Summary
The accurate assessment of the depth of anesthesia, allowing a more accurate adaptation of the doses of hypnotics, is an important end point for the anesthesiologist. It is a particularly ...crucial issue in pediatric anesthesia, in the context of the recent controversies about the potential neurological consequences of the main anesthetic drugs on the developing brain. The electroencephalogram signal reflects the electrical activity of the neurons in the cerebral cortex. It is thus the key to assessment of the level of hypnosis. Beyond visual analysis, several monitoring devices allow an automated treatment of the electroencephalographic (EEG) signal, combining time and frequency domain analysis. Each of these monitors focuses on a specific combination of characteristics of the signal and provides the clinician with useful information that remains, however, partial. For a comprehensive approach of the EEG‐derived indices, the main features of the normal EEG, in adults and children, will be presented in the awake state and during sleep. Age‐related modifications accompanying cerebral maturation during infancy and childhood will be detailed. Then, this review will provide an update on how anesthetic drugs, particularly hypnotics, influence the EEG signal, and how the main available monitors analyze these drug‐induced modifications. The relationships between pain, memory, and the EEG will be discussed. Finally, this review will focus on some specific EEG features such as the electrical epileptoid activity observed under sevoflurane anesthesia. The EEG signal is the best window we have on cortical brain activity and provides a fair pharmacodynamic feedback of the effects of hypnotics. However, the cortex is only one of several targets of anesthesia. Hypnotics and opiates, have also subcortical primary targets, and the EEG performances in the evaluation or prediction of nociception are poor. Monitoring subcortical structures in combination with the EEG might in the future allow a better evaluation and a more precise adaptation of balanced anesthesia.
The ANI is a nociception monitor based on the high frequency parts of heart rate variability. Tracheal intubation may induce potentially deleterious hemodynamic disturbances or motor reactions if ...analgesia is inadequate. We investigated whether ANI modification generated by a standardized moderate short tetanic stimulation performed before laryngoscopy could predict hemodynamic or somatic reactions to subsequent intubation. We designed a prospective, interventional, monocentric, pilot study. Regional ethics board approved the study, written informed consent was obtained from each participant. Before laryngoscopy, under steady-state total intravenous anaesthesia with propofol and remifentanil, the ulnar nerve was stimulated with a 5 s tetanus (70 mA, 50 Hz). After another steady-state period, orotracheal intubation was performed. ANI variation, hemodynamic parameters and somatic reactions associated with tetanus and intubation were collected. To assess the predictability of hemodynamic or somatic reaction during laryngoscopy by tetanus-induced ANI variation, we calculated the area under the corresponding Receiver Operating Characteristic curve (AUCROC) and the 95% confidence intervals. Thirty-five patients were analyzed. ANI decreased by 21 ± 17 after tetanus. Regarding the ability of tetanus-induced ANI variation to predict hemodynamic or somatic reactions during subsequent intubation, the AUCROCs 95% CI were 0.61 0.41–0.81 and 0.52 0.31–0.72 respectively. ANI varied after a short moderate tetanic stimulation performed before laryngoscopy but this variation was not predictive of a hemodynamic or somatic reaction during intubation.
Trial registration
NCT04354311, April 20th 2020, retrospectively registered.
Purpose
The Newborn Infant Parasympathetic Evaluation (NIPE) is a heart rate variability-based technology for assessing pain and comfort in neonates and infants under 2-years-old. This review aims to ...investigate the clinical utility of the NIPE.
Methods
Two investigators screened Pubmed/Medline and Google Scholar for relevant studies, independently. One investigator extracted data, which were reviewed by a second investigator.
Results
The NIPE was used during/after painful stimuli (6 studies), in the context of general anaesthesia (2 studies), and for comfort assessment (6 studies). A) Evaluation of procedural pain/distress: 2 studies reported that the mean-NIPE could be used for reliable monitoring of prolonged pain, and one study reported the association between instant-NIPE and pain after a stimulus but the instant-NIPE represents the NIPE average over 3 min. Two studies found no correlation between the NIPE and comfort behavior/pain scales, but they mainly differed in patients’ gestational age and evaluation methodology. B) There are only 2 studies for the evaluation of nociception during surgery under general anaesthesia with contradictory results. C) Studies assessing neonates’ comfort reported increased NIPE scores during skin-to-skin contact and during facilitated tucking associated with a human voice. No effect on NIPE scores of facilitated tucking during echocardiography was reported in preterm infants. One study reported significantly different NIPE scores with 2 surfactant therapy protocols. Overall, study populations were small and heterogeneous.
Conclusion
The results regarding NIPE’s performances differ between studies. Given the limited number of studies and the heterogeneous outcomes, more studies are required to confirm the NIPE usefulness in the different clinical settings.
Background
In this prospective study, we describe the electroencephalographic (EEG) profiles in children anesthetized with sevoflurane or propofol.
