BACKGROUND: Depth of anaesthesia (DoA) is often guided by standard dosing protocols and evaluated through clinical signs, assuming these signs reliably indicate unconsciousness. However, this assumption is problematic: patients respond differently to anaesthetic drugs, and physiological markers can misrepresent brain state. Nociceptive responses may persist despite apparent unconsciousness. Excessive DoA is associated with cardiovascular instability and post-operative cognitive dysfunction, whereas insufficient DoA increases the risk of intraoperative awareness. Processed electroencephalography (pEEG), such as the Bispectral Index (BIS), was introduced to address these limitations by enabling monitoring of frontal cortical brain activity during general anaesthesia. We aimed to investigate how pEEG, measured as BIS, reflects anaesthetic depth across patient subgroups and anaesthetic techniques.

METHODS: This large-scale prospective observational cohort study analysed electronic health records from patients who underwent general anaesthesia between 1 January 2017, and 31 December 2020. The study evaluated associations between BIS values and patient age, sex and health status measured by American Society of Anaesthesiologists (ASA) scores.

RESULTS: Clinical data were extracted from 97,733 patients, of whom 26,650 underwent continuous BIS monitoring. BIS monitoring was more frequent in patients classified as ASA scores of 1 or 2 and those receiving total intravenous anaesthesia. Patients with higher ASA scores, increasing age and female patients showed deeper anaesthesia with significantly lower BIS values.

CONCLUSION: In this large observational cohort, older patients, patients with higher ASA score and females exhibited lower BIS values during general anaesthesia compared with younger, healthier and male patients, even when anaesthetic dosing followed standard protocols. These observed associations may reflect practise patterns, unmeasured confounding or physiological differences, and should not be interpreted as causal. Further studies are warranted to explore more individualised anaesthetic strategies and tailored neuromonitoring approaches to optimise anaesthetic depth, particularly in vulnerable patient subgroups.

EDITORIAL COMMENT: Using a large database of cases with processed EEG (BIS) and anaesthesiological data, this study found that older patients and those with higher ASA-class had the deepest anaesthetic depth despite standard anaesthetic dosing protocols. These findings support the need for more individualised EEG-monitoring, especially in the elderly and frail, but also how these BIS indicators should guide management. It remains unresolved if deeper anaesthesia with presumed benefits of reducing the surgical stress, can be balanced by improving brain perfusion rather than reducing anaesthetic depth.

Use of neuraxial analgesia requires communication between the parturient and her caretakers. In this retrospective study, the use of labor analgesia is compared between parturients whose primary language is other than Finnish or Swedish and who don't communicate in these languages or English without an interpreter (Category I), who communicate in Finnish, Swedish, or English (Category II), and primary Finnish or Swedish speakers (Category III). The primary outcome of this study is the association of communication language categories with neuraxial analgesia use. The secondary outcome is the incidence of vaginal delivery without pharmacological pain relief. The parturient and labor parameters (age, body mass index (BMI), primiparity, gestational age, prior consultations for fear-of-childbirth (FOC), induction of labor, use of oxytocin, labor analgesia interventions, outcome of the attempted labor) were recorded from the electronic patient database for all 13,707 parturients that attempted vaginal delivery in the Helsinki region delivery hospitals during 2022. The distribution of parturients was 15.3%, 10.3%, and 74.4% in the language categories I, II, and III, respectively. The use rate of neuraxial analgesia was 60.8%, 65.8%, and 75.3% in the categories I, II, and III respectively. After adjustment for primiparity, maternal BMI, gestational age, FOC diagnosis, induction of labor, oxytocin use, episiotomy, and outcome of labor, the adjusted OR (aOR) for neuraxial analgesia use was (1.283 [1.093-1.506]) among parturients in Cat II compared to Cat I. Correspondingly, the ability to communicate directly (Cat II) was associated with lower use of only non-neuraxial pharmacological analgesia (aOR 0.789 [0.654-0.951]) compared to those incapable of direct communication (Cat I). No association was seen with language capability (Cat II vs. Cat I) and delivery without pharmacological pain relief (any delivery type: aOR 0.815 [0.652-1.019]; vaginal delivery: aOR 0.825 [0.645-1.055]). Ability to communicate directly with the staff is associated with shifting from non-neuraxial techniques to neuraxial analgesia but not an increase in general labor analgesia use. Cultural trends may be associated with labor analgesia choices more than language capabilities. Promotion of labor analgesia use should go beyond translation services and requires antenatal education of the available options. EDITORIAL COMMENT: This study demonstrates that language ability alone does not determine labor analgesia use but instead shapes the selection of analgesia methods. Cultural context and antenatal knowledge appear to play a central role in analgesia decision-making. Efforts to promote equitable maternity care should therefore extend beyond translation services to include culturally responsive education and communication strategies that support informed maternal choice.

