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

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Medicine in the branch of Anaesthesia Johannesburg, April 2013 / BACKGROUND: Once lauded as one of the most valuable interventions across all fields of contemporary medicine, perioperative beta blockade (PBB) is a practice that has come under intense scrutiny. Publication of the PeriOperative ISchemic Evaluation (POISE) study forced a modification of recommendations for PBB in consensus guidelines. Practice in South Africa has not been previously reported. OBJECTIVES: The primary objective of this study was to describe current intended practice, with respect to PBB, in patients undergoing major vascular surgery at South African specialist training facilities. Secondary objectives were describing participant satisfaction with current strategy, reporting suggested modifications to clinician responsibilities in the future, and identifying potential barriers to the intervention. METHOD: One anaesthesiologist and one vascular surgeon from each of the seven recognised training facilities for vascular surgery in South Africa were included in a partially selective observational survey. Data was generated by the use of a semi-structured questionnaire specifically developed to address the objectives of the study. RESULTS: The POISE study results and updated international consensus guidelines had not prompted a change in approach at most facilities. There was inconsistency in methods of risk stratification, treatment implementation, titration practices, and the timing of withdrawal of medication. Anaesthesiologist and vascular surgeon opinion on current intended practice correlated poorly. Opinions correlated least well at facilities where both clinicians claimed responsibility for PBB, implying that communication may be a problem. Similarities, where they did occur, were in keeping with recommendations that are widely supported in the literature. Less than half of the participants were satisfied with current practice. The involvement of the anaesthesiologists in the perioperative management of vascular surgery patients was less than reported in other countries. The participants supported a major role for anaesthesiologists in the future, and a move towards multidisciplinary involvement in policy development and patient management. The need for appropriate monitoring was identified as one of many important barriers. CONCLUSIONS: This study describes current intended practice at South African training facilities for vascular surgery. The variable practice across the country; the poor correlation of participant responses; widespread dissatisfaction with current strategy; suggested changes to clinician responsibilities; and the identification of multiple barriers to the implementation of strategy, highlight the need for review at all facilities. Further research is needed, since the optimal strategy for reducing risk in patients undergoing vascular surgery remains elusive.

