Margareta Warrén Stomberg

Upper extremity nerve block: how can benefit, duration, and safety be improved? An update

Upper extremity blocks are useful as both sole anaesthesia and/or a supplement to general anaesthesia and they further provide effective postoperative analgesia, reducing the need for opioid analgesics. There is without doubt a renewed interest among anaesthesiologists in the interscalene, supraclavicular, infraclavicular, and axillary plexus blocks with the increasing use of ultrasound guidance. The ultrasound-guided technique visualising the needle tip and solution injected reduces the risk of side effects, accidental intravascular injection, and possibly also trauma to surrounding tissues. The ultrasound technique has also reduced the volume needed in order to gain effective block. Still, single-shot plexus block, although it produces effective anaesthesia, has a limited duration of postoperative analgesia and a number of adjuncts have been tested in order to prolong analgesia duration. The addition of steroids, midazolam, clonidine, dexmedetomidine, and buprenorphine has been studied, all being off-label when administered by perineural injection, and the potential neurotoxicity needs further study. The use of perineural catheters is an effective option to improve and prolong the postoperative analgesic effect. Upper extremity plexus blocks have an obvious place as a sole anaesthetic technique or as a powerful complement to general anaesthesia, reducing the need for analgesics and hypnotics intraoperatively, and provide effective early postoperative pain relief. Continuous perineural infusion is an effective option to prolong the effects and improve postoperative quality.

Nursing Students' Self-Graded Motivation to Complete their Programme of Study

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.

Tools for the assessment of the recovery process following discharge from day surgery: a literature review.

This literature review provides an overview of ten studies which assessed the patients general recovery after discharge from hospital following elective surgery and anaesthesia. Ten multidimensional tools were identified and these included six common domain assessments: pain, physiological function, activities of daily living (ADL), emotions, nausea/vomiting and nutrition/ elimination. Most of the tools assessed the recovery process by using patient-subjective reported outcomes on visual analogue (VAS) or pre-graded scales.

Evaluation of the Postoperative Quality of Recovery Scale test and re-test in Swedish among healthy volunteers

Introduction Patient outcome measures are required to assess the quality of healthcare. Tools for a patients’ self-assessment of quality of recovery, during perioperative care, have been developed during the last decade. The Postoperative Quality of Recovery Scale (PostopQRS) questionnaire is one of the most well-accepted and validated tools available. Here we assess the PostopORS questionnaire in Swedish. Methods Sixty-one students from the Bachelor Program in Nursing, (50 female and 11 male; mean age, 25; range, 21-46) filled in the Swedish translation of the PostopQRS questionnaire twice. They also evaluated whether they found the queries easy to understand and respond to . Results The participants found the Swedish translation of the PostopQRS questionnaire easy to read and understand. There were minor differences in test responses between the initial test and the re-test 48 hours later. We found that the PostopQRS questionnaire has some background noise; 12 out of 61 participants (20%) reported mild pain, 25 (41%) scored some depression and 33 scored mild anxiety (54%). The cognitive domain showed a learning effect between tests in “word recall” and “word generation”, while “digit recall forward” and “digit recall backward” showed no change. We found a difference in cognitive test performance with age; younger participants had higher mean cognitive test scores compared to participants >30 years. Overall, nine participants showed a decrease in re-test scores; two experienced a mild increase in pain; one experienced a mild increase in anxiety; and six performed more poorly on cognitive tests. Conclusion The Swedish translation of the PostopQRS was found to be adequate for use in the assessment of quality of recovery, and the questions were well understood by participants. Our study shows the importance of baseline testing for assessment of recovery, since recovery is assessed as a return to or improvement in each individual’s baseline score.

Clinical Performance of a Novel Main-Stream Anaesthetic End-Tidal Gas Monitors during Routine Low Flow Anaesthesia

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 choice between surgical scrubbing and sterile covering before or after induction of anaesthesia: A prospective study

Background: Day surgery is increasing, and safe and effective logistics are sought. One part of the in-theatre logistics commonly discussed is whether surgical scrub and sterile covering should be done before or after induction of anaesthesia. The aim of the present study was to compare the impact of surgical scrub and sterile covering before vs. after the induction of anaesthesia in male patients scheduled for open hernia repair. Methods: This is a prospective randomised study. Sixty ASA 1-3 patients scheduled for open hernia repair were randomised to surgical scrub and sterile covering before or after induction of anaesthesia; group “awake” and “anaesthetised”. Need for vasoactive medication during anaesthesia was primary study objective. Duration of anaesthesia and surgery, theatre time, recovery room stay and time to discharge, patients and theatre nurses experiences and willingness to have the same logistics on further potential surgeries, by a questionnaire provided before discharge was also assessed. Results: The duration of anaesthesia was shorter and doses of propofol and remifentanil were reduced by 10 and 13%, respectively, in the awake group. We found still no difference in the need for vasoactive medication during anaesthesia Time in recovery area was significantly reduced in the awake group 39 (SD 15) vs. 48 SD 16) (p<0.05), but time to discharge was not different. There was further no difference in the patients’ assessment of quality of care, and only one patient in the awake group would prefer to be anaesthetised on a future procedure. All nurses found pre-anaesthesia scrubbing acceptable as routine. Conclusion: Surgical scrub and sterile covering before the induction of anaesthesia can be done safely and without jeopardising patients’ quality of care and possibly improve perioperative logistics. Further studies are warranted assessing impact of awake scrubbing and sterile covering on quality and efficacy of perioperative care.

Anaesthesia for open wrist fracture surgery in adults/elderly

Anaesthetic technique for open surgery of acute distal for arm fracture in adults/elderly is not well defined. Regional anaesthesia, general anaesthesia or a combined general and regional block may be considered. General anaesthetic technique, the timing and drug/drug combination for the regional block must also be considered. This is a study around published studies assessing anaesthtic technique for wrist surgery. A systematic database search was performed and papers describing the effect of anaesthetic techniques were included. We found sparse evidence for what anaesthetic technique is optimal for open wrist fracture repair. In total only six studies were found using our inclusion criteria, which all supported the short term, early recovery benefits of regional anaesthesia as part of multi-modal analgesia. More protracted outcomes and putting the type of block into context of quality of recovery and patients’ satisfaction is lacking in the literature. The risk for a pain rebound when the block vanishes should also be acknowledged. Therefore, further high quality studies are warranted concerning the anaesthetic technique for this type of surgery.

Safe Perioperative Practice, How Can We Further Improve Clinical Every Day Work?

Anaesthesia has become reassuringly safe. All modern anaesthetic agents are effective and associated to only minor side effects, anaesthetic machines and monitors helps delivery and closely in real time observation of vital signs. Anaesthesia practice has expanded and includes today perioperative care, preoperative assessment and optimisation, anaesthesia and postoperative care. Following the postoperative course up to day 30 after surgery is today of increasing interest and importance to document value based perioperative. Interprofessional care where the perioperative nurse has a major commitment will help to further improve the perioperative process.