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- Bromfalk, Åsa, 1967-
(författare)
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Intervention for prevention : easing children’s preoperative anxiety
- 2024
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Preoperative anxiety in children is associated with several adverse outcomes and consequences that can have a negative impact on the perioperative outcome and delay recovery. Anxiety can cause stress-induced cardiorespiratory instability, increased postoperative pain, nausea, emergence delirium, and long-term behavior changes. The ideal premedication for children is still debated. Only a few studies have examined the use of premedication in relation to total intravenous anesthesia (TIVA), and there is also a lack of studies exploring staff’s experiences of premedication. The aim of this thesis was to compare midazolam (a benzodiazepine), clonidine, and dexmedetomidine (a2-agonists) given as premedication to preschool children, regarding anxiety, cardiorespiratory response to sedation, time to postoperative recovery, posthospital negative behavior changes (NBCs), and staff’s experiences of the interventions.Methods: In a randomized clinical trial, 90 children aged 2–6 years, scheduled for TIVA and ear, nose, and throat surgery, were randomized to one of three groups, receiving midazolam 0.5 mg/kg, clonidine 4 mg/kg, or dexmedetomidine 2 mg/kg. The children were included at a 200-bed county hospital in northern Sweden and observed with validated tools from the day of surgery until two weeks postoperatively (Studies I–IV). To explore the clinical aspects, we conducted focus group interviews to elicit perioperative staff’s experiences of the studied interventions and analyzed the data with qualitative content analysis (Study V). Results: Midazolam reduced preoperative anxiety and provided perioperative cardiorespiratory stability. Clonidine and dexmedetomidine provided deeper sedation along with a minor decrease in heart rate. Some children, mainly from the clonidine group, awoke during the preoperative preparation, triggering anxiety, while the midazolam group remained conscious, calm, and cooperative. Postoperatively, the midazolam group emerged earlier from anesthesia compared to the two a2-agonist groups. However, the midazolam group had more episodes of postoperative anxiety, delirium, and pain compared to both groups receiving a2-agonists, and the overall recovery and discharge time from the post-anesthesia care unit was thus the same for all groups. The posthospital study showed at least one NBC in half of the children during the first two weeks after surgery. The staff’s experiences of premedication could be summarized in three themes: a matter of time, covering the efforts of building trust along with timing the administration and onset; don’t wake the sleeping bear, covering the challenge of maintaining sleep in the sleeping child in order to avoid a backlash if woken; and on responsive tiptoes, covering safety precautions and ethical perspectives on the interventions.Conclusion: The different premedications varied in their ability to reduce anxiety and to induce sleep, and this manifested itself throughout the perioperative process. Short-acting midazolam reduced preoperative anxiety but did not provide adequate sleep, and early postoperative emergence occasionally caused a rise in adverse symptom intensification. The long-lasting and sleep-inducing a2-agonists showed an unsatisfactory anxiolytic effect in comparison to midazolam. The sleep was superficial, and an awakening risked triggering anxiety. The staff strove to keep the sedated child asleep, and the recovery time was better and more peaceful when the children slept for a long time postoperatively. However, despite a calm perioperative process, one in two children presented with posthospital NBC. At the doses used in this study, all these premedications seem to be safe in cardiorespiratory terms, and the decision of which one to use should be tailored by individual and time.
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| 2. |
- Ahlander, Britt-Marie, 1954-
(författare)
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Magnetic Resonance Imaging of the Heart : Image quality, measurement accuracy and patient experience
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Non-invasive diagnostic imaging of atherosclerotic coronary artery disease (CAD) is frequently carried out with cardiovascular magnetic resonance imaging (CMR) or myocardial perfusion single photon emission computed tomography (MPS). CMR is the gold standard for the evaluation of scar after myocardial infarction and MPS the clinical gold standard for ischemia. Magnetic Resonance Imaging (MRI) is at times difficult for patients and may induce anxiety while patient experience of MPS is largely unknown.Aims: To evaluate image quality in CMR with respect to the sequences employed, the influence of atrial fibrillation, myocardial perfusion and the impact of patient information. Further, to study patient experience in relation to MRI with the goal of improving the care of these patients.Method: Four study designs have been used. In paper I, experimental cross-over, paper (II) experimental controlled clinical trial, paper (III) psychometric crosssectional study and paper (IV) prospective intervention study. A total of 475 patients ≥ 18 years with primarily cardiac problems (I-IV) except for those referred for MRI of the spine (III) were included in the four studies.Result: In patients (n=20) with atrial fibrillation, a single shot steady state free precession (SS-SSFP) sequence showed significantly better image quality than the standard segmented inversion recovery fast gradient echo (IR-FGRE) sequence (I). In first-pass perfusion imaging the gradient echo-echo planar imaging sequence (GREEPI) (n=30) had lower signal-to-noise and contrast–to-noise ratios than the steady state free precession sequence (SSFP) (n=30) but displayed a higher correlation with the MPS results, evaluated both qualitatively and quantitatively (II). The MRIAnxiety Questionnaire (MRI-AQ) was validated on patients, referred for MRI of either the spine (n=193) or the heart (n=54). The final instrument had 15 items divided in two factors regarding Anxiety and Relaxation. The instrument was found to have satisfactory psychometric properties (III). Patients who prior CMR viewed an information video scored significantly (lower) better in the factor Relaxation, than those who received standard information. Patients who underwent MPS scored lower on both factors, Anxiety and Relaxation. The extra video information had no effect on CMR image quality (IV).Conclusion: Single shot imaging in atrial fibrillation produced images with less artefact than a segmented sequence. In first-pass perfusion imaging, the sequence GRE-EPI was superior to SSFP. A questionnaire depicting anxiety during MRI showed that video information prior to imaging helped patients relax but did not result in an improvement in image quality.
