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Current trends in anesthetic depth and antinociception monitoring: an international survey

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Abstract

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 Chi2 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.

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Acknowledgements

The authors would like to thank the European Society of Anaesthesiology and Intensive Care and the Belgian Society of Anesthesiology, Resuscitation, Perioperative Medicine and Pain Management for their help with this work. The authors would also like to thank Kyle V. Roerick, M.A., for language editing.

Funding

Departmental/not applicable.

Author information

Authors and Affiliations

  1. Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium

    Sean Coeckelenbergh & Alexandre Joosten

  2. Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium

    Sean Coeckelenbergh & Stefan De Hert

  3. Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de L’Est de L’Ile de Montréal (CEMTL), University of Montreal, Montreal, Canada

    Philippe Richebé

  4. Department of Anesthesiology and Intensive Care, Hôpital Bichat—Claude-Bernard, AP-HP. Nord—Université de Paris, Paris, France

    Dan Longrois

  5. Department of Anesthesiology, Hôpital-Paul Brousse, Université Paris-Saclay, Villejuif, France

    Alexandre Joosten

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  1. Sean Coeckelenbergh
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Contributions

SC designed the study, analyzed the data, and wrote the manuscript; PR designed the study and critically reviewed the manuscript; DL designed the study and critically reviewed the manuscript; AJ designed the study and critically reviewed the manuscript; SDH designed the study and critically reviewed the manuscript.

Corresponding author

Correspondence to Sean Coeckelenbergh.

Ethics declarations

Conflict of interest

SC has received honoraria from Medtronic, Medasense, and Med-Storm Innovations. PR has received honoraria and trial funding (investigator initiated/not sponsored) from Medtronic and Medasense. DL has received honoraria from Medtronic, Masimo and Medasense. AJ has no conflicts of interest regarding this work. SDH has no conflicts of interest regarding this work.

Ethical approval

The Research Ethics Committee of the Société Française d’Anesthésie-Réanimation (IRB 00010254-2020-191; 7 Septembre 2020: Chairman Pr. JE. Bazin) approved this study.

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Respondents were informed that their answers would be studied anonymously.

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The authors give consent for publication of this study after peer-review and acceptance by the Journal.

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Appendices

Appendix 1

Anaesthetic depth monitoring: where are we in 2020?

Do you monitor anaesthesia depth? What do you think about antinociception monitoring? Do you believe that personalising these components of anaesthesia with monitors can improve outcome?

Please, participate in this ESAIC sponsored survey and help us describe the perspective of medical professionals practicing in the field of anaesthesia!

2.1 Background

General anaesthesia has become one of the safest procedures in medicine thanks to perioperative monitoring strategies that guide therapy. Almost every component of anaesthesia can be monitored (e.g., neuromuscular blockade, anaesthetic depth, haemodynamics, antinociception, etc.), but to this day it remains unclear: (1) to what extent each of the above-mentioned components of anaesthesia are monitored by clinicians in their daily practice; (2) how the information provided by the different monitors is integrated by clinicians.

Desired anaesthetic depth was historically defined as the intensity of the hypnotic component of anaesthesia (which is often maintained with propofol, inhaled ethers, ketamine, or other intravenous agents) that could avoid explicit/implicit awareness and excessive anaesthesia. In other words, it corresponds to the circulating concentrations of hypnotics. As consciousness requires cortical interactions and the forehead is an easily accessible site to monitor, frontal electroencephalogram (EEG) monitoring (e.g., Bispectral Index, SedLine, Entropy) has become a commonly used tool to measure anaesthetic depth.

Antinociception, on the other hand, can be defined as the control of nociception (i.e., the unconscious response to a noxious stimulus) through the use of opioids or other drugs (e.g. intravenous lidocaine, magnesium, alpha2 agonists as part of opioid-free/opioid sparing regimens). Nociceptive responses principally activate the sympathetic nervous system and this activation can be estimated by intraoperative monitors [e.g., pupil dilation reflex, antinociception/nociception index (ANI), nociception level (NOL) index, and skin conductance]. Most of these monitors quantify the antinociception/nociception balance. None of these monitors (anaesthesia depth or nociception), however, combine the hypnotic/antinociceptive components and their integration is consequently performed by the anaesthesiologists.

The aim of this survey is to describe the perspective of practicing anaesthesiologist and nurse anaesthetists on the use of anaesthesia depth and antinociception monitoring. In addition, we aim to determine how many clinicians use these tools and in what situations. We also attempt to describe the gaps in knowledge concerning monitoring depth of anaesthesia. The results of this survey will help us to redefine educational goals.

Thank you very much for participating in this survey which we strongly believe will lead to a clearer understanding of perioperative anaesthesia monitoring and the potential for improvement.

2.2 Survey

  1. (1)

    Where do you practice anaesthesia?

    1. (a)

      Africa

    2. (b)

      Asia

    3. (c)

      Europe

    4. (d)

      North America

    5. (e)

      South America

    6. (f)

      Oceania

      1. (i)

        In what country do you practice?