Methods
Seventy‐three subjects (11 years, range ...5‐18) were included and randomly assigned to two groups according to the anesthetic agent. Anesthesia was performed by target‐controlled infusion of propofol (group P) or by sevoflurane inhalation (group S). Steady‐state periods were performed at a fixed randomized concentration between 2, 3, 4, 5, and 6 μg.ml−1 of propofol in group P and between 1, 2, 3, 4, and 5% of sevoflurane in group S. Remifentanil was continuously administered throughout the study. Clinical data, Bispectral Index (BIS), and raw EEG were continuously recorded. The relationship between BIS and anesthetic concentrations was studied using nonlinear regression. For all steady‐state periods, EEG traces were reviewed to assess the presence of epileptoid signs, and spectral analysis of raw EEG was performed.
Results
Under propofol, BIS decreased monotonically and EEG slowed down as concentrations increased from 2 to 6 μg.ml−1. Under sevoflurane, BIS decreased from 0% to 4% and paradoxically rose from 4% to 5% of expired concentration: this increase in BIS was associated with the occurrence of fast oscillations and epileptoid signs on the EEG trace. Propofol was associated with more delta waves and burst suppression periods compared to sevoflurane.
Conclusion
Under deep anesthesia, the BIS and electroencephalographic profiles differ between propofol and sevoflurane. For high concentrations of sevoflurane, an elevated BIS value may be interpreted as a sign of epileptoid patterns or EEG fast oscillations rather than an insufficient depth of hypnosis.
While objective clinical structured examination (OSCE) is a worldwide recognized and effective method to assess clinical skills of undergraduate medical students, the latest Ottawa conference on the ...assessment of competences raised vigorous debates regarding the future and innovations of OSCE. This study aimed to provide a comprehensive view of the global research activity on OSCE over the past decades and to identify clues for its improvement. We performed a bibliometric and scientometric analysis of OSCE papers published until March 2024. We included a description of the overall scientific productivity, as well as an unsupervised analysis of the main topics and the international scientific collaborations. A total of 3,224 items were identified from the Scopus database. There was a sudden spike in publications, especially related to virtual/remote OSCE, from 2020 to 2024. We identified leading journals and countries in terms of number of publications and citations. A co-occurrence term network identified three main clusters corresponding to different topics of research in OSCE. Two connected clusters related to OSCE performance and reliability, and a third cluster on student's experience, mental health (anxiety), and perception with few connections to the two previous clusters. Finally, the United States, the United Kingdom, and Canada were identified as leading countries in terms of scientific publications and collaborations in an international scientific network involving other European countries (the Netherlands, Belgium, Italy) as well as Saudi Arabia and Australia, and revealed the lack of important collaboration with Asian countries. Various avenues for improving OSCE research have been identified: i) developing remote OSCE with comparative studies between live and remote OSCE and issuing international recommendations for sharing remote OSCE between universities and countries; ii) fostering international collaborative studies with the support of key collaborating countries; iii) investigating the relationships between student performance and anxiety.While objective clinical structured examination (OSCE) is a worldwide recognized and effective method to assess clinical skills of undergraduate medical students, the latest Ottawa conference on the assessment of competences raised vigorous debates regarding the future and innovations of OSCE. This study aimed to provide a comprehensive view of the global research activity on OSCE over the past decades and to identify clues for its improvement. We performed a bibliometric and scientometric analysis of OSCE papers published until March 2024. We included a description of the overall scientific productivity, as well as an unsupervised analysis of the main topics and the international scientific collaborations. A total of 3,224 items were identified from the Scopus database. There was a sudden spike in publications, especially related to virtual/remote OSCE, from 2020 to 2024. We identified leading journals and countries in terms of number of publications and citations. A co-occurrence term network identified three main clusters corresponding to different topics of research in OSCE. Two connected clusters related to OSCE performance and reliability, and a third cluster on student's experience, mental health (anxiety), and perception with few connections to the two previous clusters. Finally, the United States, the United Kingdom, and Canada were identified as leading countries in terms of scientific publications and collaborations in an international scientific network involving other European countries (the Netherlands, Belgium, Italy) as well as Saudi Arabia and Australia, and revealed the lack of important collaboration with Asian countries. Various avenues for improving OSCE research have been identified: i) developing remote OSCE with comparative studies between live and remote OSCE and issuing international recommendations for sharing remote OSCE between universities and countries; ii) fostering international collaborative studies with the support of key collaborating countries; iii) investigating the relationships between student performance and anxiety.
