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  • 1.
    Ahlander, Britt-Marie
    et al.
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden; Department of Radiology, Ryhov County Hospital, Jönköping, Sweden.
    Arestedt, Kristofer
    Center for Collaborative Palliative Care, Linnaeus University, Kalmar, Sweden.
    Maret, Eva
    Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden; Department of Radiology, Ryhov County Hospital, Jönköping, Sweden.
    Engvall, Jan E.
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden; Center of Image Science and Visualization, Linköping University, Linköping, Sweden.
    Ericsson, Elisabeth
    Örebro University, School of Health Sciences.
    Development and validation of a questionnaire evaluating patient anxiety during Magnetic Resonance Imaging: the Magnetic Resonance Imaging-Anxiety Questionnaire (MRI-AQ)2016In: 19th Annual SCMR Scientific Sessio: Meeting abstracts, BioMed Central, 2016, Vol. 18 S1, article id P312Conference paper (Refereed)
    Abstract [en]

    Background: MR examinations of the heart are sometimes negatively affected by anxiety that could have been detected by the pre-scan administration of a suitable questionnaire and psychological support given. To better understand patient experience during the examination and to evaluate psychological intervention, use of general anxiety scales is unsuitable and an MR-specific questionnaire was developed.

    Methods: A new questionnaire, MRI-AQ, was designed from patient expressions of anxiety in MRI-scanners. The patient sample was recruited between October 2012 and October 2014. Factor structure was evaluated with exploratory factor analysis and internal consistency with Cronbach’s alpha. Criterion-related validity, known-group validity and test-retest was evaluated. The new instrument was compared with the Spielberg State Anxiety Index (STAI), the Hospital Anxiety and Depression Scale (HAD), and with nine statements from the Fear Survey Schedule developed by Lukins et al.

    Results: In total, 247 participants (54.7 ± 14.3 years), referred for MRI examinations of either the spine or the heart, accepted to participate in the study. The development and validation of MRI-AQ resulted in 15 items which could be used as an overall global score or as two sub scale scores. Cronbach’s alpha was found to be high (a = 0.90). MRI-AQ correlated higher with instruments measuring anxiety than with depression scales. Known-group validity demonstrated a higher level of anxiety for patients undergoing MRI scan of the heart than for those examining the spine (p < 0.01). Test-retest reliability demonstrated acceptable level for the scale (ICC = 0.90; CCC = 0.90). Conclusions: MRI-AQ bridges a gap among existing questionnaires, making it a simple and useful tool for measuring patient anxiety during MRI examinations.

  • 2.
    Ahlander, Britt-Marie
    et al.
    Örebro University, School of Health Sciences.
    Engvall, Jan
    Linköping University, Linköping, Sweden.
    Ericsson, Elisabeth
    Örebro University, School of Health Sciences.
    Anxiety during Magnetic Resonance Imaging of the spine in relation to scanner design and size.2019Conference paper (Refereed)
    Abstract [en]

    Background

    Magnetic resonance imaging in closed-bore scanners is at times anxiety-ridden. Open scanners are easier to tolerate. Manufacturers are working towards making the bores wider and shorter.

    Aim

    To compare patient anxiety in closed-bore scanners with bore diameters of 62cm and 70 cm compared to that of open design scanners.

    Method

    Consecutive patients referred for examination of the spine in 62 cm and 70 cm scanners and one open design were asked to participate. Most of those who were scheduled for examination in the open scanner, was it due to problems with closed bores. For anxiety evaluation, four questionnaires were used:

     Before the examination: Spielberger State and Trait anxiety – state (STAI-S) [1]. Hospital Anxiety and Depression scale, Anxiety (HAD-A) and depression (HAD-D) [2], The Magnetic Resonance Imaging- Fear survey schedule (MRI-FSS) [3].  

    Directly after the examination: The Magnetic Resonance Imaging- Anxiety Questionnaire (MRI-AQ) consisting of two factors anxiety and relaxation [4], STAI-S, patients also ranged their level of worry and experience.

    One week after the examination: MRI-AQ, HAD, MRI-FSS

    Result

    155 patients responded to the questionnaires before and immediately after the examination. 109 responded also one week after. Patients in the open scanner rated higher levels of anxiety (<0.001) before, directly after and one week after the examination, compared to closed bore scanners. No difference was found in the patient scores between the 62 cm and the 70 cm scanners on the examination day. At follow-up, patients in the 62 cm bore rated their examination experience lower (<0.05), compared to patients in the 70 cm bore.