INTRODUCTION: Malignant hyperthermia (MH) is a pharmacogenetic, hypermetabolic and potentially lethal reaction to potent volatile anaesthetics and the muscle relaxant succinylcholine. To improve the understanding of MH, the aim of this retrospective study was to describe the Swedish cohort with respect to clinical manifestations, demographics and genetic findings.

METHOD: The Swedish MH Registry covers a total of 2852 individuals belonging to 544 different families investigated for MH since 1980. For this study, the index case in each family was included for further description.

RESULTS: In total, MH was confirmed in 1555 individuals. Among the 288 index cases with a history of an MH reaction and confirmed MH, 58% were male and 57% were < 18 years of age. MH was confirmed in 41% of index cases where masseter muscle spasm was the only clinical sign of MH. The overall case fatality following an MH reaction in Sweden was 5.2%, but no fatal MH reaction has been reported since 2001. Out of 163 genetically investigated MH families, 61 had a diagnostic variant and 23 had a variant of unknown significance.

CONCLUSIONS: We found that MH reactions predominantly occur in young individuals and that case fatality has declined over recent decades, with no deaths reported in the past 20 years. Less than 40% of the genetically investigated MH families, corresponding to around 20% of all Swedish MH families, currently have an identified genetic diagnostic variant.

EDITORIAL COMMENT: This analysis of the national Swedish Malignant Hyperthermia patient registry presents case factors and outcomes from cases among recognised families from the last 45 years. Presenting symptoms and then case confirmation details are presented, along with results from cases and families where genetic variants has been assessed.

BACKGROUND: Decisions to withhold or withdraw life-sustaining treatments for critically ill children are challenging. This study aims to identify Swedish intensivists' attitudes, values and experiences towards the decision-making process concerning withholding or withdrawal of life-sustaining treatment in critically ill children.

METHODS: The nine intensive care units in Sweden that treated more than 10 children for more than 48 h during 2023 were approached. A web-based questionnaire on attitudes and experiences on end-of-life decision-making in critically ill children was distributed to the 360 physicians employed at the above-mentioned intensive care units. The results were analysed descriptively.

RESULTS: Fifty-five answers were retrieved. The participating physicians were experienced, 93% having personal experience with end-of-life decision-making in children. The main findings were that the child's wishes were considered important or very important by 93% of respondents. The guardians' wishes were considered important or very important by 82% of respondents. Seventy-three percent of physicians considered it ethically acceptable to withdraw life-sustaining treatment against the patients' and guardians' wishes. To continue life-sustaining treatment without the patient's and guardian's consent was considered ethically acceptable by 26% of participants.

CONCLUSIONS: This study demonstrated that Swedish intensivists share common attitudes and values regarding most issues related to end-of-life decisions in critically ill children. However, there is variability in attitudes concerning patients' and guardians' wishes. Further studies concerning end-of-life decisions in critically ill children within a Nordic context are warranted.

EDITORIAL COMMENT: This survey study presents a sampling of views on pediatric intensive care withholding or withdrawing of treatment and from specialist physicians in one Nordic country.