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| 3. |
- Alm, Fredrik, 1983-
(författare)
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Postoperative recovery in children after tonsil surgery : with a focus on pain and pain management from the child's, caregivers', and professionals' perspectives
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Tonsil surgery is one of the most common surgical procedures in children. Although there are several health benefits associated with this surgery, the recovery can be challenging. The overall aim of this thesis was to explore varied perspectives of the recovery process following pediatric tonsil surgery, with a focus on postoperative pain and pain management at home. Study I used data from the National Tonsil Surgery Register in Sweden (n=32,225) to investigate factors affecting pain after pediatric tonsil surgery. Age, surgical method, and indication for surgery influenced the outcome of the patient-reported pain-related outcome measures. In Study II, children (n=299) and their caregiver(s) filled in a diary containing age-appropriate instruments, up to 12 days postoperatively. Data were then analyzed to explore the severity and duration of postoperative pain, the management of analgesics, and postoperative recovery. Children and caregivers reported significant pain for several days, along with a range of physical symptoms and impact on daily activities and emotional state. There was a lack of regular administration of analgesics in the home, particularly during late evening and night. In Study III, interviews with children (n=20) and their caregivers were performed to explore experiences and management of postoperative recovery at home. The results showed that the families struggled to establish resilience during the challenging recovery. The families used both pharmacological and complementary strategies to manage this period. Some families reported insufficient analgesia in preventing breakthrough pain, a lack of preparedness, inadequate information, and insufficient support from the healthcare. In Study IV, nurses and physicians (n=139) from Swedish ear, nose, and throat departments (n=48) responded to a questionnaire covering their opinions of and adherence to the Swedish guidelines for the treatment of pain in pediatric tonsil surgery. In accordance with the guidelines, the departments provided instructions for a multimodal analgesic regimen to manage pain in the home after tonsil surgery. Still, differences were noted between the departments regarding doses and routines around rescue analgesics. Overall, the experience of pain was significant, and often complex to manage. Besides pain, the postoperative period included several troublesome experiences for which neither the children nor the caregivers were informed or prepared. These findings offer knowledge to multidisciplinary teams which can help them improve the support they give to families and increase the child’s participation during the recovery process after tonsil surgery.
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| 4. |
- Ericsson, Elisabeth, 1959-
(författare)
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Health and well-being of children and young adults in relation to surgery of the tonsils
- 2007
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Tonsillectomy is one of the most frequently performed surgical procedures in children and youths. The aim of this thesis was to study children and youths in relation to tonsil surgery with the goal of improving the care, and to describe partial tonsillectomy/tonsillotomy (TT) using radiofrequency technique (RF) (Ellman International) in comparison with the more commonly used total tonsillectomy (TE).The thesis covers studies of wo age-groups with obstructive problems, with or without recurrent tonsillitis. Randomization to surgery was done from the existing waiting list; 92 children, 5-15 years old to 49/TT and 43/TE, (I-III) and 76 youths, 16-25 years old to 32/TT and 44/TE (IV-V).The first purpose (I, IV) was to compare the two surgical techniques with respect to pain and postoperative morbidity. Pain measures were for the children the Face Pain Scale and for the youths and parents and staff a verbal-pain-rating-scale. From the first day, the TT-groups scored significantly less pain than the TE-groups. The doses of pain-killing drugs (paracetamol and diclofenac) taken were significantly less for the children and youths receiving the TT-surgery, they could stop taking pain-killers sooner, and were back to normal activity three (5-15yrs) or four (16-25yrs) days earlier compared with TE-groups.Paper II focused on the child’s behavior (Child Behavior Checklist/CBCL), experience of pain, anxiety (State-Trait-Anxiety Inventory for Children /STAIC), previous experiences of surgery/tonsillitis, and the management of pain. The children scored higher on CBCL than a normative group before surgery, but no connection was observed between CBCL rating and experience of pain reported post surgically. There was no relation between preoperative anxiety and reported pain, but the postoperative anxiety level correlated with pain. The Egroup scored higher anxiety after surgery. Previous experience of surgery or tonsillitis did not influence the postoperative pain. The nurses scored pain lower than the parents/children and under-medicated.The second purpose was to compare the long-term effects of TT and TE-surgery after one and three years (5-15yrs) and one year (16-25yrs) (III, IV). The effect on snoring was the same for both TT and TE-groups and the rate of recurrence of throat infections was low after both surgical techniques.After one year, all children (TT/TE) showed improvements on CBCL to the same degree and there was no longer a difference between total behavior and normative values. They also scored improvements in health-related quality of life (HRQL) with Glasgow-Children-Benefit-Inventory.For both TT and TE, the older group reported lower HRQL preoperatively on all dimensions of Study-Short-Form (SF-36) compared with a normal population. After one year, a large improvement was found in HRQL in both groups and there were no differences compared with a normal population.Conclusion: Preoperative obstructive problems, in combination with recurrent tonsillitis have a negative impact on HRQL. Both after TE and TT there are large improvements in HRQL, infections, obstructive, and behavior problems one to three years after surgery, indicating that both surgical methods are equally effective. With fewer postoperative complications, less pain, shorter recovery time, and lower cost, TT with RF should be considered as method of choice.