    Conclusion

    In conclusion patient experience of the examination was similar in the 62 cm and 70 cm bores immediately after the examination. However, patient recall of the examination was more pleasant for those examined in the 70 cm bore scanner.

    MRI in an open scanner may be the only way for patients with anxiety problems to endure an examination. If open scanners are unavailable, different interventions are needed to enable these patients to undergo an examination. Patient anxiety in connection with MRI is a challenge for the radiographers necessitating constant improvements in technology and interventions.

     

    1.         Spielberger CD, Goursch, R.L., Lushene, R.E.: Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologist Press 1970.

    2.         Zigmond AS, Snaith RP: The hospital anxiety and depression scale. Acta Psychiatr Scand 1983, 67(6):361-370.

    3.         Lukins R, Davan IGP, Drummond PD: A cognitive behavioural approach to preventing anxiety during magnetic resonance imaging. Journal of behavior therapy and experimental psychiatry 1997, 28(2):97-104.

    4.         Ahlander BM, Arestedt K, Engvall J, Maret E, Ericsson E: Development and validation of a questionnaire evaluating patient anxiety during Magnetic Resonance Imaging: the Magnetic Resonance Imaging-Anxiety Questionnaire (MRI-AQ). J Adv Nurs 2016, 72(6):1368-1380.

  • 3.
    Ahlander, Britt-Marie
    et al.
    Örebro University, School of Health Sciences.
    Engvall, Jan
    Department of Clinical Physiology, Linköping University, Linköping, Sweden; Center of Medical Image Science and Visualization, Linköping University, Linköping, Sweden.
    Maret, Eva
    Department of Clinical Physiology, Karolinska Institute, Stockholm, Sweden; Karolinska University Hospital, Stockholm, Sweden.
    Ericsson, Elisabeth
    Örebro University, School of Health Sciences.
    Positive effect on patient experience of video information given prior to cardiovascular magnetic resonance imaging: A clinical trial2018Conference paper (Refereed)
  • 4.
    Ahlander, Britt-Marie
    et al.
    Department of Radiology, Ryhov County Hosptial, Jönköping, Sweden.
    Engvall, Jan
    Department of Clinical Physiology, Linköping University, Linköping, Sweden; Center of Medical Image Science and Visualization, Linköping University, Linköping, Sweden.
    Maret, Eva
    Department of Clinical Physiology, Karolinska Institutet, stockholm, Sweden; Karolinska University Hospital, Stockholm, Sweden.
    Ericsson, Elisabeth
    Örebro University, School of Health Sciences.
    Positive effect on patient experience of video-information given prior to cardiovascular magnetic resonance imaging, a clinical trial2018In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 27, no 5-6, p. 1250-1261Article in journal (Refereed)
    Abstract [en]

    Aims and objectives: To evaluate the effect of video information given before cardiovascular magnetic resonance imaging on patient anxiety and to compare patient experiences of cardiovascular magnetic resonance imaging versus myocardial perfusion scintigraphy. To evaluate whether additional information has an impact on motion artefacts.

    Background: Cardiovascular magnetic resonance imaging and myocardial perfusion scintigraphy are technically advanced methods for the evaluation of heart diseases. Although cardiovascular magnetic resonance imaging is considered to be painless, patients may experience anxiety due to the closed environment.

    Design: A prospective randomised intervention study, not registered.

    Methods: The sample (n = 148) consisted of 97 patients referred for cardiovascular magnetic resonance imaging, randomised to receive either video information in addition to standard text-information (CMR-video/n = 49) or standard text-information alone (CMR-standard/n = 48). A third group undergoing myocardial perfusion scintigraphy (n = 51) was compared with the cardiovascular magnetic resonance imaging-standard group. Anxiety was evaluated before, immediately after the procedure and 1 week later. Five questionnaires were used: Cardiac Anxiety Questionnaire, State-Trait Anxiety Inventory, Hospital Anxiety and Depression scale, MRI Fear Survey Schedule and the MRI-Anxiety Questionnaire. Motion artefacts were evaluated by three observers, blinded to the information given. Data were collected between April 2015–April 2016. The study followed the CONSORT guidelines.

    Result: The CMR-video group scored lower (better) than the cardiovascular magnetic resonance imaging-standard group in the factor Relaxation (p =.039) but not in the factor Anxiety. Anxiety levels were lower during scintigraphic examinations compared to the CMR-standard group (p <.001). No difference was found regarding motion artefacts between CMR-video and CMR-standard.

    Conclusion: Patient ability to relax during cardiovascular magnetic resonance imaging increased by adding video information prior the exam, which is important in relation to perceived quality in nursing. No effect was seen on motion artefacts.

