To Örebro University

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.

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.

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.

Background/Objectives: Older patients are more susceptible to the process of understanding and retrieving information. To provide adequate preoperative information, reduce their vulnerability and anxiety, and thereby facilitate pre-, intra-, and postoperative care, the adoption of new information technologies is essential. This study aimed to explore elderly patients' experiences and perceptions of a Virtual Reality (VR)-based preoperative informational tool designed for individuals scheduled to undergo TKA.

Method: A qualitative content analysis was conducted from February to June 2025 based on 14 semi-structured post-discharge interviews. Participants were recruited as part of a randomized controlled trial.

Results: One main theme and two categories describe patients' experiences of using VR information, which is perceived as a valuable supplement to standard preoperative information. The category "Using VR as an information tool" includes how patients experienced the immersive environment, how it affected them, and their views on using the VR glasses. The category "Apply the information provided" described how patients evaluated and applied the VR content in relation to their expectations and the actual surgical experience.

Conclusions: Immersive virtual reality (VR) shows promise as a preoperative information tool, improving patients' understanding of the perioperative process and supporting engagement in their own care. Its effectiveness depends on reliable technical performance and adaptation to individual needs. VR should complement, not replace, communication with healthcare professionals. Further research is needed to identify optimal timing for VR delivery and its impact on preoperative anxiety and patient experience.