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| 5. |
- Grossmann, Benjamin
(författare)
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Procedural sedation : Aspects on methods, safety and effectiveness
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Safety and effectiveness are fundamental principles within the healthcare sector to provide quality of care and health improvement for patients. By ensuring that care is provided based on evidence-based knowledge, risks and complications can be minimised and the use of scarce resources optimised. An increasing demand for diagnostic and therapeutic procedures challenges the traditional methods for sedation regarding safety and effectiveness. It is desirable that the fundamental principles are improved when refining existing or developing new sedation methods. In this doctoral thesis, safety and effectiveness were evaluated for adult patient-controlled sedation (PCS) using propofol during two endoscopic procedures: endoscopic retrograde cholangiopancreaticography (ERCP) and flexible bronchoscopy (FB); and different doses of rectal racemic ketamine for paediatric (< 4 years) burn wound care.Methods: Data on vital functions, sedation level, safety interventions, procedure feasibility, patient-reported outcome and experience measures, and recovery, from three clinical randomised controlled trials were collected. Costs of sedation for the endoscopic procedures were compiled in a cost-analysis study.Results: PCS with propofol and bedside anaesthetic personnel was shown to be a safe and effective alternative method of sedation during ERCP and FB compared with intravenous sedation with midazolam. The PCS method gives stable cardiorespiratory conditions with few adverse events and interventions, with a low risk of oversedation. PCS offers similar (FB) or better (ERCP) procedure feasibility and patient satisfaction during the procedures than midazolam. Recovery after PCS is quick, minimises the risk for prolonged hospitalisation and is thereby a potential cost-saving sedation method. The optimal dose of rectal racemic ketamine, 6 mg/kg with the addition of 0.5 mg/kg midazolam during severely painful procedures, gives minimal risk for outbreaks of pain, offers stable vital signs conditions and allows rapid recovery without affecting procedure feasibility.Conclusions: The sedation method can be adjusted to type of procedure and patient population. PCS with propofol offers an alternative and reliable method for adult sedation during endoscopic procedures, whereas rectal racemic ketamine combined with midazolam provides good conditions for burn care dressing procedures in young children.
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| 6. |
- Svensson, Sofia, 1969-
(författare)
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Språkhandlingar i flerspråkiga elevers gruppsamtal : en studie av identitetskonstruktion
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim of this thesis is to investigate how multilingual fifth-grade pupils in Sweden construct their own and each other’s identities through verbal and non-verbal discourse acts, in group discussions of diary texts without a teacher present. The group discussions were audio and video recorded by the pupils themselves and transcribed by me as a researcher.The theoretical foundation of this study is the social constructionist view of identities as multiple, negotiable and flexible processes which are constructed in and through interaction. This is investigated through the participants’ use of discourse acts in the form of initiatives, responses and follow-ups, drawing on the Exchange Structure Model combined with interactional tools from Conversation Analysis. The use of ESM has been expanded in the study for the investigation of non-verbal discourse acts as well. Zimmerman’s framework of the three identity dimensions discourse, situated, and transportable identities has been applied to the analysis of discourse acts, to study the pupils’ identity constructions. Their use of code-switching has been studied in connection with the third identity dimension, here the transportable identity as multilinguals.The results show that the pupils as a group cannot be said to make their transportable identities as multilinguals relevant to a high degree in the group discussions. However, some of the pupils make their multilingualism relevant locally, using code-switching as a resource to express feelings, to wield power, and for face-saving effects etc.Furthermore, reciprocal contingency between the three dimensions of identity is shown by the pupils’ identity constructions and co-constructions in the group discussions. Discourse identities like initiating diary reporter, confirmation seeker, questioner, responder and endorser are constructed at the micro level of interaction by the participants using verbal and non-verbal discourse acts. These identities build up situated identities together with existing participation frames, such as leader, ‘disser’, ‘group clown’ or reluctant. Both these identity dimensions build up transportable identities as multilinguals together with tacit background information of the participants’ language proficiency. Moreover, the results show how an expanded ESM can be used for analysing both verbal and non-verbal discourse acts and the construction of all three identity dimensions.
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