    Relevance to clinical practice: Video information prior to examinations can be an easy and time effective method to help patients cooperate in imaging procedures.

  • 5.
    Ahlander, Britt-Marie
    et al.
    Örebro University, School of Health Sciences.
    Ericsson, Elisabeth
    Örebro University, School of Health Sciences.
    Maret, Eva
    Department of Clinical Physiology, Karolinska Institutet, Stockholm, Sweden; Karolinska University Hospital, Stockholm, Sweden.
    Engvall, Jan
    Department of Clinical Physiology, Linköping University, Linköping, Sweden; Center of Medical Image Science and Visualization, Linköping University, Linköping, Sweden.
    Magnetkameraundersökning av hjärtat2014Conference paper (Other academic)
  • 6.
    Ahlander, Britt-Marie
    et al.
    Örebro University, School of Health Sciences. Röntgenavdelningen, Ryhov, Jönköping.
    Ericsson, Elisabeth
    Örebro University, School of Health Sciences.
    Maret, Eva
    Department of Clinical Physiology, Karolinska Institute, Stockholm, Sweden; Karolinska University Hospital, Stockholm, Sweden.
    Engvall, Jan
    Department of Clinical Physiology, Linköping University Hospital, Linköping, Sweden; Center of Medical Image Science and Visualization, Linköping University, Linköping, Sweden.
    Magnetkameraundersökning av hjärtat: bildkvalitet, mätnoggrannhet och patientupplevelse2017Conference paper (Refereed)
    Abstract [sv]

    Syfte:

    Att utvärdera bildkvaliteten vid magnetkamera undersökning av hjärtat (hjärt-MR) genom val av sekvens vid undersökning av infarktutbredning hos patienter med förmaksflimmer och vid studie av hjärtmuskelns genomblödning, samt eventuell inverkan av given information.

    Att studera patientens upplevelse vid hjärt-MR med målet att kunna förbättre patientupplevelsenoch bildkvaliteten.

    Material och metoder:

    På 20 patienter med förmaksflimmer och genomgången hjärtinfarkt har två viabilitetssekvenser jämförts, en segmenterad (bilden samlas in under flera hjärtslag) och en single shot (bilden samlas in under ett hjärtslag).

    På 60 patienter remitterade för hjärtscintigrafi gjordes även hjärt-MR. Perfusionssekvenser utfördes under Adenosine-stress. Två olika sekvenser användes, SSFP och GRE-EPI. Undersökningarna har utvärderats både visuellt och semi-kvantitativt med hjärtscintigrafi som referensmetod.

    Med resultatet från en studie av Erna Törnqvist et al (2006), har ett skattningsinstrument konstruerats, Magnetic Resonance Imaging - Anxiety Questionnaire (MRI-QA). För validering har 247 patienter remitterade för MR-undersökning av rygg (n=193) och hjärta (n=54) besvarat frågorna.

    På två grupper av patienter remitterade för hjärt-MR har informationens betydelse utvärderats. En grupp erhöll video information (n=49) och en standard information (n=48). Likaså utvärderades informationens betydelse för bildkvaliteten.

    Resultat:

    Single shot sekvensen hade bättre bildkvalitet än den segmenterade. Hjärtinfarktens utbredning överensstämde mellan de båda sekvenserna.

    Trots att SSFP sekvensen hade bättre signal brus och kontrast brus förhållande överensstämde GREEPI sekvensen bäst med myokardscintigrafin både vid visuell och vid semi-kvantitativ bedömning.

    MRI-AQ resulterade i 15 påståenden. Det består av två faktorer, en som mäter ångest (12 påståenden) och en som mäter avslappning (tre påståenden). Det har psykometriska förutsättningar att kunna värdera patienters upplevelse av MR-undersökning.

    Patienter som fick utökad information i form av en film var signifikant mer avslappnade under undersökningen än patienter som fick standardinformation. Däremot påverkade inte den utökade informationen bildkvaliteten.

    Konklusion:

    Vid undersökning av infarktstorleken hos patienter med förmaksflimmer hade single shot sekvensen högre bildkvalitet än den segmenterade sekvensen.

    Vid bedömning av ischemi överensstämde hjärt-MR bättre med myokardscintigrafin om GRE-EPI sekvensen användes jämfört med SSFP sekvensen. Detta gällde både vid visuell och semi-kvantitativ bedömning.

    MRI-AQ bedöms som ett tillförlitligt instrument att använda för att utvärdera effekter av intervention vid MR-undersökning.

