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The Nociception Level (NOL) index uses a multiparametric approach to measure the balance between sympathetic and parasympathetic systems activity. Recently, a strong correlation between the NOL index response to nociceptive stimuli and the level of opioid analgesia during surgery was reported. Others observed that intraoperative doses of remifentanil and sufentanil were reduced when the NOL index was used. So far, no study has evaluated the impact of NOL-guided fentanyl antinociception in laparoscopic gynecological surgery. The primary hypothesis of this present study was to evaluate whether intraoperative NOL-guided fentanyl administration would reduce intra-operative opioid consumption. Secondary hypotheses were to assess whether this would lead to lower postoperative opioid consumption and pain scores, as well as improved postoperative outcomes. University hospital, operating room. 70 adult patients, ASA 1–3, scheduled for total laparoscopic hysterectomy. Patients were randomized into 2 groups: SOC (standardization of care) and NOL (using the NOL index to guide the administration of fentanyl). The depth of anesthesia was monitored with BIS™. Intraoperative fentanyl boluses were administered based on heart rate and mean arterial pressure variations in the SOC group, and NOL index for the NOL group. Fentanyl total intraoperative dose administered was collected and also averaged per hour. Pain scores and hydromorphone consumption were assessed in the post-anesthesia care unit and up to 24 h. Sixty-six patients completed the study, 33 in each group. Total intraoperative fentanyl administration was not different between the two groups (217 (70) in the NOL group vs 280 (210) in the SOC group (P = 0.11)). Nevertheless, intraoperative fentanyl administration per hour was reduced by 25% in the NOL-guided group compared to the SOC group: 81 (24) vs 108 (66) μg.h−1, respectively (P = 0.03). Hydromorphone consumption and pain scores in the post-anesthesia care unit and at 24 h were not significantly different between the two groups. NOL-guided analgesia allowed for a 22% reduction of the total amount of intraoperative fentanyl which was not significant. Nevertheless, results reported a significant reduction by 25% in the doses of fentanyl averaged per hour of surgery and administered in the NOL-guided group compared with the standardized practice in laparoscopic gynecological surgery. The pain measured postoperatively was similar in the two groups while the average postoperative consumption of opioids to achieve the same level of pain scores in post-anesthesia care unit and at 24 h was not significantly reduced. Further larger multicenter studies centered towards postoperative outcomes are needed. •NOL index is a recently developped index to better assess intraoperative nociception level•NOL-guided intraoperative antinociception allows for rationalized and personalized management of opioids•In hysterectomies it resulted in a significant reduction of intraoperative doses of fentanyl per hour of surgery•No significant difference was seen on postoperative pain scores and analgesics' consumption•Larger studies must be proposed in the future, powered on these postoperative outcomes.

Maintaining optimum analgesia in anesthetized patients is challenging due to the inability to self-report pain or exhibit pain-related behaviours. The Analgesia Nociception Index (ANI) (based on heart rate variability [HRV]) and the Nociception Level Index (NOL) (based on HRV, photoplethysmography, skin conductance, and temperature) both include HRV and provide continuous index monitoring for nociception assessment. The research question was: “What are the validation strategies of the NOL and ANI for nociception assessment in anesthetized patients?”. The objectives were to describe and analyze the validation strategies and results. A systematized review was conducted using a comprehensive search with keywords under three concepts (nociception/pain, ANI/NOL, and validity) in four databases. A quality assessment using an adapted GRADE approach for measurement tools, and a risk of bias assessment using QUADAS-2 tool were performed by two reviewers. Out of 525 results, 15 validation studies were included. Strategies included hypothesis testing, discriminative, and criterion validation. Significant changes in ANI/NOL values were found in response to nociceptive stimuli at different opioid concentrations (hypothesis testing). Higher ANI/NOL values were observed during nociceptive stimuli (discriminative). AUCs ranging from 0.83 to 0.99 were obtained to detect nociceptive stimuli (criterion). Both technologies performed superiorly in detecting nociceptive stimuli compared to individual monitoring of HR and blood pressure. Although the aforementioned validation strategies are deemed appropriate, in the absence of a gold standard, criterion validation findings should be interpreted with caution. Moreover, reliability could be examined using test–retest with consistent ANI/NOL values during a stable time-interval.