Background: Adolescent idiopathic scoliosis (AIS) affects 1 – 3% of all children aged 10 – 16 years; of these approximately 80% are girls. Scoliosis surgery is a major (one of the most extensive) elective paediatric orthopaedic procedure and is known to cause severe and excruciating pain that requires advanced postoperative pain management. Until now, scoliosis surgery has mainly been studied in terms of corrective surgical outcomes, and techniques for surgery and pain management. Adolescents’ narratives and experiences of recovery after scoliosis surgery, as well as psychological aspects in correlation to postoperative pain have seldom been studied. Aim: The overall aim of this thesis was to explore adolescents’ experiences of undergoing scoliosis surgery, experiences and self-reporting of pain, and psychological consequences. Methods: This thesis comprises four studies. The participants in Studies I and II belonged to the same cohort, all of whom underwent corrective surgery in the period from 2004 to 2007. In Study I there was a cohort of 87 adolescents and young adults with different types of scoliosis, some of whom had impaired verbal communication. The patients and their parents/caregivers were asked to complete a survey with questions regarding experienced pain, nausea and overall satisfaction with the hospital stay. Study II was a qualitative study in which six adolescents from the cohort in Study I were interviewed. The adolescents included in Study II had idiopathic scoliosis, and the interviews took place about two years after they had undergone surgery. Study III, which included 37 adolescents, was a prospective study of adolescents with idiopathic scoliosis (AIS) from four spine centres in Sweden. They completed two psychometric instruments and one structured interview both before surgery and about six months afterward. They also self-measured pain on the third postoperative day. In Study IV the adolescents included belonged to the same cohort as in Study III. In this prospective, mixed-method study, the participants self-reported pain before surgery, every four hours for the first five days after surgery, once a day for the first fourteen days at home after discharge from the hospital, and finally at the six-month follow-up. They were also asked to keep a diary during the first two weeks at home after discharge from the hospital. At the six-month follow-up they were interviewed about the overall experience of undergoing scoliosis surgery: how they experienced the time before surgery, during the hospital stay and the recovery period up through the date of the interview. iv Results: Study I showed that the patients experienced severe pain and nausea postoperatively during the hospital stay. The parents/caregivers felt helpless and sometimes lacked confidence in the nurses. Despite this, overall satisfaction with the hospital stay was rated as good. Study II showed that the adolescents experienced nervousness and fear before surgery, severe pain and postoperative nausea and vomiting (PONV) during the hospital stay, had problems with the scars and experienced social difficulties during recovery. Nightmares were reported for up to two years after surgery. In Study III, the ratings of stress symptoms were higher before surgery than after. There were significant correlations between stress symptoms before surgery and levels of postoperative pain. There were also significant correlations between levels of postoperative pain and stress symptoms at the six-month follow-up. In Study IV, postoperative pain ratings showed great individual variation, and in the analysis of drop-outs it was found that those who did not keep a diary at home self-reported higher levels of pain at the six-month follow-up as well as higher levels of stress symptoms and internalizing symptoms. The participants described experiences of severe pain at the hospital and also during recovery. Nausea, constipation and lack of energy emerged from the narratives - but so did the desire to get back to school, sports and friends. The adolescents described how they were hovering between suffering and control and also striving towards normality. Conclusion: The results indicate a need for interventions among adolescent patients to reduce stress symptoms before major surgery. Nurses need to identify adolescents with stress symptoms, use stress-reduction techniques, and support adolescent patients with coping strategies aimed at reducing preoperative stress and managing postoperative pain. Postoperative pain management needs to be improved, both as regards pain assessment and pharmacological and non-pharmacological pain management. Nurses need to improve their medical technical skills in order to optimize pain treatment. After discharge from the hospital adolescents have to struggle with difficulties at home such as pain, nausea, constipation, mobilization and a lack of energy. An intervention with follow-up telephone calls during the second week at home could reduce stress and help resolve difficulties. Since this study indicates stress symptoms at the six-month follow-up, there should also be a nurse interview to check on well-being and to see if any further intervention is needed at that time. If preoperative stress can be reduced, postoperative pain management optimized and the recovery period better supported, the overall experience of going through scoliosis surgery should improve.

Patienter i den perioperativa vården är ofta med om blodförluster. Anestesisjuksköterskor ansvarar för att övervaka, hantera och dokumentera patienters perioperativa vård. Patienters förlorade blodvolymer är viktiga att uppskatta korrekt, för att patienter ska få rätt behandling. Anestesisjuksköterskor ansvarar för bedömning och visuell uppskattning av blodvolymen på kompresser, sugbehållare och operationsdukar som används perioperativt. Studiens syfte är att kartlägga anestesisjuksköterskors förmåga att göra visuell uppskattning av patienters blodförluster perioperativt. En kvantitativ studie genomfördes med ett stickprov av 30 anestesisjuksköterskor. De analysmetoder som användes var: Wilcoxon’s rangsummetest, Mann-Whitney U test, Kruskal-Wallis test och Spearman’s korrelationstest. Deltagarna fick uppskatta blodvolymen på tre olika material vid två efterföljande stationer och fylla i en pappersenkät. Resultatet visar på att en stor majoritet underskattar blodvolymen vid de två efterföljande stationerna. Inget signifikant samband fanns mellan deltagarnas typer av uppskattningar (underskattning, korrekt skattning och överskattning) relaterat till kön, yrkeserfarenhet och självskattad förmåga. I studien påvisas det att anestesisjuksköterskors förmågor att visuellt uppskatta blödningar inte förbättras med längre yrkeserfarenhet. Det framkommer i studien att visuella uppskattningar av blodvolymer ofta blir underskattade och att effektiva och objektiva verktyg eller metoder att uppskatta blödningar perioperativt är något som saknas för anestesisjuksköterskor. Blödningar som inte uppskattas korrekt leder till att patienter i den perioperativa vården blir lidande.