    Utökad information med video gör patienten mer avslappnad i undersökningssituationen men har ingen påverkan på bildkvaliteten.

  • 7.
    Ahlander, Britt-Marie
    et al.
    Örebro University, School of Health Sciences. Jönköping County Hospital, Jönköping, Sweden.
    Ericsson, Elisabeth
    Örebro University, School of Health Sciences.
    Maret, Eva
    Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden.
    Engvall, Jan
    Linköping University, Linköping, Sweden.
    Video information prior to cardiovascular magnetic resonance imaging improves patient experience which still remains more challenging than in myocardial perfusion scintigraphy2017In: Abstract Proceedings from the 20th Annual SCMR Scientific Sessions, Society for Cardiovascular Magnetic Resonance (SCMR) , 2017Conference paper (Refereed)
    Abstract [en]

    Background: Cardiovascular magnetic resonance imaging (CMR) and myocardial perfusion scintigraphy (MPS) are two technically advanced methods for imaging cardiac diseases. Although CMR is considered to be painless, considerable patient cooperation is necessary during scanning. Some patients may experience anxiety because of the closed environment of the procedure.

    The aims of this paper were to evaluate the potential effect on patient anxiety and on motion artefacts by adding a 5 min video sequence to the standard written information given before CMR. Additionally, the patient experience of CMR was compared to that of MPS.

    Methods: The sample (n=146) consisted of 97 patients randomized to receive either video information in addition to standard written information (CMR-video/n=49) or standard written information alone (CMR-standard/n=48). A third group undergoing MPS (n=51) was used to compare CMR-standard and MPS. Anxiety was evaluated before, immediately after the procedure and one week later. Four questionnaires were used: State-Trait-Anxiety Inventory, Hospital-Anxiety and Depression-scale, MRI-Fear-Survey-Schedule and the MRI-Anxiety-Questionnaire (MRI-AQ). Motion artefacts were evaluated by three observers, blinded to the information given. Motion artefacts due to arrhythmia were not considered.

    Results: Measured with MRI-AQ, the CMR-video and the CMR-standard groups did not score significantly different on the factor Anxiety. However, CMR-video scored lower (=better) in the factor Relaxation (p=0.039). Younger patients and women scored a higher level of anxiety in most scales. Anxiety levels (MRI-AQ) were lower during MPS examinations compared to the CMRstandard group (p < 0.001 ). The presence of motion artefacts was similar in the CMR-video compared to the CMR-standard group.

    Conclusions: Patient ability to relax during CMR increased by adding video information prior to the exam. This positive effect on patient experience is important to enable technologists to obtain full patient cooperation. An apparent lack of effect on motion artefact could possibly be due to the addition of compensatory extra scans when a low image quality was recognized by the technologists.

  • 8.
    Ahlander, Britt-Marie
    et al.
    Örebro University, School of Health Sciences. Department of Radiology, Ryhov County Hospital, Jönköping, Sweden.
    Årestedt, Kristofer
    Department of Medical and Health Sciences, Division of Nursing Science, Linköping University, Linköping, Sweden; Center for Collaborative Palliative Care, Linnaeus University, Kalmar, Sweden.
    Engvall, Jan
    Department of Clinical Physiology, Linköping University, Linköping, Sweden; Center of Medical Image Science and Visualization, Linköping University, Linköping, Sweden.
    Maret, Eva
    Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden; Karolinska Institutet, Stockholm, Sweden.
    Ericsson, Elisabeth
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Development and validation of a questionnaire evaluating patient anxiety during Magnetic Resonance Imaging: the Magnetic Resonance Imaging- Anxiety Questionnaire (MRI-AQ)2016In: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648, Vol. 72, no 6, p. 1368-1380Article in journal (Refereed)
    Abstract [en]

    Aim: To develop and validate a new instrument measuring patient anxiety during Magnetic Resonance Imaging examinations, Magnetic Resonance Imaging-Anxiety Questionnaire.

    Background: Questionnaires measuring patients’ anxiety during Magnetic Resonance Imaging examinations have been the same as used in a wide range of conditions. To learn about patients’ experience during examination and to evaluate interventions, a specific questionnaire measuring patient anxiety during Magnetic Resonance Imaging is needed.

    Design: Psychometric cross-sectional study with test-retest design.

    Methods: A new questionnaire, Magnetic Resonance Imaging-Anxiety Questionnaire, was designed from patient expressions of anxiety in Magnetic Resonance Imagingscanners. The sample was recruited between October 2012–October 2014. Factor structure was evaluated with exploratory factor analysis and internal consistency with Cronbach’s alpha. Criterion-related validity, known-group validity and test-retest was calculated.