      2. (ii)

        In what language do you practice anaesthesia?

      3. (iii)

        In what state do you practice (optional)?

  1. (2)

    How many years have you been practicing anaesthesia (including specialization training)?

    1. (a)

      0–5

    2. (b)

      6–15

    3. (c)

      16–25

    4. (d)

      26–35

    5. (e)

      35 or more

  1. (3)

    You work in (select all that apply)

    1. (a)

      An academic hospital

    2. (b)

      A public hospital

    3. (c)

      A private hospital

    4. (d)

      Other

  1. (4)

    You are a:

    1. (a)

      Nurse

    2. (b)

      Medical doctor

  1. (5)

    How much of your professional time do you spend in the operating room per week?

    1. (a)

      Less than 25%

    2. (b)

      26–50%

    3. (c)

      51–75%

    4. (d)

      76–100%

  1. (6)

    What do you consider to be your anaesthetic specialization? (choose only one)

    1. (a)

      General anaesthesia

    2. (b)

      Cardiac anaesthesia

    3. (c)

      Thoracic anaesthesia

    4. (d)

      Neuroanaesthesia

    5. (e)

      Orthopaedic anaesthesia

    6. (f)

      Obstetric anaesthesia

    7. (g)

      Anaesthesia for “one-day” ambulatory surgery

    8. (h)

      Transplantation anaesthesia

    9. (i)

      Perioperative medicine

    10. (j)

      Paediatric anaesthesia

    11. (k)

      Chronic pain medicine

    12. (l)

      Intensive care medicine

  1. (7)

    Do you consider anaesthetic depth (hypnotic component) monitoring important to your general practice?

    1. (a)

      Always

    2. (b)

      On most occasions (> 50% of the anaesthetic procedures that you perform)

    3. (c)

      Occasionally (< 25% of the anaesthetic procedures that you perform)

    4. (d)

      Never

  1. (8)

    Do you consider antinociceptive monitoring important to your general practice?

    1. (a)

      Always

    2. (b)

      On most occasions (> 50% of the anaesthetic procedures that you perform)

    3. (c)

      Occasionally (< 25% of the anaesthetic procedures that you perform)

    4. (d)

      Never

  1. (9)

    Do the national/international perioperative monitoring guidelines you adhere to recommend anaesthesia depth monitoring?

    1. (a)

      Yes

    2. (b)

      No

    3. (c)

      Not sure

  1. (10)

    Do the national/international perioperative monitoring guidelines you adhere to recommend antinociception monitoring?

    1. (a)

      Yes

    2. (b)

      No

    3. (c)

      Not sure

  1. (11)

    Which of the following intraoperative monitors are recommended in the national/international perioperative patient safety guidelines you adhere to (select all that apply)?

    1. (a)

      Pulse oximetry

    2. (b)

      Electrocardioscopy

    3. (c)

      Blood pressure monitoring (non-invasive or invasive)

    4. (d)

      End tidal gases (CO2, O2, inhaled ethers, N2O, etc.)

    5. (e)

      Frontal-EEG or other anaesthetic depth monitoring

    6. (f)

      Nociception monitoring (NOL Index, pupil reactivity, etc.)

    7. (g)

      I’m not sure

    8. (h)

      None of the above

  1. (12)

    Which anaesthetic depth monitor do you use most frequently? (One choice)

    1. (a)

      Bispectral index

    2. (b)

      Entropy

    3. (c)

      Sedline

    4. (d)

      Neurosense

    5. (e)

      Unprocessed EEG

    6. (f)

      Other (please specify)

    7. (g)

      I never use anaesthetic depth monitoring because I consider other parameters (e.g., MAC) sufficient

  1. (13)

    Which nociception monitor do you use most frequently? (one choice)

    1. (a)

      Nociception level (NOL) Index

    2. (b)

      Analgesia/Nociception Index (ANI)

    3. (c)

      Surgical Plethysmographic Index (SPI)

    4. (d)

      Pain Monitor (skin conductance)

    5. (e)

      Response entropy

    6. (f)

      Frontal EEG variations

    7. (g)

      Pupil diameter reflex

    8. (h)

      I never use nociceptive depth monitoring because I consider other parameters sufficient (e.g., heart rate and blood pressure)

  1. (14)

    When administering continuous hypnotic infusions (e.g., propofol), you monitor anaesthetic depth with a frontal EEG:

    1. (a)

      In all patients

    2. (b)

      In high- and moderate-risk patients

    3. (c)

      In high-risk patients

    4. (d)

      Never

  1. (15)

    When administering continuous inhaled anaesthetic (e.g., sevoflurane, desflurane, isoflurane), do monitor anaesthetic depth with a frontal EEG:

    1. (a)

      In all patients

    2. (b)

      In high- and moderate-risk patients

    3. (c)

      In high-risk patients

    4. (d)

      Never

  1. (16)

    What are the reasons that you do not always use anaesthetic depth monitoring with a frontal EEG? (select all that apply)?

