Högskolan i Skövde

A multi-modal approach for the management of postoperative pain has become increasingly popular. Strategies to avoid the use of opioids and thus any opioid analgesic related side-effect is an important part of the expansion of ambulatory surgery Combining long acting local anesthesia in the wound area and non-opioid analgesics are today a basic concept in management of day care, short stay patients. Paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) is often sufficient to provide satisfactory pain relief after minor and intermediate procedures. The use of multimodal or balanced analgesia has since long been shown to facilitate resumption of activities of daily living. The opioid sparing effects of the addition of NSAIDs to morphine patient-controlled analgesic (PCA) after major surgery has also shown repeatedly. The development and introduction of the most selective cyclo-oxygenase-2-inhibitors (Coxibs) was primarily indicated to reduce the risk and severity of gastrointestinal bleeding. The Coxibs have become an interesting option in postoperative pain management. The less pronounced effect on platelet function and subsequent lower risk for impaired hemeostasis makes them, in theory, a preferred option to the nonselective traditional NSAIDs. The benefit versus risk for a more generalized use of Coxibs must, however, be based on a thorough evaluation of the overall benefits and risks for the use of NSAIDs and a further evaluation on whether the specific therapeutic features of the Coxibs provide benefits outweighing their increased cost. This review aims at providing a background and an overview of the benefits versus risks for the use of Coxibs as part of a multimodal postoperative pain management. (Minerva Anestesiol 2011;77:1084-98)

Background: Patients’ own assessment of recovery after ambulatory surgery has not been well studied. The aim was to study patients’ self-assessed recovery, the occurrence and time course of post-operative problems in relation to the type of ambulatory surgery.Methods: A questionnaire was filled in by 355 patients at five time points: pre-operative, first day at home, 1, 2 and 4 weeks post-operatively. Consecutive patients who underwent either inguinal hernia repair (IHR), arthroscopic procedures (AS) or cosmetic breast augmentation (CBA) were included.Results: Unplanned return to hospital was rare (3/355). Health care contacts were noted for 9% of the patients during the first week; a total of 70 contacts occurred during the entire period. Pain was the most frequently reported symptom; 40% of the patients reported pain or mobility problems at 1 week, 28% after 2 weeks and 20% after 4 weeks. Pre-operative pain was associated with an increased level of pain during the early post-operative course, in the recovery room and at 1 week post-operatively. IHR was associated with an overall rapid recovery, while AS patients experienced a slower restitution. All AS patients who reported pain after 4 weeks had reported pain problems already pre-operatively. Pain was not present pre-operatively in the CBA group, but was common at 1 and 2 post-operative weeks and was still reported by 11% at 4 weeks.Conclusion: Self-assessed recovery was found to cover several weeks with procedure-specific recovery patterns. Pain and mobility impairment were still frequently reported 4 weeks post-operatively.

End-tidal anaesthetic gas concentration monitoring during inhalation anaesthesia has become standard of care. Explorative study comparing the end-tidal anaesthetic gas measured by a new main-stream anaesthetic gas monitor (IRMA, Phasein, Stockholm, Sweden) as compared to standard Datex side-stream monitoring during routine low flow anaesthesia Day surgical centre in StockholmThirty two healthy, ASA 1-2, patients undergoing elective day case anaesthesia with low flow 0.2-0.5 L/min. Simultaneous recording of the end-tidal gas concentration during routine day case anaesthesia with low flow sevoflurane or desflurane anaesthesia. The new monitor was found to be clinically acceptable. The mean bias between IRMA and Datex measures -0.125 vol % (± 0.145, limits of agreement were -0.41 – 0.16). The new main stream gas monitor is clinically acceptable alternative for end-tidal anaesthetic gas monitoring during routine anaesthesia with low flow, 0.2-0.5 L/min.

The aim of this study was to explore variation in nursing students’ motivation to complete their programme of study,  as  well  as  factors  relating  to  low  versus  high  motivation  and  students’  opinions  of  what  would  increase  their motivation to complete their programme of study. A study was carried out between April 2006 and December 2007. A total of 872 students registered in a 3-year nursing programme  randomly  participated  in  self-rating  their  motivation  score  once  each  semester.  Descriptive  statistics, statistical calculations and content analysis regarding open-ended questions were performed. Most of the students, 73%, rated their motivation as ≥6 on a 0-10 Likert scale; and 16% gave a rating of ≤4. The desire to become  a registered nurse (RN)  and having  a positive  attitude towards the  studies were  the main factors influencing high motivation to complete the programme of study. Having a negative attitude towards the studies was an explanation of decreased motivation. There was a significant decrease (p=0.001) in the motivation score with respect to number of semesters, and motivation increased with the student’s age (p=0.0119). Suggestions for increasing motivation given by those who rated their motivation as ≤4 mainly focused on improvements in didactics and study organisation.

Aim: Patient assessed quality of life is one of the principal end-points after day surgery. The aim of the present study was to describe the natural course, differences and timing of final evaluation for three common day surgical procedures; inguinal hernia repair (IHR), arthroscopic procedures (AS); and cosmetic breast augmentation (CBA). Method: A total of 355 patients prospectively completed an extended eight-item EQ-5D questionnaire (pain, mobility, mood, self-care, activities, sleep, sex, need for analgesic), preoperatively and at one, three and six months postoperatively. Results: Pain and mobility problems were frequently reported prior to surgery among IHR and AS patients, while CBA patients had less deviation from normal in the preoperative health profile. The proportions of patients reporting surgery-related deviations were 35%, 20% and 5% at one, three and six months respectively. After one month, 50% of AS patients still suffered subjective discomfort as compared to 13% and 20% of the IHR and CBA patients, respectively. Pain and ambulation problems were the most common symptoms in all groups. Six months after surgery, 94% of IHR, 89% of AS and 97% of CBA patients were fully recovered. Conclusions: No major morbidity or severe complications were observed and patients’ satisfaction was high overall. We found procedure-specific changes in the postoperative health profile after day surgery. AS patients recovered more slowly compared with IHR and CBA patients. We conclude that time for final evaluation differs significantly between procedures.

