Multiparametric Monitoring of Hypnosis and Nociception-Antinociception Balance during General Anesthesia-A New Era in Patient Safety Standards and Healthcare Management

Unlocking opportunities to transform patient care: an expert insight on limitations and opportunities in patient monitoring

BACKGROUND

Current patient monitoring technologies are crucial for delivering personalised and timely care and are critical in achieving the best health outcomes while maintaining high care standards. However, these technologies also present several challenges affecting patients and healthcare professionals.

INFORMATION OVERLOAD

Healthcare providers often deal with excess data, making it challenging to identify the most critical patient information quickly. This may lead to delays in necessary interventions and potentially poorer patient outcomes.

ALARM FATIGUE

Many patient monitoring systems trigger frequent false alarms. This high incidence can cause healthcare providers to become desensitised, potentially leading to slower response times or overlooked important alerts.

INTEGRATION CHALLENGES

Current systems often need more seamless integration with other healthcare technologies, making it difficult for healthcare providers to have a cohesive view of the patient's health. This lack of integration can impair care coordination and increase workloads. This paper presents the findings from a group of experts who described the state of the art of patient monitoring and discussed potential solutions and new pathways for developing these technologies.

A novel electroencephalographic evaluation of noxious stimulation during isoflurane anesthesia in dogs

In veterinary clinical medicine, evaluating the balance between nociception and antinociception presents a great challenge for anesthesiologists during canine surgeries. Heart rate (HR) and mean arterial pressure (MAP) are suitable indexes for monitoring noxious stimuli during anesthesia. Frontal electroencephalography (EEG) records, including processed parameters, are recommended for evaluating nociceptive balance in anesthetized unconscious human patients, which is unexplored in veterinary medicine. Therefore, the objective is to explore the response of processed EEG parameters to noxious stimulation and elucidate the impact of noxious stimulation on frontal cortical activity in dogs anesthetized with 1.5% isoflurane. Fourteen dogs were included and underwent frontal EEG monitoring, measuring the patient state index (PSI) and spectral edge frequency (SEF) before and after administering noxious stimulation using the towel clamp method on the tail of each 1.5% isoflurane-anesthetized dog. As the noxious stimulation was applied, there was a simultaneous increase in PSI, HR, and MAP, with PSI exhibiting a drastic response. SEF, especially on the left side, also increased with noxious stimulation. In EEG power spectral analysis, the delta band was decreased, and the alpha and beta bands showed an increase following noxious stimulation, with a more profound elevation of beta band on the left side. This study suggests that noxious stimulation brings asymmetric frontal cortical arousal, changing brain activity by suppressing delta wave and augmenting alpha and beta waves. Consequently, PSI seems to be a potential indicator for detecting stimuli in canine isoflurane anesthesia.

Latent profiles and determinants of postoperative sleep quality in elective surgery patients

It is crucial to determine the potential subgroups of sleep disturbances in patients undergoing elective surgery based on the importance of symptom clusters and individual characteristics in order to develop targeted symptom management plans. This study explored the potential categories of postoperative sleep disturbances in patients undergoing elective surgery through latent profile analysis, and explored the influencing factors of each category. A total of 400 eligible elective surgery patients were included in the analysis, and three potential subgroups were identified: mild sleep disturbance group (c1 = 140,35.0%), moderate sleep sleep disturbance group (c2 = 177,44.2%), and severe sleep disturbance group (c3 = 83,20.8%). It was found that the higher the BMI, the greater the probability of patients belonging to the moderate sleep disturbance group (OR = 1.114, P = 0.002) and the severe sleep disturbance group (OR = 1.258, P < 0.001),the longer the duration of anesthesia the greater the likelihood of patients belonging to the severe sleep disturbance group (OR = 1.004,P = 0.011), the greater the pain the greater the probability of patients belonging to the moderate sleep disturbance group (OR = 1.590,P < 0.001) and severe sleep disturbance group (OR = 1.785,P < 0.001), and the higher the anxiety level the greater the probability that patients were in the moderate sleep disturbance group (OR = 1.135,P = 0.007) and severe sleep disturbance group (OR = 1.261,P < 0.001).

Effect of classical music on light-plane anaesthesia and analgesia in dogs subjected to surgical nociceptive stimuli

The objectives of this prospective, randomized, blinded, crossover, experimental study were to detect the potential anaesthetic- and analgesic-sparing effects of classical music provided to dogs undergoing skin surgery, and to investigate the role of substance P as an intraoperative pain indicator. Twenty dogs were included, each subjected to three different treatments: Chopin music, Mozart music and no music. They were premedicated with acepromazine, butorphanol and meloxicam and anaesthetized with propofol and isoflurane. Fentanyl was used as rescue analgesia. The anaesthetic depth was monitored by using the bispectral index along with standard anaesthetic monitoring, and autonomic nervous system responses were used to monitor the adequacy of analgesia. Furthermore, measurements of substance P serum concentration were carried out. Dogs exposed to music required less isoflurane and fentanyl. Furthermore, a statistically significant effect of time on substance P concentration was observed regardless of exposure to music, and there was a significant interaction effect between different timepoints and the type of acoustic stimulus. Classical music seems to have an isoflurane and fentanyl sparing effect on dogs undergoing minor surgery. Following surgical stimulation, the serum substance P concentration increases rapidly, and thus appears to be a potentially useful pain indicator.

