A dissertation submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfillment of the requirements for the degree of Master of Science in Nursing Johannesburg, 2018. / Undergoing surgery without having general anaesthesia has become an option for many surgical patients. Awake patients are able to communicate with the surgical team which allows the surgical team to gain understanding of the patient’s experience. This is an important aspect of perioperative care and is in line with the theory of Human Becoming according to Parse, (2011). Literature suggests that patients who have received information preoperatively about their planned perioperative journey experience less anxiety and fear relating to their surgery. The purpose of this study was to explore the perioperative experiences and needs of patients undergoing awake surgery. A qualitative exploratory descriptive three step design of data collection was implemented for this study. In step one an integrative review identified patient experiences of the perioperative journey. The literature was critically analysed for relevance and inclusion. This information formed the basis for inclusion in step two. Step two explored the perioperative experience of participants who had undergone awake surgery by interviewing a group of participants using interviews and probe questions extracted from the literature. The information gleaned from the interviews was grouped for content similarity and was used to create an information pamphlet which informed participants about their perioperative journey. In step three the information pamphlet was handed to participants preoperatively and the same participants rated the usefulness of the information pamphlet postoperatively by answering a dichotomous question. Participants had the opportunity to add comments. The population for this study was all patients who were scheduled for ophthalmic, orthopaedic, urological or plastic, surgery using awake surgery in four large private hospitals in Gauteng and Mpumalanga. Patients younger than 18 years of age as well as those receiving sedation or general anaesthesia were excluded from the population. This study showed that participants had positive experiences of being awake during surgery. A number of participants found the experience of being awake during surgery interesting and enjoyed being able to ask questions and participate in dialogue. Participants rated the information pamphlet as useful. Two areas of concern was elicited, namely communication and nursing care within the operating theatre environment. The objectives for this study were met. Key words: perioperative journey, awake surgery, regional and local anaesthesia, nursing / LG2018

Background: Careful airway management, including tracheal intubation, is important when performing anaesthesia in order to achieve safe tracheal intubation. Aim: To study airway management in anaesthesia care from both the professional and patient perspectives. Methods: 11 RNAs performed three airway tests in 87 patients, monitored in a study-specific questionnaire. The tests usefulness for predicting an easy intubation was analysed (Study I). 68 of 74 anaesthesia departments in Sweden answered a self-reported questionnaire about the presence of airway guidelines (Study II). 20 anaesthesiologists were interviewed; a phenomenographic analysis was performed to describe how anaesthesiologists' understand algorithms for management of the difficult airway (Study III). 13 patients were interviewed; content analysis was performed to describe patients' experiences of being awake fiberoptic intubated (Study IV). Results: The Mallampati classification is a good screening test for predicting easy intubation and intubation can be safely performed by RNAs (Study I). The presence of airway guidelines in Swedish anaesthesia departments is poorly implemented (Study II). Algorithms can be understood as law-like rules, a succinct plan to follow in difficult airway situations, an action plan kept in the back of one's mind while creating flexible and versatile personal algorithms, or as consensus guidelines based on expert opinion in order to be followed in clinical practice (Study III). One theme emerged describing experiences of being awake intubated; feelings of being in a vulnerable situation but cared for in safe hands, described in five categories: a need for tailored information, distress and fear of the intubation, acceptance and trust of the staff's competence, professional caring and support, and no hesitation about new awake intubation (Study IV). Conclusions: The Mallampati classification is a good screening test for predicting easy intubation, when the airway assessment is performed in a structured manner by RNAs. The presence of airway guidelines in Swedish anaesthesia departments was poorly implemented and should receive higher priority. Algorithms need to be simple and easy to follow and based on the best available scientific evidence. Tailored information about what to expect, ensuring eye contact, and giving breathing instructions during the procedure may reduce patients' feeling distress.

This thesis is an exploration of the concepts of what the spirituality of consciousness means in several key areas of the intellectual, emotional, and spiritual self. Many students and professionals walk through their educational and professional careers filled with confusion, lack of self-understanding, a yearning for something more but never discovering it in the places we find ourselves for most of our day-to-day interactions. My hope is that this thesis will give insight to how students can overcome obstacles and fears in their lives in order to move forward, and, when necessary, to move past themselves. As a young, Black, immigrant woman who is a first-generation college student and student affairs professional, the methodology of Scholarly Personal Narrative (SPN) appeals to me the most in exploring the spirituality of consciousness. Therefore, I will be using SPN to highlight a portion of my journey through three lenses: mindfulness counseling, religo-spirituality, and understanding what it means to unlock our minds and its complexities through a spiritually-enriched education. I will also highlight how we can disseminate the knowledge of self-awareness and self-awakening as life teachers, educators, and learners to those who come after us--the next generation. The holistic preservation of self and mind is a vital stage in our human existence. As higher education administrators and teachers, we should be able to take the risk and accept the challenge to delve deeper within ourselves to be able to move beyond the curriculum and see the full humanity of our students, hopefully leading to more joyful, productive, loving, creative and brilliant minds. How do we do this? How do we awaken to life, to learning, to each other, in the midst of chaos? This thesis attempts to point the way.