The clinical benefits to be expected from intraoperative nociception monitors are currently under investigation. Among these devices, the Analgesia Nociception-Index (ANI) has shown promising results ...under sevoflurane anesthesia. Our study investigated ANI-guided remifentanil administration under propofol anesthesia. We hypothesized that ANI guidance would result in reduced remifentanil consumption compared with standard management. This prospective, randomized, controlled, single-blinded, bi-centric study included women undergoing elective gynecologic surgery under target-controlled infusion of propofol and remifentanil. Patients were randomly assigned to an ANI or Standard group. In the ANI group, remifentanil target concentration was adjusted by 0.5 ng mL
steps every 5 min according to the ANI value. In the Standard group, remifentanil was managed according to standard practice. Our primary objective was to compare remifentanil consumption between the groups. Our secondary objectives were to compare the quality of anesthesia, postoperative analgesia and the incidence of chronic pain. Eighty patients were included. Remifentanil consumption was lower in the ANI group: 4.4 (3.3; 5.7) vs. 5.8 (4.9; 7.1) µg kg
h
(difference = -1.4 (95% CI, -2.6 to -0.2),
= 0.0026). Propofol consumption was not different between the groups. Postoperative pain scores were low in both groups. There was no difference in morphine consumption 24 h after surgery. The proportion of patients reporting pain 3 months after surgery was 18.8% in the ANI group and 30.8% in the Standard group (difference = -12.0 (95% CI, -32.2 to 9.2)). ANI guidance resulted in lower remifentanil consumption compared with standard practice under propofol anesthesia. There was no difference in short- or long-term postoperative analgesia.
Summary
Background
Few data are available in the literature on risk factors for postoperative vomiting (POV) in children.
Objective
The aim of the study was to establish independent risk factors for ...POV and to construct a pediatric specific risk score to predict POV in children.
Methods
Characteristics of 2392 children operated under general anesthesia were recorded. The dataset was randomly split into an evaluation set (n = 1761), analyzed with a multivariate analysis including logistic regression and backward stepwise procedure, and a validation set (n = 450), used to confirm the accuracy of prediction using the area under the receiver operating characteristic curve (ROCAUC), to optimize sensitivity and specificity.
Results
The overall incidence of POV was 24.1%. Five independent risk factors were identified: stratified age (>3 and <6 or >13 years: adjusted OR 2.46 95% CI 1.75–3.45; ≥6 and ≤13 years: aOR 3.09 95% CI 2.23–4.29), duration of anesthesia (aOR 1.44 95% IC 1.06–1.96), surgery at risk (aOR 2.13 95% IC 1.49–3.06), predisposition to POV (aOR 1.81 95% CI 1.43–2.31), and multiple opioids doses (aOR 2.76 95% CI 2.06–3.70, P < 0.001). A simplified score was created, ranging from 0 to 6 points. Respective incidences of POV were 5%, 6%, 13%, 21%, 36%, 48%, and 52% when the risk score ranged from 0 to 6. The model yielded a ROCAUC of 0.73 95% CI 0.67–0.78 when applied to the validation dataset.
Conclusions
Independent risk factors for POV were identified and used to create a new score to predict which children are at high risk of POV.
Monitoring of intraoperative nociception has made substantial progress in adult anesthesia during the last 10 years. Several monitors have been validated and their use has been associated with ...intraoperative or postoperative benefits in the adult population. In pediatric anesthesia, less data are available. However, several recent publications have assessed the performance of nociception monitors in children, and investigated their potential benefits in this context. This review will describe the main validated intraoperative nociception monitors, summarize adult findings and describe the available pediatric data.
Six intraoperative nociception indices were included in this review. Among them, four have shown promising results in children: Surgical Pleth Index (GE-Healthcare, Helsinki, Finland), Analgesia-Nociception Index (Mdoloris Medical Systems, Loos, France), Newborn-Infant Parasympathetic Evaluation (Mdoloris Medical Systems), and Pupillometry (IDMED, Marseille, France). The relevance of Skin Conductance (MedStorm innovations, AS, Oslo, Norway) under general anesthesia could not be established. Finally, the Nociception Level (Medasense, Ramat Gan, Israel) still requires to be investigated in children.
To date, four monitors may provide a relevant assessment of intraoperative nociception in children. However, the potential clinical benefits associated with their use to guide analgesia remain to be demonstrated.
Summary
Anesthesia results from several inhibitor processes, which interact to lead to loss of consciousness, amnesia, immobility, and analgesia. The anesthetic agents act on the whole brain, the ...cortical and subcortical areas according to their receptor targets. The conscious processes are rather integrated at the level of the cortical neuronal network, while the nonconscious processes such as the nociception or implicit memory require subcortical processing. A reliable and meaningful monitoring of depth of anesthesia should provide assessment of these different processes. Besides the EEG monitoring which gives mainly information on cortical anesthetic effects, it would be relevant to have also a subcortical feedback allowing an assessment of nociception. Several devices have been proposed in this last decade, to give us an idea of the analgesia/nociception balance. Up to now, most of them are based on the assessment of the autonomic response to noxious stimulation. Among the emerging clinical devices, we can mention those which assess vascular sympathetic response (skin conductance), cardiac and vascular sympathetic response (surgical pleth index), parasympathetic cardiac response (analgesia nociception index), and finally the pupillometry which is based on the assessment of the pupillary reflex dilatation induced by nociceptive stimulations. Basically, the skin conductance might be the most adapted to assess the stress in the awake or sedated neonate, while the performances of this method appear disappointing under anesthesia. The surgical pleth index is still poorly investigated in children. The analgesia nociception index showed promising results in adults, which have to be confirmed, especially in children and in infants, and lastly pupillometry, which can be considered as reliable and reactive in children as in adults, but which is still sometimes complicated in its use.
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