Evaluation of qCON and qNOX indices in pediatric surgery under general anesthesia

Background and Aims

The objective of the study was to evaluate the performances of qCON and qNOX indices in pediatric populations undergoing surgery under general anesthesia (GA), focusing on the induction and recovery periods. Both the indices are derived from electroencephalogram (EEG) and implemented in the CONOX monitor (Fresenius Kabi, Germany).

Material and Methods

After approval of the institutional ethics committee, this prospective observational study was conducted in pediatric patients of either sex in the age group of 1-12 years belonging to the American Society of Anesthesiology (ASA) grade I and II undergoing elective surgery under GA. Anesthetic technique was GA with or without regional analgesia (RA). All patients underwent inhalation induction and maintenance using sevoflurane. Patients were monitored with the use of a CONOX monitoring system (Fresenius Kabi, Germany), connected via a set of electrodes placed over the forehead. qCON and qNOX scores were recorded during awake (on operating table premedicated with oral midazolam 0.5 mg/kg), at induction, at loss of eyelash reflex, intubation/laryngeal mask airway (LMA) insertion, before and after regional anesthesia, surgical incision, at cessation of anesthesia, emergence, extubation, and eye-opening. Registered results were also analyzed compared with the minimum alveolar concentration of sevoflurane (MAC).

Results

A total of 46 pediatric patients were enrolled in the study with a mean age of 5.6 years. All the patients were either ASA I or II. There was a simultaneous fall and rise of qCON and qNOX upon induction and recovery, respectively. There was a rise in qNOX with surgical incision irrespective of RA. However, there was a greater rise in qNOX following surgical incision in those who did not receive RA (P = 0.33) Also both qCON (P = 0.06) and qNOX (P = 0.41) were poorly correlated with MAC values of sevoflurane during GA in the pediatric population.

Conclusions

Both qCON and qNOX values change predictably with changes in the conscious level and with different noxious stimuli. Further studies are required to confirm the findings taking into account the postoperative assessment of delirium and recall of intraoperative events.

The association of hemodynamic parameters and clinical demographic variables with acute postoperative pain in female oncological breast surgery patients: A retrospective cohort study

OBJECTIVES

Appropriate administration of intraoperative analgesia is an essential factor in care and reasonable recovery times. Inappropriate intraoperative analgesia puts the patient at risk of acute postoperative pain (APOP). The absence of an objective standard for intraoperative nociceptive monitoring complicates pain care. Heart rate (HR) and mean arterial blood pressure (MABP) have been suggested as useful parameters during general anesthesia for nociceptive monitoring. However, studies focusing on whether intraoperative heart rate variability (HRv) and mean arterial blood pressure variability (MABPv) during general anesthesia can accurately monitor nociception in patients have remained inconclusive. The current study aimed to (1) identify the association of intraoperative heart rate and blood pressure variability in patients undergoing low-risk surgery with the incidence of APOP in the immediate postoperative setting and (2) evaluate the associations of clinical demographic factors with the incidence of APOP.

METHODS

A retrospective observational cohort study was conducted. The outcome was moderate-to-severe APOP, defined as a numeric rating scale score of ≥ 4. HRv, MABPv, and potential confounders, such as age, body mass index, duration of surgery, smoking, depression, preoperative use of analgesics, and type of surgery, were used as independent variables.

RESULTS

Data from 764 female oncological breast surgery patients were analyzed. No statistically significant association of HRv and MABPv with APOP was found. Lower age was associated with higher odds of APOP (odds ratio [OR] 0.978, p = 0.001). Increased length of surgery (OR 1.013, p = 0.022) and a history of depression were associated with increased odds of APOP (OR 2.327, p = 0.010). The subtype of surgery was statistically significantly associated with APOP (p = 0.006).

CONCLUSIONS

Our results suggest that heart rate and blood pressure variability intraoperatively, in female patients undergoing low-risk surgery, are not associated with, and thus not predictive of, APOP in the immediate postoperative setting.

Assessment and management of pain/nociception in patients with disorders of consciousness or locked-in syndrome: A narrative review

The assessment and management of pain and nociception is very challenging in patients unable to communicate functionally such as patients with disorders of consciousness (DoC) or in locked-in syndrome (LIS). In a clinical setting, the detection of signs of pain and nociception by the medical staff is therefore essential for the wellbeing and management of these patients. However, there is still a lot unknown and a lack of clear guidelines regarding the assessment, management and treatment of pain and nociception in these populations. The purpose of this narrative review is to examine the current knowledge regarding this issue by covering different topics such as: the neurophysiology of pain and nociception (in healthy subjects and patients), the source and impact of nociception and pain in DoC and LIS and, finally, the assessment and treatment of pain and nociception in these populations. In this review we will also give possible research directions that could help to improve the management of this specific population of severely brain damaged patients.

General Anesthesia as a Multimodal Individualized Clinical Concept

In the last decades, several new and modern techniques have been developed for the continuous monitoring of vitals for patients undergoing surgery under general anesthesia. These complex methods are meant to come as an adjunct to classical monitoring protocols used in general anesthesia to increase patient safety. The main objectives of multimodal monitoring are avoiding the over- or underdosing of anesthetic drugs, adapting the concentration for the substances in use, reducing post-anesthetic complications, and increasing patient comfort. Recent studies have shown a series of benefits with significant clinical impact such as a reduced incidence of nausea and vomiting, shorter reversal times, a reduction in opioid consumption, shorter hospital stays, and an increase in patient satisfaction.