Handen har en mycket central roll för människans funktion och benämns ofta som hjärnans förlängning mot världen. Huvudsyftet inom handkirurgi är att vid skador, återskapa handens funktion för att förbättra människans livskvalité. De flesta operationer inom handkirurgi sker i någon form av lokalanestesi och majoriteten kräver blodtomhet i operationsområdet. Dagens former av lokalanestesi medför vissa begränsningar av operationstiden då trycket av blodtomhetsmanschetten orsakar smärta och obehag för patienten. Då det vid vissa handkirurgiska operationer är av stor fördel för operationsresultatet att patienten är vaken och vid uppmaning aktivt kan medverka vid operationen är det bra med vaken patient och därför bra om generell anestesi kan undvikas. Genom att bedöva patienten med en buffrad lokalbedövningsblandning med adrenalin kan patienten bli bedövad samtidigt som blodtomhet uppnås i operationsområdet, patienten behåller sin rörelseförmåga och kan på så sätt medverka vid operationen. Denna metod kallas Wide Awake. Syftet: Syftet med denna studie var att jämföra patientens smärtskattning vid Wide Awake lokalbedövningsmetod och den nuvarande lokalbedövningsmetoden som används vid handkirurgiska kliniken, samt beskriva patientens smärtupplevelse vid båda metoderna. Metod: Studien utfördes som en pilotstudie med både kvalitativ och kvantitativ ansats, en så kallad mixad metod. Tjugo forskningspatienter följdes under operationsprocessen med numeriskt kvantitativt protokoll där smärtskattningsdata samlades in och analyserades enligt Mann-Whitney U test. Ett uppföljande samtal dagen efter operation gjordes och sammanställdes med en manifest innehållsanalys enligt Graneheim och Lundman. Resultat: Studien visar på en skillnad i smärtupplevelse där patienter som opereras i Wide Awake lokalbedövningsmetod upplever mindre smärta och obehag än patienter som opereras i nuvarande lokalbedövningsmetod. Slutsats: Slutsatsen av denna studie visar på att Wide Awake är en bedövningsform som är lindrigare ur smärtsynpunkt för patienten vid mindre handkirurgiska ingrepp än den nuvarande traditionella lokalbedövning som används idag på handkirurgiska kliniken.

京都大学 / 新制・課程博士 / 博士(人間健康科学) / 甲第24142号 / 人健博第105号 / 新制||人健||7(附属図書館) / 京都大学大学院医学研究科人間健康科学系専攻 / (主査)教授 青山 朋樹, 教授 黒木 裕士, 教授 小林 恭 / 学位規則第4条第1項該当 / Doctor of Human Health Sciences / Kyoto University / DFAM