Aims. The main purpose of this study was to analyse, prospectively, patient symptoms during the first four weeks following elective colon surgery. A secondary aim was to find areas to improve inpatient information and postoperative care.

Background. Fast-track recovery following colon surgery has been proven beneficial to patients in the early postoperative phase. Less is known about the continuous recovery at home.

Design. A prospective follow-up survey.

Methods. Consecutive patients (n = 32) planned for elective colon surgery were evaluated. Both open and laparoscopic operations were included. All followed a fast-track protocol in hospital. Patient symptoms were recorded by validated quality of life questionnaires (EORTC QLQ-C 30, EORTC QLQ-CR 38 and Brief Pain Inventory). An interview was conducted five weeks and one year after surgery.

Results. The hospital stay was six days, and 10% of patients were readmitted. The fast-track concept worked well. The main problems after discharge were fatigue, nausea and bowel disturbances. Pain was not a significant issue. Most symptoms had disappeared after four weeks.

Conclusions. The first period at home is troublesome, and better information about common symptoms is needed. A direct telephone line has been set up to answer questions and to lower patient anxiety.

Relevance to clinical practice. Clinical guidelines for patient’s discharge planning can be performed based on the results from this study. Further improvement regarding the epidural anaesthesia is needed to reduce minor side effects.

Background: The aim was to study the effects of different tobacco administration routes on pain and post-operative nausea and vomiting (PONV), following three common day surgical procedures: cosmetic breast augmentation (CBA), inguinal hernia repair (IHR) and arthroscopic procedures (AS). We have prospectively investigated the effects of regular tobacco use in ambulatory surgery.

Methods: The 355 allocated patients were followed during recovery and the first day at home.

Results: Thirty-two percent of the patients used tobacco regularly, 33% of CBA, 27% of IHR and 34% of AS. Pain was well controlled in the post-anesthesia care unit at rest; during ambulation, 37% of all patients reported VAS>3. Tobacco use had no impact on early post-operative pain. Post-operative nausea was experienced by 30% of patients during recovery while in hospital. On day 1, 14% experienced nausea. We found a significant reduction of PONV among tobacco users (smoking and/or snuffing). Smoking or snuffing reduced the risk of PONV by nearly 50% in both genders on the day of surgery and at the first day at home. The reduction of PONV was equal, regardless of tobacco administration routes.

Conclusion: We found that regular use of tobacco, both by smoking and snuffing, had a significant effect on PONV during the early post-operative period. Non-tobacco users undergoing breast surgery were found to have the highest risk for PONV. We could not see any influence of nicotine use on post-operative pain. Thus, it seems of value to identify regular tobacco use, not only smoking, as a part of the pre-operative risk assessment.

Aim: The aim of this study was to survey the occurrence of musculoskeletal disorders in the population of gynecologists and general surgeons performing laparoscopic surgery.

Methods: A questionnaire was distributed to 558 general surgeons and gynecologists and 378 were answered (68%). Descriptive data analysis and statistical calculations were performed.

Results: One or more disturbing symptoms were common among laparoscopists. More than 70% of the laparoscopists had one or more symptom. Pain was the most common symptom followed by fatigue and stiffness. Lower back, neck, and shoulders were most frequently affected. Headache and visual discomfort were also reported. Longer workload over time and ageing resulted in significantly more disorders (P<0.01). Female physicians had significantly more disorders (P<0.01).

Conclusions: This study revealed musculoskeletal disorders in a majority of laparoscopists. The laparoscopic technique often requires static and tiring work positions, sometimes extreme, which can explain musculoskeletal disorders among general surgeons and gynecologist.

The aim of this study was to investigate which factors that influences decision making among Swedish ambulance nurses in emergency care situations. Nurses in ambulance are sometimes forced to make decisions without adequate information. Data collected from interviews with 14 ambulance nurses was analyzed. The informants described 30 incidents during which they had to make fast decisions. A qualitative content analysis of the text was made, from which different categories were identified. It was found that when nurses are called to an emergency, the extent and degree of difficulty of the incident is decisive for how decisions are made. In addition, the nurses’ experience is important for decision making, because the experience factor constitutes a qualitative difference between a novice nurse and a more experienced nurse’s influence on decision-making. Furthermore, external factors, such as the uncertainty of a prehospital environment, expectations and pressures from an environment in which one is working while being observed by other people, and collaborating with many different operators, all contribute to making decisions in an urgent situation even more complex. Further studies are needed to understand the complexity of decision making in emergency situations.

This study focuses on daily life situation of terminally ill guests residing at a hospice. In the study, interviews were conducted with 9 such guests. Data were analyzed using a method similar to content analysis. Categories emerged that were related to aspects regarding as external and internal essentials for the well-being of the individual at the hospice. These essentials were as follows: encouragement from the staff, the alleviation of pain, a pleasant and calm atmosphere at the hospice, the significance of visits from relatives, the regret of not being able to take care of oneself, and time to reconcile to one's life. These results not only show the need for close community with both family and staff but also the need for privacy to reflect on life.