IntroductionChronic pain is a common health condition that significantly impacts the quality of life of those affected, affecting one in five people in Canada. The prevalence of this condition tends to increase with age, making it a major health issue given the ageing population. However, its management remains inadequate and requires significant mobilisation of healthcare professionals as well as the development of multiple therapeutic solutions. Among these, non-pharmacological interventions such as hypnosis and virtual reality have proven effective. Nevertheless, while the existing literature seems promising, it presents methodological limitations. Therefore, this study aims to assess the effectiveness of an intervention combining virtual reality and hypnosis in an ageing population suffering from a widespread chronic pain condition, that is, hand arthritis.Methods and analysisThis study will be a single-centre randomised clinical trial. Participants will be randomly assigned to one of two conditions: one receiving an intervention combining virtual reality and hypnosis, and the other receiving only virtual reality. The effectiveness of the intervention on current perceived pain before and after the intervention (primary outcome) will be evaluated. Secondary outcomes will include anxiety and depressive symptoms, quality of life, relaxation and fatigue. Exploratory analyses will also be conducted to contribute to the emerging literature by examining physiological variables such as heart rate variability, respiratory rate and electrodermal activity during the intervention, and their relationship with primary and secondary outcomes.Ethics and disseminationThe project was approved by the Research Ethical Committee of the Hospital Maisonneuve-Rosemont (Project no 2024-3539). Participants will be asked to provide written consent for their participation. Results from this study will be shared through peer-reviewed publications, as well as oral and poster presentations at scientific events. The protocol for this study was preregistered on Open Science Framework and raw anonymised data will be available on this platform (https://osf.io/vbh72/?view_only=1d17c5708f894faab6669d85e1fde75d).Trial registration numberNCT06833905.

Stem cell transplantation is a highly stressful treatment for hematological cancer patients, negatively impacting their quality of life. Hypnosis has proven effective in managing symptoms like pain, fatigue, and anxiety, and improving quality of life. Virtual reality (VR) is used in cancer treatments to distract from pain, and combining VR with hypnosis (VRH) could enhance the hypnotic experience. However, methodological limitations in current studies prevent clear evaluation of its effectiveness, particularly for individualized care and psychosocial interventions. 1) To evaluate the preliminary effects of VRH in reducing anxiety, pain, and fatigue during stem cell transplant, improving quality of life post-intervention. 2) To assess intervention feasibility, including patients' experiences, satisfaction levels, and recommendations for improving the VRH tool. This study will involve 60 hematology patients divided into two groups: VRH and waiting list. Anxiodepressive symptoms, pain, quality of life, fatigue, absorption, dissociation, and amusement will be assessed before, immediately after the intervention, and at one- and three-month follow-ups using validated psychological scales and numeric rating scales (0-10). Semi-structured interviews will capture patient expectations, satisfaction, and feedback. Data will be analyzed using MANOVA (or non-parametric alternatives) and thematic analysis. The study's primary goal is to assess VRH's effectiveness compared to standard care in a feasibility randomized controlled trial (RCT). It will also provide data for improving the VRH tool (version 2.0) and assess its usability. In the long term, findings will help integrate VRH into oncology clinics, offering an innovative intervention to support patients throughout treatment. ClinicalTrials.gov NCT06817759.

Incivilities in healthcare, especially in operating rooms, can cause emotional exhaustion, burnout, and reduced job satisfaction. Verbal and physical aggression, harassment, and sexual misconduct are common in surgical environments, negatively impacting healthcare workers and patient safety. This study assessed the prevalence of incivility in anesthesia teams in France and its impact. A survey collecting demographic data and experiences of incivility was distributed to 4232 French Society of Anesthesia and Intensive Care (SFAR) members in 2022. The final sample (n = 873) showed a distribution of gender and professional roles broadly comparable to the overall SFAR membership. An adapted Maslach Burnout Inventory (MBI) was used to measure emotional exhaustion, depersonalization (interpreted here as loss of empathy), and personal accomplishment. Out of 989 responses, 873 were included (20,6 % of SFAR members), with the following gender distribution: 48 % male and 52 % female. A total of 83 % reported experiencing incivility, and over 60 % witnessed it regularly. The overall effect of incivility was low for emotional exhaustion and loss of empathy. Women reported significantly more verbal aggression, sexual harassment, and deviant behaviors. Emotional exhaustion was higher in women and nurse anesthetists, while anesthesiologists reported greater loss of personal accomplishment. No significant differences in depersonalization or loss of empathy were found. Incivility is widespread in operating rooms toward anesthesia teams, with notable emotional impacts, especially on women and nurse anesthetists. Despite this, empathy for patients remains largely preserved. Addressing gender and hierarchical dynamics is essential for improve workplace culture and support staff well-being. •83 % of anesthesiologists and nurse anesthetists had been target of incivility.•On a daily to monthly basis, more than 1/5 respondents had been target of incivility.•Only 1 % of respondents reported never having witnessed any form of incivility.