Det är vanligt att patienter som genomgår kirurgi får antingen lokal eller regional anestesi istället för att bli helt sövda. Denna anestesiform kräver mycket av patienten avseende samarbete. Den perioperativa omvårdnaden anpassas under varje operation efter den enskilde patientens behov. Denna studie har utförts som en litteraturstudie med syftet att beskriva patienters upplevelser under vaken kirurgi. Resultatet kategoriserades utefter tre teman; Upplevelser av smärta och obekvämlighet, Upplevelser av oro och ångest och Upplevelser av utsatthet eller delaktighet. Patienter som genomgår vaken kirurgi upplever smärta, känslor av obekvämlighet, oro, ångest och rädslor för att behöva höra, se och känna något av operationen. Känslan av att inte ha kontroll över sin egen kropp skapar känslor av utsatthet. Närvaro och kommunikation mellan anestesisjuksköterskan och patienten skapar upplevelser av delaktighet. Resultatet diskuteras utifrån Comfort Theory’s fyra kontexter; Fysisk, Psykospirituell, Sociokulturell och Miljömässig. Anestesisjuksköterskans uppgifter blir att hitta de omvårdnadsinterventioner som lindrar och underlättar patientens situation i den perioperativa miljön. Vidare finns det således behov av att undersöka vilka olika omvårdnadsinterventioner som påverkar patientens perioperativa nöjdhet och bekvämlighet. / A common procedure in surgery is local or regional anesthesia in contrast to general anesthesia. These forms of anesthesia demand a lot from the patient in terms of collaboration. During the surgical procedure, the perioperative nursing care needs to be adapted to each patient’s individual needs. Therefore, this study is a literature review with the aim to describe patients’ experiences during awake surgery. The results were categorised from three themes, experiences of pain and discomfort, experiences of anxiety and fear, experiences of vulnerability or participation. Patients undergoing awake surgery experience pain, discomfort, anxiety and fear of hearing, seeing and feeling anything during the surgical procedure. The feeling of not having control of your own body results in experiences of feeling vulnerable. To be close to the patient and have a good communication between the nurse anesthetist and the patient create experiences of participation. The role of the nurse anesthetist is to find nursing interventions which relieve and help the patient in these situations. The results are discussed according to the Comfort Theory’s context; physical, psychospiritual, sociocultural and environmental. The skills for the nurse anesthetist are to find nursing interventions which relief and ease the situation for the patient. Furthermore, there is a need to investigate effects of different nursing interventions on patients’ satisfaction and comfort in the perioperative setting.

Det är en unik upplevelse att bli opererad med lokalanestesi och vara vaken under ett operativt ingrepp. Patienten överlämnas till vårdpersonalen och är beroende av deras omhändertagande och kunskap. Kontinuerlig information under ingreppet samt ett gott bemötande från personalen kring patienten är avstor vikt för att skapa en trygg miljö och ge god omvårdnad. Syftet med studien var att beskriva patienters upplevelse och känslor av den perioperativa omvårdnaden när de var vakna under ett operativt ingrepp. Fyra intervjuer med konsekutivt utvalda patienter som genomgått operationen på sjukhus i sydvästra Sverige inkluderades i studien. Öppna, övergripande frågor samt följdfrågor användes under intervjuerna. Kvalitativ innehållsanalys användes. Analysen ledde till tre kategorier; tidigare upplevelser av vården, omvårdnad kring operationen samt känslor som uppstod under operationen. Tidigare erfarenhet samt personalens omvårdnad gav trygghet i de aktuella operationerna. Känslorna som uppstod under en vaken operation var både positiva och negativa. Resultatet kan bidra tillvidare utveckling och förbättring av den perioperativa omvårdnaden kring envaken patient. / Being awake during surgery is a unique experience. The patient is handed over to the nursing staff and is dependent on their care and knowledge. Continuous information during surgery and professional care from the nursing staff is important to create a safe environment and provide good healthcare. The aim of the study was to describe the patient’s experience and feelings of the perioperative nursing care when being awake during surgery. Four interviews with consecutively selected patients who had undergone surgery in a hospital in the south west of Sweden were included. Open, general questions and supplementary questions were used during the interviews. Qualitative content analyz was used. The analyz resulted in three categories: past experiences of care, care during the surgery and feelings that occurred during the operation. Previous experience and the care provided by the nurses gave patients the feelings of security. Both negative and positive feeling occurred during surgery. The results may contribute to further development and improvement of the perioperative nursing care on patients that are awake during surgery.