    1. (a)

      No reason, I always measure anaesthesia depth with a frontal EEG

    2. (b)

      I think it costs too much for the potential benefit

    3. (c)

      I don’t think it works

    4. (d)

      I don’t know how it works

    5. (e)

      I use other parameters to guide my anaesthetic depth

    6. (f)

      There is a conflict of space between anaesthesia and surgery for the placement of electrodes

    7. (g)

      Other reasons (please elaborate)

  1. (17)

    What do you consider to be adequate surrogates to anaesthetic depth during propofol infusion anaesthesia (select all that apply)?

    1. (a)

      Heart rate

    2. (b)

      Blood pressure

    3. (c)

      Patient movement

    4. (d)

      Processed frontal EEG target values

    5. (e)

      Frontal EEG spectrogram analysis (i.e., frequency, time, and intensity of EEG waves)

    6. (f)

      Textbook doses of anaesthetics based on empirical evidence

    7. (g)

      None of the above

  1. (18)

    What do you consider to be adequate surrogates to anaesthetic depth during inhaled anaesthesia (select all that apply)?

    1. (a)

      Heart rate

    2. (b)

      Blood pressure

    3. (c)

      Patient movement

    4. (d)

      Spontaneous respiration

    5. (e)

      End-tidal halogenated gas concentration

    6. (f)

      Processed frontal EEG target values

    7. (g)

      Frontal EEG spectrogram analysis (i.e., frequency, time, and intensity of EEG waves)

    8. (h)

      None of the above

  1. (19)

    What do you consider to be adequate surrogates to anaesthetic depth during multimodal anaesthesia (e.g., propofol combined with sevoflurane, ketamine and clonidine) (select all that apply)?

    1. (a)

      Heart rate

    2. (b)

      Blood pressure

    3. (c)

      Patient movement

    4. (d)

      Spontaneous respiration

    5. (e)

      End-tidal halogenated gas concentration

    6. (f)

      Processed frontal EEG target values

    7. (g)

      Frontal EEG spectrogram analysis (i.e., frequency, time, and intensity of EEG waves)

    8. (h)

      None of the above

  1. (20)

    Do you measure and modify anaesthetic depth according to burst suppression (an equivalent of isoelectric or flat EEG) when using a frontal EEG?

    1. (a)

      Always

    2. (b)

      On most occasions (> 50% of the time)

    3. (c)

      Occasionally (< 25% of the time)

    4. (d)

      Never

  1. (21)

    Do you feel safe lowering your anaesthesia infusion/end-tidal partial pressure when burst suppression is present?

    1. (a)

      Always

    2. (b)

      On most occasions (> 50% of the time)

    3. (c)

      Occasionally (< 25% of the time)

    4. (d)

      Never

  1. (22)

    Which of the following complications do you think anaesthesia depth monitoring coupled with a goal-directed approach (e.g., titration of hypnotic to maintain Bispectral Index between 40 and 60) can decrease (select all that apply)?

    1. (a)

      Post-operative delirium

    2. (b)

      Post-operative cognitive dysfunction

    3. (c)

      Stroke

    4. (d)

      Awareness

    5. (e)

      Myocardial infarction

    6. (f)

      Acute kidney injury

    7. (g)

      None of the above

  1. (23)

    Which of the following complications do you think nociception monitoring coupled with a goal-directed approach (e.g., titration of opiates to maintain NOL Index between 10 and 25) can decrease (select all that apply)?

    1. (a)

      Post-operative delirium

    2. (b)

      Post-operative cognitive dysfunction

    3. (c)

      Stroke

    4. (d)

      Awareness

    5. (e)

      Myocardial infarction

    6. (f)

      Acute kidney injury

    7. (g)

      None of the above

  1. (24)

    Which of the following complications do you think nociception monitoring can lead to the following postoperative outcomes? (select all that apply)

    1. (a)

      Decreased post-operative nausea or vomiting

    2. (b)

      Decreased time to extubation

    3. (c)

      Decreased opioid induced hyperalgesia

    4. (d)

      Decreased post-operative pain and opioid use

    5. (e)

      Decreased PACU length of stay

    6. (f)

      None of the above

  1. (25)

    Are you aware of published algorithms to titrate hypnotic and/or antinociceptive drugs based on the information provided by the monitors?

    1. (a)

      Yes

    2. (b)

      No

  1. (26)

    In 2020, do you believe combining nociceptive and anaesthetic depth monitoring will improve patient care in the operating room?

    1. (a)

      Always

    2. (b)

      On most occasions (> 50% of the time)

    3. (c)

      Occasionally (< 25% of the time)

    4. (d)

      Never

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Coeckelenbergh, S., Richebé, P., Longrois, D. et al. Current trends in anesthetic depth and antinociception monitoring: an international survey. J Clin Monit Comput 36, 1407–1422 (2022). https://doi.org/10.1007/s10877-021-00781-2

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