Operationssjuksköterskan träffar dagligen patientersom ska genomgå någon form av kirurgi. Många patienter upplever rädsla och oroi den perioperativa perioden där operationssjuksköterskan har som uppgift attskapa en tillitsfull relation och vara ett stöd för patienten. Humor har visatsig ha en positiv inverkan på interaktionen mellan patient och vårdare. Syfte: Att sammanställa kunskap om hur patientenoch sjuksköterskan kan uppleva humor i omvårdnaden och hur humor kan användassom ett kommunikationsredskap. Metod: Metodenvar litteraturstudie. De 14 inkluderade artiklarna syntetiserades med hjälp avNoblit & Hare’s beskrivning av metasyntes med arbetets syfte somutgångspunkt. Resultat: Humor ikommunikationen mellan sjuksköterskan och patienten ger god respons då detanvänds vid rätt tillfälle. Det framkom att humor kunde verka somrelationsskapande och underlätta kommunikationen. Patienten kunde med hjälp avhumor ge uttryck för- och hantera känslor. Slutsats: Ökad kunskap omhumor och dess användning i kommunikationen kan verka som ett välfungeranderedskap i kommunikationen mellan operationssjuksköterskan och patienten

Att opereras under lokalanestesi innebär att patienten kan vara vaken under operationen, forskning visar på både positiva och negativa upplevelser av detta. Ångest och oro är påtagligt och att patienterna känner att de tappar kontrollen över situationen. Samtidigt är anestesisjuksköterskans roll viktig för att se och bekräfta patienten. Att låta patienten lyssna på musik kan vara ett verktyg som sjuksköterskan kan ta till, eftersom musik har kunnat minska ångest hos andra patientgrupper. Syftet med denna studie är att utforska upplevelser hos patienter som lyssnar på musik perioperativt i lokalanestesi. Den metod som används är en systematisk litteraturöversikt med en integrativ design. Resultatet baserades på 21 artiklar, varav 18 är kvantitativa och 3 kvalitativa. Studien utmynnar i fem teman; ångest, smärta, välbefinnande, coping och upplevelser utöver musiken. Musik påverkar patienternas ångest och smärta på olika sätt. Ofta lindras ångest och smärta men i flera studier har musiken ingen eller tveksam inverkan. Musiken har även effekter på patienternas välbefinnande och påverkar deras copingstrategi. Studien visar på viktiga upplevelser utöver musiken, där sjuksköterskans betydelse för patienten är framträdande. Musik visas öka patienternas välbefinnande men att sjuksköterskan har kännedom om hur smärtsamt och ångestladdat ett ingrepp är, kan vara angeläget för att inte lägga för stor tilltro till musikens effekt på patienten. Ytterligare forskning krävs för att få en ännu djupare förståelse och beskrivning av patienters upplevelse. Att även belysa olika ingrepps inverkan på patienternas upplevelse av musik, är av vikt.

Close to one million red blood cell (RBC) units are transfused annually in Canadian hospitals, with surgical inpatients accounting for up to 44% of transfusions. There is evidence of significant variation in transfusion practice in the operating room (i.e., intraoperative). Although variation is expected based on disease severity and patient preference, inappropriate clinical care due to either under- or over-transfusion likely also contributes to significant variation. Indeed, estimates of unwarranted intraoperative RBC transfusions in the literature range from 19% to 49%, owing partly to a lack of evidence-based consensus on RBC transfusion practice in the OR. Our two systematic reviews have highlighted this gap, demonstrating a lack of evidence from trials or actionable clinical practice guidelines to inform decisions in the OR. Perhaps more importantly, avoidance of blood product exposure is an important patient-prioritized outcome that has yet to be studied empirically in the OR. As such, the observed variation in transfusion practice suggests that transfusion decision-making during surgery represents a clear and important knowledge and evidence gap. Transfusion decision-making in the OR is a complex and dynamic process that we cannot begin to improve without first understanding it. It is influenced by 1) physiologic parameters such as acute blood loss, the effects of general anesthesia, and surgical manipulation. Decision-making is also likely heavily influenced by 2) behavioural factors in the OR (heuristics, team dynamics, institutional culture), for which very little empirical work has been conducted. Finally, the importance of 3) patient input in influencing transfusion decisions is inadequately studied, given the documented disconnect between patient priorities and outcomes used in the medical literature and by clinicians. In this context, the aim of my thesis was to develop an empirical understanding of transfusion decision-making in the OR based on stakeholder perceptions and priorities, informed by an integrated patient engagement process. With this work, I address an important knowledge gap in intraoperative blood transfusion, thereby contributing to efforts to reduce variation in blood transfusion practice in surgery. It is my hope that this work will be influential in informing actionable perioperative tools to optimize blood management including providing both evidence and knowledge gaps for future research.

Neurocognitive events after surgery, can occur as an acute event, such as postoperative delirium (POD) or in the form of decline in cognitive performance in the early or delayed postoperative period such as postoperative cognitive dysfunction (POCD). Neurocognitive events are patient- important outcomes which are associated with an increased risk of adverse outcomes. Surgery has been suggested to be a trigger for POD and to be associated with cognitive decline after surgery. Postoperative pain is common after surgery, and it is biologically plausible for pain to play a role in the development of neurocognitive outcomes. This thesis comprises six chapters focusing on pain and neurocognitive outcomes after non-cardiac surgery in older patients. Chapter 1 is an introduction and rationale for the included studies. Chapter 2 is a protocol for a series of systematic reviews to summarize the evidence regarding the association between postoperative pain (acute and chronic) and opioid-sparing pain management strategies for acute and chronic postoperative pain, and the incidence of POD and POCD. Chapter 3 reports the results of a systematic review and dose-response meta-analysis of observational studies evaluating the association of postoperative pain and POD and POCD. Chapter 4 describes a methodological approach to evaluate the robustness of meta-analyses with POD as an outcome to the variation in the methods (timing and frequency) of POD assessment. Chapter 5 presents the results of the Co-TELESURGE study, a longitudinal prospective cohort study of perioperative cognitive trajectories in older adults who were waiting for elective non-cardiac surgery during the COVID-19 pandemic. Chapter 6 discusses the key findings, limitations, implications for research, future recommendations and final conclusions of the research presented in this doctoral thesis. / Thesis / Doctor of Philosophy (PhD)

Kirurgiska ingrepp, operationer, medför ofta ett personligt trauma för patienten där denne oundvikligen hamnar i en utsatt situation. Inför operation kan patienten uppleva en rad olika tankar och känslor som alla kan ha en inverkan på patientens mående och välbefinnande. Operationer som genomförs under regional anestesi ställer högre krav på operationspersonalens bemötande, då de har en viktig roll för att stötta den vakna patienten.   Syftet med denna studie var därför att undersöka hur patienter som opereras under regional anestesi upplever att de blir bemötta av personalen på operationssalen och hur de upplever att det påverkar deras välbefinnande. Studien utgick från en deskriptiv design med en kvalitativ ansats och baserades på sju intervjuer. Intervjuerna transkriberades och en manifest innehållsanalys gjordes efter Graneheim och Lundmans (2004) metod.   Resultatet visar att samtliga informanter hade upplevt ett gott bemötande av operationspersonalen. Informanterna angav att delaktighet, personalens närvaro och ett gott omhändertagande bidrog till denna upplevelse. Bemötandet visade sig även ha betydelse för hur informanterna upplevde välbefinnandet. Det som informanterna framför allt upplevde hade en positiv påverkan på deras välbefinnande var känslan av att känna sig sedd av operationspersonalen. Samtidigt kunde informanterna inte ange något i personalens bemötande som hade upplevts som negativt eller haft en negativ påverkan på deras välbefinnande. Däremot påpekade vissa informanter att det är viktigt att hänsyn tas till patienternas personligheter och känslouttryck för att patienten ska bemötas på bästa sätt.  Således upplevde samtliga informanter som genomgått höft- eller knäoperation under regional anestesi att de fått ett gott bemötande och eller blivit väl omhändertagna av operationspersonalen. Då studien är begränsad i sitt omfång och då det är ett outforskat område som undersökts behövs ytterligare forskning för att styrka studiens resultat. / Surgical procedures, i.e. operation, often inflicts personal trauma for the patient where the patient unavoidably is put in a vulnerable situation. Before surgery the patient can experience a range of emotions and thought that all can affect the patients well being. Surgery performed under regional anesthesia puts higher demands on the operating staff’s behavior, since they play a key role in offering support to the patient who is awake.  The aim of this study was therefore to investigate how patients undergoing regional anesthesia perceive the treatment from the staff in the operating room and how their treatment affect the patients experience of well being. The study had a descriptive, qualitative design based on seven interviews. The interviews were transcribed and a manifest content analysis was conducted after Graneheim and Lundmans (2004) method. The results showed that all of the informants had had a good experience of the treatment they got from the operating staff. The informants claimed that being included, the staffs’ presence and good care taking all contributed to this experience. How they perceived the treatment from the staff also had an effect on the patients well being.  The informants stated that what had the most influence on contributing to their well being was a notion of being seen by the operating staff.  In conclusion, all informants who had undergone either hip- or knee surgery under regional anesthesia had a positive experience of the treatment they received from the operating staff and stated they had been well taken care of. Due to the limitations of this study in regards to the small sample and due to the fact that this subject is an unexplored area, further research is therefore needed to verify the results of this study.

Att upprätthålla patientens integritet är en utmaning för anestesisjuksköterskan i hens dagliga arbete. Orsakerna är den fysiska miljön på den postoperativa enheten, patient- tätheten, den sederade patienten samt vikten av att säkerställa god och säker vård efter överlämnandet. Anestesisjuksköterskan kan aldrig förutse hur och i vilken grad patien- ten uppfattar stimuli strax efter uppvaknandet och därför blir behovet att skydda integri- teten särskilt viktigt. Forskningsläget är oklart då inga artiklar som gäller bevarandet av patientens integritet i samband med överlämning till den postoperativa enheten har kun- nat identifieras. Överlämningen och överrapporteringen sker i ett vårdrum där obehö- riga  och eventuellt deras närstående befinner sig. Anestesisjuksköterskans tystnadsplikt utmanas och patienten som överlämnas är inte helt vaken vilket begränsar patientens möjlighet att värja sig för utlämnande situationer. Studiens syfte var att undersöka vilka tillvägagångssätt som anestesisjuksköterskan använder för att skydda patientens integri- tet i samband med överlämning till den postoperativa enheten. Kvalitativ observations- studie som kombinerades med kortare intervjuer valdes som metod. Studien utfördes på två mindre operationsenheter i västra Sverige. Totalt genomfördes 26 observationer och 12 intervjuer. Dataanalysen utfördes med tematisk analys enligt Braun och  Clarke (2006). Resultatet presenteras i tre huvudteman som utkristalliserades under analysen: Skapa trygghet och tillfredställelse, Skapa skyddande revir och Skapa lämpliga tillvä- gagångssätt.  Det framkom att medvetenheten om komplexiteten i situationen hos anes- tesisjuksköterskan var stor och att hen använde olika strategier för att skydda patientens integritet i samband med överlämningen. Forskning inom andra kontext bekräftar delar av studiens resultat. Den postoperativa miljön med ständiga avbrott,  närvaro av obehö- riga samt patientens halvvakna tillstånd och hens utsatthet försatte anestesisjuksköters- kan och patienten i situationer där integritetsskyddet brast. Anestesisjuksköterskan var till viss del medveten om risker som kunde utgöra en integritetskränkning. Hen använde tillvägagångssätt för att skapa skydd både genom fysiska medel samt genom att avstå eller begränsa verbal kommunikation. En ökad medvetenhet kräver tid för en aktiv dis- kussion om patientens integritet och hur den skyddas. Det bör vara ett gemensamt an- svar för all personal som på något sätt är delaktig i överlämningssituationen eller befin- ner sig på den postoperativa enheten.