PurposeHypotension is common following spinal anesthesia (SA) during elective Cesarean delivery (CD). Although common practice is to alleviate inferior vena cava (IVC) compression, limited evidence supports a 15° tilt for CD. We measured collapsibility of the IVC in supine and 15° left lateral tilt positions with ultrasound before and after SA and phenylephrine infusion in term parturients.MethodsTwenty term parturients scheduled for CD were recruited for this prospective study. Ultrasound measurements of the IVC were taken 1) supine before SA, 2) tilted 15° before SA, 3) supine after SA, and 4) tilted 15° after SA. A phenylephrine infusion was begun after injection of SA. The primary outcome was to evaluate the impact of position on the IVC collapsibility index (IVCCI): a measure of the difference between the maximum and minimum IVC diameter with respiration.ResultsThe mean (standard deviation) IVCCI (%) before SA was higher in the supine 19.5 (8.0) than in the tilted 15.0 (6.4) position (mean difference, 4.5; 95% confidence interval [CI], 0.1 to 8.9; P = 0.04). After SA, there was no significant difference between IVCCI (%) in the supine 17.8 (8.3) and tilted 14.2 (6.9) position (mean difference, 3.5; 95% CI, -0.9 to 7.9; P = 0.13). There was no correlation between the pre-spinal IVVCI measurements and the quantity of phenylephrine used during the surgery.ConclusionThe IVCCI was lower in the 15° tilt position than in the supine position, but not after SA with a phenylephrine infusion. Ultrasound imaging can help identify IVC compression.Trial registrationwww.clinicaltrials.gov (NCT03410199); registered 18 January 2018.

Background Residual neuromuscular blockade (rNMB) after surgery can lead to complications such as respiratory distress, increased length of hospital stay, and higher healthcare costs. Sugammadex, a selective relaxant-binding agent, has shown efficacy in reversing rocuronium-induced neuromuscular blockade more rapidly than neostigmine. This study aimed to evaluate the effectiveness of a low dose of sugammadex (0.5 mg.kg −1 ) compared to standard neostigmine with glycopyrrolate for the reversal of moderate rocuronium-induced neuromuscular blockade. Methods This randomized, double-blind, controlled trial included adult patients undergoing surgery with rocuronium-induced moderate neuromuscular blockade. Participants were randomized to receive either low-dose sugammadex or standard-dose neostigmine with glycopyrrolate at the end of surgery. The primary outcome was the time to achieve a Train-of-Four (TOF) ratio of ≥ 0.9 after administration of the reversal agent. Secondary outcomes included extubation time, incidence of sugammadex rescue therapy for incomplete reversal, and postoperative complications. Statistical analysis used t-tests and Mann–Whitney-Wilcoxon tests for continuous variables and chi-square tests for categorical variables, with significance set at p  < 0.05. Results The median time to reach TOF ratio of ≥ 0.9 was significantly shorter in the sugammadex group (4.3 min, IQR: 3.2–6) compared to the neostigmine group (20.6 min, IQR: 10.1–21.3, p  < 0.001). Extubation times were also reduced with sugammadex, with a median of 11.6 (IQR: 8.6–15.1) minutes versus 25.9 (IQR: 17.7–29.7) minutes in the neostigmine group ( p  < 0.001). Only 4.8% of patients in the sugammadex group required rescue therapy to reverse the neuromuscular block with TOF ratio of ≥ 0.9, compared to 60.6% in the neostigmine group ( p  < 0.001). No significant differences were observed in postoperative respiratory complications or PACU length of stay. Conclusions Low-dose sugammadex provides a faster and more reliable reversal of moderate neuromuscular blockade than standard-dose neostigmine, with implications for improved operating room efficiency and patient safety. Continuous neuromuscular monitoring remains essential, as a small proportion of patients may still require additional intervention. Trial registration Registered retrospectively at ClinicalTrials.gov with registration number NCT05718934 on 2023–02-08.

