpharmacological options were rarely used postoperatively: 23% routinely offered TENS, typically delivered by nurses or physiotherapists, while 59% relied primarily on opioids.

CONCLUSIONS: Perioperative pain management remains predominantly opioid-based, yet respondents showed openness toward individualized, opioid-free strategies.

CLINICAL IMPLICATIONS: Key barriers included limited knowledge among HCPs, conceptual ambiguity around OFA, and low routine use of non-pharmacological methods. Targeted education, outcome evaluation, and team-based protocols are needed to bridge the gap between the evidence and practice.

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.

OBJECTIVES: Opioid-free anesthesia (OFA) is a promising alternative to traditional opioid-based anesthesia. Research indicates that OFA reduces postoperative opioid consumption and related adverse effects while maintaining effective pain control and patient safety. Despite these benefits, clinical adoption of OFA remains limited, possible due to gaps in evidence. To bridge this knowledge gap, a web-based survey was used to assess Swedish healthcare professionals' (HCPs') knowledge, attitudes, and practices regarding OFA, aiming to identify barriers and facilitators for its broader integration into routine anesthesia care.

METHODS: A web-based survey was sent to anesthesiology department heads at all university hospitals in Sweden and three randomly selected smaller hospitals. The department heads distributed the survey to anesthesiologists, nurse anesthetists, critical care nurses, and registered nurses involved in intraoperative care. The questionnaire had four sections: demographic data, general questions regarding intraoperative care, specific questions on OFA usage, and an open-ended question.

RESULTS: A total of 309 HCPs responded to the survey, corresponding to a response rate of 35%. The majority of respondents (77%) had seven or more years of perioperative experience, 63% were female, and 82% worked at university hospitals. Knowledge about OFA was generally low, with 62% reporting insufficient knowledge, and 14% actively applied OFA. Self-report data demonstrated that anesthesiologists had significantly lower knowledge levels on applying OFA compared to nurse anesthetists and critical care nurses (p < 0.01). However, 85% of all HCPs expressed interest in acquiring additional theoretical knowledge about OFA. Additionally, 87% reported either absent guidelines or uncertainty about their existence, while most (57%) agreed that guidelines supporting the practice of OFA should be introduced at their clinic.

CONCLUSION: This survey indicated interest in OFA among Swedish perioperative HCPs while revealing key barriers to implementation, including knowledge gaps and limited guidelines. Addressing these challenges through targeted education and institutional support may facilitate broader OFA adoption, enhancing patient safety and multimodal perioperative pain management.

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.

BACKGROUND: Simulation-based learning is used to educate students in anaesthetics and critical care. At the postgraduate level, the aim is to foster an understanding of the connection between theory and practice and prepare nurses for the clinical environment. In this context, we created a new wherein we integrated simulation-based learning with clinical learning activities e.g. before start of clinical practice, during and after end of clinical practice. The postgraduate nurses were educated and instructed by university teachers from the postgraduate program and clinical active tutors, critical care nurses and registered nurse anaesthetists from the simulation center. This study aimed to explore the experiences of postgraduate nurses with simulation-based learning and its impact on their overall learning outcomes.

METHOD: This is a descriptive qualitative interview study with a purposeful sample of postgraduate nurses with experience with simulation-based learning during clinical practice. The data were analysed using inductive and thematic analysis.

RESULTS: We identified two themes 'pros of simulation-based learning' and 'cons of simulation- based learning' describing opportunities and obstacles related to the postgraduate nurses' experience of simulation-based learning. 'Pros of simulation-based learning' included the subthemes 'learning through scenarios facilitates preparedness for clinical practice,' 'learning via reflection gives you time to think over your actions' and 'Learning from tutors is valuable and highly regarded 'Cons of simulation based learning' included the subthemes 'it is difficult to accept the simulation situation and environment, 'the design of the scenarios and technical conditions constitutes a barrier' and 'Unfamiliar groups interfere with learning.

CONCLUSION: This study shows that simulation-based learning activities promoted postgraduate nurses learning especially later in the education. Competence required for critical care nurses and registered nurse anesthetists is situational and competence specific, theoretical background and clinical experience are therefore required to promote progression in learning.

BACKGROUND: Monitoring of vital signs is essential in anaesthesia care and plays a key role in preventing adverse events. Technological innovation is recognised as an important factor in enhancing patient safety. Smart glasses represent a novel tool that may support anaesthesia professionals in monitoring vital signs; however, their practical use and user experiences in anaesthesia care remain insufficiently explored. Understanding anaesthesia healthcare professionals' experiences with this technology is crucial to ensure its safe and effective implementation. In this study, smart glasses from Microsoft HoloLens 2 were used to visualize vital signs in the user's field of vision. The aim was to explore anaesthesia health care professionals' experience of using Microsoft HoloLens 2 smart glasses for monitoring vital signs in various simulated anaesthesia care scenarios.

METHODS: A qualitative study design was used to explore the experiences of nurse anaesthetists and anaesthesiologists. Data were gathered through focus group interviews and subsequently analysed using qualitative content analysis.

RESULTS: One overarching theme - a positive yet cautious attitude towards smart glasses - was identified, comprising three categories: Impact on intraoperative monitoring, Usability of the smart glass technology, and Communication challenges. These categories illustrated both advantages and limitations of using smart glasses in simulated anaesthesia care scenarios.

CONCLUSIONS: The experience of using Microsoft HoloLens 2 for monitoring vital signs in simulated anaesthesia care scenarios revealed a generally positive but careful attitude towards the technology. Participants appreciated its potential to enhance situational awareness through continuous access to vital signs, while also highlighting concerns related to ergonomics, restricted field of view, and possible distraction. The findings offer insights for developers aiming to optimise smart glasses for clinical use. Further refinement and evaluation in clinical settings are needed before broader implementation in anaesthesia practice.