Introduction: Obstructive sleep apnea (OSA) is a common breathing disorder with numerous health consequences, including greater risk of complications perioperatively. Undiagnosed OSA is known to place surgical patients at a higher risk of serious adverse events, including stroke and death. Polysomnography (PSG) assessment is the current gold standard test for diagnosing OSA. However, due to the significant time commitment and cost associated with PSG, a substantial number of OSA patients go undiagnosed before the perioperative period. Although the STOP-Bang questionnaire screening tool is currently used to help detect OSA patients, the low specificity to screen people without the disease is considered a major limitation. There is a clear need to develop a quick and effective prediction rule with higher overall accuracy to help streamline OSA diagnosis. Tracheal breathing sound analysis in awake patients at the bedside has shown potential to screen OSA patients with higher specificity compared to the STOP-Bang questionnaire. To date, no screening tools exist to detect OSA patients that combine the results of breathing sound analysis and STOP-Bang. Objectives: The present study aimed to develop a prediction rule, using both breathing sound analysis and variables in the STOP-Bang questionnaire, to better streamline the diagnosis of OSA. Methods: This prospective cohort study recruited patients referred for PSG at the Ottawa Hospital Sleep Centre from November 2016 to May 2017. The study conduct was approved by the Ottawa Health Science Network Research Ethics Board (#20160494-01H). After obtaining informed consent, anthropomorphic, breathing sound recordings, and STOP-Bang questionnaire data was collected from over 400 consenting patients. All patients that met the eligibility criteria were included. The breathing sound analysis and STOP-Bang results were utilized to design a prediction rule using logistic regression. Sensitivity, specificity, and likelihood ratio were used to compare the diagnostic performance of the final model. Results: Of the 439 consenting study participants, 280 study participants data were eligible for inclusion in the logistic regression analysis. Physician sleep specialists diagnosed 114 participants (41%) with moderate-to-severe OSA and 166 participants (59%) with normal-to-mild OSA. At a predicted probability of moderate-to-severe OSA greater than or equal to 0.5, breathing sound analysis had a similar sensitivity of 75.9 (95%CI; 65.4, 82.0) and higher specificity of 74.5% (95%CI; 68.5, 82.0) when compared to STOP-Bang with a sensitivity and specificity of 68.4% (95%CI; 58.9, 76.6) and 63.2% (95%CI: 55.0, 70.1), respectively. The sensitivity and specificity for the Safe-OSA rule, obtained by combining breathing sound analysis and STOP-Bang variables, were determined to be 75.4% (95%CI; 65.4, 82.0) and 74.5% (95%CI; 68.5, 82.0), respectively. A sensitivity analysis using a likelihood ratio test showed that breathing sound analysis contributed significantly to the performance of the Safe-OSA rule. The Safe-OSA rule was determined to be reasonably discriminative and well calibrated. The five-fold cross-validation showed similar results for the final model in the derivation and testing subsamples, which provides support for the internal validity of the Safe-OSA rule in our study population. Conclusion: The present study lends further support for the future testing of tracheal breathing sound analysis as a potential method to screen for moderate-to-severe OSA to help streamline patient care in the perioperative setting. Trial registration: ClinicalTrials.gov identifier NCT02987283.

The 3Rs of reduction, refinement and replacement are the guiding principles of animal research and embedded in national and international legislation regulating the use of animals in scientific procedures. Awake imaging by MRI of rodents can offer a reduction by increasing the quality of scientific data through longitudinal imaging using less animals by avoiding a serial sacrifice design and refinement through reducing the stressful effects animals are exposed to, in comparison to existing models. Before awake imaging can become an established biomarker it must be demonstrated that pathology is traceable with comparable or an improvement on results using existing biomarkers. To validate awake imaging of rodents three study types were conducted in two different rodent species: imaging of the progression of Aspergillus fumigatus infection in the mouse lung using anaesthetized animals; analysis of stress in rats during imaging and imaging restraint; imaging of the abdomen in awake rats and a prospective study into the utility of this method for imaging the progression of Candida albicans renal infection. The first study type used an established model of invasive pulmonary aspergillosis in mice to test the utility of MRI for tracking infection in the lung parenchyma. Images of collapsed parenchyma were obtained and shown to increase as the infection progressed. Further work is required to establish this as a clinically relevant biomarker. The study type used restraint, blood collection and imaging as stressors using corticosterone levels as a surrogate of stress. Analysis of levels in blood and faeces by RIA and ELISA allowed comparison of stress during anaethetised and awake imaging for the first time. There were no differences in rat corticosterone levels during anaethetised and awake imaging indicating that awake imaging was no more stressful than currently used procedures. The third study type employed restrainers and acclimatisation to MRI scanner noise to acclimatize rats for awake abdomen imaging. Both anaethetised and awake rats were imaged with FLASH and IntraGate™ sequences. These methods were utilized in an established model of disseminated candidiasis by imaging the kidney. Comparable image quality was obtained in awake animals, with the utility of the method validated by imaging differences in renal pathology between vehicle and low and high dose treated animals. In conclusion, the first steps have been taken towards establishing awake animal imaging by MRI. The imaging is no more stressful than using an anaesthetic and was a useful biomarker in the rat abdomen and capable of tracking disease development. Further work is required to make the technique fully quantitative and automated and hence become a useful tool for monitoring progression of fungal infection and other pathology.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第18180号 / 医博第3900号 / 新制||医||1004(附属図書館) / 31038 / 京都大学大学院医学研究科医学専攻 / (主査)教授 髙橋 良輔, 教授 金子 武嗣, 教授 渡邉 大 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM