published_or_final_version / abstract / toc / Surgery / Master / Master of Philosophy

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Introduktion: Depression, ångest, stress och ätstörningsproblematik har visat sig ha en hög prevalens hos personer som lider av obesitas. Syfte: Att undersöka om och i så fall hur ångest och depression mätt i HADS förändras i en grupp som genomgått överviktskirurgi. Av intresse var också att undersöka om viktnedgång samt om preoperativa symtom på stress, hetsätning och känslomässigt ätande predicerar utfallet av symtom på ångest och depression postoperativt. Metod: 30 patienter som genomgått överviktskirurgi på Akademiska sjukhuset i Uppsala under våren 2011 inkluderades i studien. Dessa patienter hade innan genomgången operation och vid en uppföljning sex månader postoperativt besvarat olika screeningformulär avseende psykiskt välmående, ätstörningar och stress. Resultat: Preoperativa symtom på stress, hetsätning och känslomässigt ätande predicerar inte utfallet av symtom på ångest och depression sex månader postoperativt. Viktnedgång predicerar inte utfallet av symtom på ångest postoperativt, däremot kan viktnedgång predicera utfallet av symtom på depression sex månader efter operation. Ingen signifikant skillnad fanns mellan pre- och postoperativa symtom på ångest eller depression. Slutsats: I en grupp patienter där symtom på ångest och depression inte varit högt förekommande preoperativt kan det vara svårt att upptäcka förändringar i hur dessa patienter mår. Fler studier behövs för att kunna ge ett utökat professionellt stöd till denna patientgrupp. / Background: People with obesity have a high prevalence of depression, anxiety, stress and binge eating/emotional eating behaviours. Aim: To analyze if and how anxiety and depression measured with the Hospital and Anxiety Depression Scale change in a group of patients who have gone through Gastric Bypass surgery. Of interest was also to study if weight loss and preoperative symptoms in stress, binge- eating and emotional eating behaviours could predict anxiety and depression postoperatively. Method: 30 patients whom all gone through Gastric Bypass surgery in Uppsala University Hospital were included in the study. All patients had answered screening questionnaires about physically wellbeing, eating disorders and stress before surgery and six months postoperatively. Results: Preoperative symptoms of stress, binge eating and emotional eating disorders do not predict anxiety and depression postoperatively. Weight loss does not predict symptoms of anxiety postoperatively, but could predict symptoms of depression six months after Gastric Bypass surgery. There was no statistically significant difference between pre- and postoperative symptoms of anxiety and depression. Conclusion: Changes in wellbeing following Gastric Bypass surgery are difficult to identify in a group of patients where the occurrence of symptoms of anxiety and depression is low preoperatively. Further research is needed to find and develop professional support to this group of patients.

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Our objective was to study the effect of GLN supplementation on whole body protein turnover, somatic growth and gastrointestinal tolerance to enteral feeding in neonates following surgical stress. We hypothesized that GLN in total parenteral nutrition (TPN) would (1) favor retention of lean body mass by reducing protein breakdown (PB) during the acute phase after surgery, (2) promote somatic growth, (3) decrease length of time to achieve full feeds. Protein turnover was measured in a double-blind randomized trial involving neonates admitted to the Neonatal Intensive Care Unit after major surgery. L-GLN (n = 6) was added to TPN at a dose of 200 mg/g of protein intake. Controls (n = 7) were isonitrogenous. Isotope studies were performed on Day 4 of TPN. Subjects were given a 4-hour primed constant intravenous infusion of L-[1-13C]-leucine and [15N2]-urea. In the GLN group, a 15% reduction in PB was measured (unpaired t-test, p < 0.05). There was a trend towards improved net protein balance which was statistically different from zero in the GLN group. There were no differences in somatic growth during TPN course and in the length of time to achieve full enteral feeds. Results suggest that early TPN supplemented with GLN has a beneficial sparing effect on protein metabolism in critically ill neonates after major surgical stress.

The present study evaluates the efficacy of self-hypnosis and its components--relaxation instructions and waking analgesia suggestions--for pain reduction in patients recovering from gallbladder surgery. Forty elective surgery patients were randomly assigned to one of the three experimental pain control procedures or to a standard treatment control group--preoperative teaching. The treatments were found to be equally credible and generated equivalent expectancies for success. Pain was assessed using multiple subjective and objective measures sampled across the postoperative period. Multivariate analysis of these data indicated that the experimental treatments were no more effective in diminishing postoperative pain than the control procedure. However, the analysis revealed several significant correlates and predictors of postoperative pain. These included trait anxiety, depression, stress coping style as well as interview and rating scale reports of cognitive coping strategies. Significant predictors of credibility--expectancy, treatment utilization and cognitive coping classifications were also found. Analysis of the pain measurement strategy indicated consistency among the subjective measures--the McGill Pain Questionnaire and visual analogue scales--which were relatively independent from the objective measures, which comprised electronically monitored gross motor activity and analgesic medication requirements. Possible interpretations and implications of these results as well as suggestions for future research are discussed.

Following vestibular schwannoma excision, a subset of cases has been reported in which hearing is present immediately after surgery, but is lost in the early postoperative period. Such cases have rarely been reported, and the postoperative audiological data collected from patients in these cases lacks the time resolution necessary to determine the pathophysiological mechanism responsible for the pattern of hearing loss. The present study aimed to more clearly define delayed hearing loss by collecting detailed data documenting changes in behavioural and electrophysiological auditory responses following vestibular schwannoma surgery. In particular, we aimed to use this data to determine the time course of changes in auditory function and to identify whether the site of impairment was cochlear or neural. Preoperative and daily postoperative monitoring of auditory function was performed in 19 patients undergoing vestibular schwannoma excision via the retrosigmoid approach at Christchurch Public Hospital. The pre- and postoperative assessment battery included pure-tone and speech audiometry, tympanometry, tone decay, distortion product otoacoustic emissions (DPOAEs), and auditory brainstem response (ABR) measurement. Intraoperative ABR was performed in four cases in which clear preoperative waveforms were present. Transtympanic electrocochleography (ECochG) was carried out if wave I was lost in the early postoperative period. Thirteen of the 19 patients suffered immediate anacusis following surgery and six had measurable hearing postoperatively. The behavioural and electrophysiological data collected in each case is discussed with regard to the likely pathophysiology of pre- and postoperative hearing loss. No patients demonstrated behavioural evidence of delayed hearing loss, however a gradual deterioration of ABR in the early postoperative period was observed in Case 16. ECochG and DPOAEs in this case indicated the presence of cochlear function although the patient presented with immediate postoperative anacusis in the ipsilateral ear. These results are consistent with postoperative retrograde degeneration of the cochlear nerve.

Children undergoing surgical procedures often experience pain in the recovery room where parents are typically responsible for managing children’s distress. Research suggests that parents’ behavior influences children’s distress; however, no study has used time-window sequential analysis to examine the likelihood of parents’ reassurance and children’s distress interactions. The purpose of this study was to utilize time-window sequential analysis to examine the likelihood of parents’ distress preceding and following the start of children’s distress. Participants included 148 families with children 2-11 years old undergoing outpatient surgery. Reassurance was positively associated with children’s distress, but sequential analyses revealed that children’s nonverbal distress was significantly less likely to start and stop following parents’ reassurance and children’s verbal distress was significantly less likely to occur after fathers’ reassurance. These data suggest that reassurance does not prompt distress to start; however, it may maintain children’s distress.

Sjuksköterskan har en viktig roll, vad gäller den postoperativa smärtbehandlingen och ansvarar för att smärtbehandlingen överensstämmer med patientens önskemål och behov. Kirurgiska ingrepp kan leda till långvarig postoperativ smärta som orsakar patienten förlängd vårdtid och begränsar individen i vardagen. Syftet med litteratur-studien var att belysa faktorer av betydelse vid smärtbedömning och dokumentation i samband med postoperativ smärtbehandling. Analys av 14 vetenskapliga artiklar sammanställdes. I resultatet framkom två kategorier: utbildning och erfarenhet, smärtskattning och dokumentation. Sjuksköterskors och patienters kunskap samt utbildning främjade optimal smärtbehandling i kombination med att evidensbaserade metoder för smärtskattning genomfördes, förutsatt att kommunikation och dialog fördes mellan sjuksköterskor och patienter. Sammanfattningsvis var det otillräcklig utbildning, bristande kommunikation och dokumentation samt inadekvat smärtskattning som påverkade smärtbehandlingen av patienters postoperativa smärta. Mer forskning inom området behövs då det visade sig att dokumentationens betydelse vid smärtbedömning för patienter med postoperativ smärta är begränsat beskriven. / The nurse has an important role in post-operative analgesica and is responsible for pain treatment consistent with the patient's wishes and needs. Surgical procedures can lead to prolonged postoperative pain that causes the patient extended care and limits the individual in everyday life. The aim of this study was to elucidate factors of importance in pain assessment and documentation associated with postoperative pain management. Analysis of 14 scientific articles were compiled. The results revealed two categories: education and experience, pain assessment and documentation. Hospital nurses ' and patients' knowledge and education promoted optimum pain treatment in combination with evidence-based methods for pain assessment was carried out, provided that communication and dialogue took place between nurses and patients. In summery it was inadequate education, lack of communication and documentation and inadequate pain assessment were factors that influenced pain treatment of patients' post-operative pain. More research in this area is needed when it was apparent that the importance of the documentation of pain assessment for patients with postoperative pain is limited as described.

Bakgrund: Postoperativa sårinfektioner [PSI] är en allvarlig komplikation och ett hälsoproblem som orsakar lidande för patienten. Såsom vid alla operativa ingrepp förekommer en risk att få PSI i operationssåret/-såren efter Coronary Artery Bypass Graft [CABG], men det finns redan en rad kända riskfaktorer som ökar risken för PSI. Syfte och metod: Syftet med rapporten var att undersöka om kombinationen av ett antal sedan tidigare kända riskfaktorer ökade risken för PSI efter CABG på ett mellansvenskt sjukhus åren 2009-2012. En retrospektiv journalgranskningsstudie med totalt 228 patienter genomfördes. Resultat: Av 228 undersökta hade totalt 50 patienter rapporterat sårinfektion och 73 patienter hade ≥ 3 riskfaktorer. Bland de som hade ≥ 3 riskfaktorer rapporterade 32,9% PSI och bland de som hade &lt; 3 riskfaktorer rapporterade 16,8% PSI. Risken att få PSI efter CABG-kirurgi är nästan dubbelt så stor (RR=1,960) hos patienter med ≥ 3 riskfaktorer jämfört med patienter med &lt; 3 riskfaktorer (X2=7,516 df=1 p=0,006). Slutsats: Det finns en signifikant högre risk för PSI efter CABG vid förekomst av tre eller fler än tre patientrelaterade riskfaktorer jämfört med färre än tre riskfaktorer. Fler, större studier av detta slag efterfrågas då denna rapport kan ge en fingervisning om hur situationen föreligger på ett mellansvenskt sjukhus. / Objective: Postoperative surgery site infections [SSI] is not only a severe complication but a health problem which often cause suffering and prolonged hospitalization among afflicted patients. As with all surgical procedures, a coronary artery bypass graft [CABG] always implicates a risk for SSI and a number of risk factors have to be taken into account when dealing with it. The objective of this report is to investigate if a combination of several patient-related risk factors implicates greater risk of getting SSI after CABG. Method: A quantitative retrospective journal review of 228 patients who completed a CABG between 2009-2012 was performed on a university hospital in central Sweden. Result: Among 228 patients a total of 50 reported SSI and 73 patients had ≥ 3 patient-related risk factors. Among those who had ≥ 3 risk factors 32.9% reported SSI and among those who had &lt; 3 risk factors 16.8% reported SSI. The risk of getting SSI after CABG is almost twice as high (RR = 1.960) in patients with ≥ 3 risk factors compared to patients with &lt; 3 risk factors (X2 = 7.516 df = 1 p = 0.006). Conclusion: There is a significantly higher risk of getting SSI after CABG in the presence of three or more than three patient-related risk factors, compared with fewer than three risk factors. More, larger studies of this kind are in demand since this report provides an indication of how the situation may prevail on a central Swedish university hospital.