ObjectivesOur primary objective was to assess the association between symptoms at the time of surgery and postoperative pulmonary complications and mortality in patients with COVID-19. Our secondary objective was to compare postoperative outcomes between patients who had recovered from COVID-19 and asymptomatic patients and explore the effect of the time elapsed between infection and surgery in the former. Our hypotheses were that symptomatic patients had a higher risk of pulmonary complications, whereas patients who had recovered from the infection would exhibit outcomes similar to those of asymptomatic patients.BackgroundManaging COVID-19-positive patients requiring surgery is complex due to perceived heightened perioperative risks. However, Canadian data in this context remains scarce.DesignTo address this gap, we conducted a multicentre observational cohort study.SettingAcross seven hospitals in the province of Québec, the Canadian province was most affected during the initial waves of the pandemic.ParticipantsWe included adult surgical patients with either active COVID-19 at the time of surgery or those who had recovered from the disease, from March 22, 2020 to April 30, 2021.OutcomesWe evaluated the association between symptoms or recovery time and postoperative pulmonary complications and hospital mortality using multivariable logistic regression and Cox models. The primary outcome was a composite of any postoperative pulmonary complication (atelectasis, pneumonia, acute respiratory distress syndrome and pneumothorax). Our secondary outcome was hospital mortality, assessed from the date of surgery up to hospital discharge.ResultsWe included 105 patients with an active infection (47 were symptomatic and 58 were asymptomatic) at the time of surgery and 206 who had recovered from COVID-19 prior to surgery in seven hospitals. Among patients with an active infection, those who were symptomatic had a higher risk of pulmonary complications (OR 3.19, 95% CI 1.12 to 9.68, p=0.03) and hospital mortality (HR 3.67, 95% CI 1.19 to 11.32, p=0.02). We did not observe any significant effect of the duration of recovery prior to surgery on patients who had recovered from their infection. Their postoperative outcomes were also similar to those observed in asymptomatic patients.InterpretationSymptomatic status should be considered in the decision to proceed with surgery in COVID-19-positive patients. Our results may help optimise surgical care in this patient population.Study registrationClinicalTrials.gov Identifier: NCT04458337 registration date: 7 July 2020.

Current trends in anesthetic depth (i.e., hypnosis) and antinociception monitoring are unclear. We thus aimed to determine contemporary perspectives on monitoring these components of anesthesia during general anesthesia. Participants received and responded anonymously to an internet-based international survey supported by the European Society of Anaesthesiology and Intensive Care. Comparisons, when applicable, were carried out using Chi 2 analysis or Fischer’s exact test. A total of 564 respondents, predominantly from Europe (80.1%), participated. There was a strong participation from Belgium (11.5%). A majority (70.9%) of anesthetists considered hypnotic monitoring important on most occasions to always. In contrast, a majority (62.6%) never or only occasionally considered antinociception monitoring important. This difference in the perceived importance of anesthetic depth versus antinociception monitoring was significant (p < 0.0001). A majority of respondents (70.1%) believed that guiding hypnosis and antinociception using these monitors would improve patient care on most occasions to always. Nonetheless, a substantial number of participants were unsure if hypnotic (23%) or antinociception (32%) monitoring were recommended and there was a lack of knowledge (58%) of any published algorithms to titrate hypnotic and/or antinociceptive drugs based on the information provided by the monitors. In conclusion, current trends in European academic centers prioritize anesthesia depth over antinociception monitoring. Despite an agreement among respondents that applying strategies that optimize anesthetic depth and antinociception could improve outcome, there remains a lack of knowledge of appropriate algorithms. Future studies and recommendations should focus on clarifying goal-directed anesthetic strategies and determine their impact on perioperative patient outcome.

The number of elderly patients undergoing major surgery is rapidly increasing. They are particularly at risk of developing postoperative neurocognitive disorders (NCD). Earlier studies suggested that processed electroencephalographic (EEG) monitors may reduce the incidence of postoperative NCD. However, none of these studies controlled for intraoperative nociception levels or personalized blood pressure targets. Their results remain unclear if the reduction in the incidence of postoperative NCD relates to avoidance of any electroencephalographic pattern suggesting excessive anesthesia depth. The objective of this trial is to investigate-in patients ≥ 70 years old undergoing major non-cardiac surgery-the effect of EEG-guided anesthesia on postoperative NCD while controlling for intraoperative nociception, personalized blood pressure targets, and using detailed information provided by the EEG monitor (including burst suppression ratio, density spectral array, and raw EEG waveform). This prospective, randomized, controlled trial will be conducted in a single Canadian university hospital. Patients ≥ 70 years old undergoing elective major non-cardiac surgery will be included in the trial. The administration of sevoflurane will be adjusted to maintain a BIS index value between 40 and 60, to keep a Suppression Ratio (SR) at 0%, to keep a direct EEG display without any suppression time and a spectrogram with most of the EEG wave frequency within the alpha, theta, and delta frequencies in the EEG-guided group. In the control group, sevoflurane will be administered to achieve an age-adjusted minimum alveolar concentration of [0.8-1.2]. In both groups, a nociception monitor will guide intraoperative opioid administration, individual blood pressure targets will be used, and cerebral oximetry used to tailor intraoperative hemodynamic management. The primary endpoint will be the incidence of NCD at postoperative day 1, as evaluated by the Montreal Cognitive Assessment (MoCA). Secondary endpoints will include the incidence of postoperative NCD at different time points and the evaluation of cognitive trajectories up to 90 days after surgery among EEG-guided and control groups. NCT04825847 on ClinicalTrials.gov.