    Results: Patients referred for Magnetic Resonance Imaging of either the spine or the heart, were invited to participate. The development and validation of Magnetic Resonance Imaging-Anxiety Questionnaire resulted in 15 items consisting of two factors. Cronbach’s alpha was found to be high. Magnetic Resonance Imaging-Anxiety Questionnaire correlated higher with instruments measuring anxiety than with depression scales. Known-group validity demonstrated a higher level of anxiety for patients undergoing Magnetic Resonance Imaging scan of the heart than for those examining the spine. Test-retest reliability demonstrated acceptable level for the scale.

    Conclusion: Magnetic Resonance Imaging-Anxiety Questionnaire bridges a gap among existing questionnaires, making it a simple and useful tool for measuring patient anxiety during Magnetic Resonance Imaging examinations.

  • 9.
    Ahlgren Andersson, Eva
    et al.
    Department of Anaesthesiology and Intensive Care, Östergötlands Läns Landsting, Linköping, Sweden.
    Almerud Österberg, S.
    Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden.
    Elneborg, Karin
    Ericsson, Elisabeth
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Johansson, E.
    Minthon, Lennart
    Pettersson, M.
    Thulesius, H.
    Wohlin, S.
    Åberg, B.
    Östberg, H.
    Låg kognitiv hastighet före operation hade samband med postoperativ förvirring efter elektiv hjärtkirurgi2012Conference paper (Other academic)
  • 10.
    Alm, Fredrik
    et al.
    Örebro University, School of Health Sciences. Department of Anaesthesia and Intensive Care.
    Ericsson, Elisabeth
    Örebro University, School of Health Sciences.
    Pain and pain management after pediatric tonsil surgery2017Conference paper (Refereed)
  • 11.
    Alm, Fredrik
    et al.
    Örebro University, School of Health Sciences. Department of Anaesthesia and Intensive Care.
    Ericsson, Elisabeth
    Örebro University, School of Health Sciences.
    Smärta och smärtbehandling i samband med tonsillkirurgi på barn: ett ständigt pågående förbättringsarbete med ett multidisciplinärt ansvar2018Conference paper (Other academic)
    Abstract [en]

    Smärta efter tonsillkirurgi på barn har varit och är fortfarande en utmaning för ÖNH-professionen. Trots ett stort antal publikationer inom området saknas nationellt och internationellt konsensus om vad som är den optimala smärtbehandlingen. Registerdata i Sverige visar på hög andel patienter/närstående som kontaktar hälso- och sjukvården efter tonsillkirurgi pga. bristfällig smärtbehandling. Under de senaste åren har flera förbättringsarbeten utförts med implementering av nationella riktlinjer för smärtbehandling och patientinformation på hemsidan tonsilloperation.se. Mot denna bakgrund pågår nu ett forskningsprojekt där smärta och smärtbehandling i samband med tonsillkirurgi utvärderas från professionens, barnets och anhörigas perspektiv. Studier i projektet har visat att den svenska ÖNH-professionens åsikt om och följsamhet till de nationella riktlinjerna är god. Vidare visar analys av registerdata att implementeringen av nationella riktlinjer har gjort avtryck i tonsilloperationsregistrets smärtrelaterade variabler, med längre postoperativ analgetikabehandling och en viss minskning av oplanerade kontakter med hälso- och sjukvård. Samtidigt visar data från registret att operationsmetoder och tekniker, men även patientfaktorer som ålder och indikation för kirurgi, påverkar smärtutfallet. Preliminära resultat från en större kvantitativ datainsamling via åldersanpassade smärtdagböcker och kvalitativa intervjuer med barn och anhöriga visar att återhämtningen efter tonsillkirurgi påverkas av vilken typ av smärtbehandling barnet ordinerats.

  • 12.
    Alm, Fredrik
    et al.
    Örebro University, School of Health Sciences. Department of Anaesthesia and Intensive Care.
    Ericsson, Elisabeth
    Örebro University, School of Health Sciences.
    Vilka faktorer påverkar den postoperativa smärtan i samband med tonsillkirurgi?2017Conference paper (Other academic)
  • 13.
    Alm, Fredrik
    et al.
    Örebro University, School of Health Sciences. Department of Anaesthesia and Intensive Care, School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Jaensson, Maria
    Örebro University, School of Health Sciences.
    Lundeberg, Stefan
    Pain Treatment Service, Astrid Lindgren Children's Hospital, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden.
    Ericsson, Elisabeth
    Örebro University, School of Health Sciences.
    Adherence to Swedish guidelines for pain treatment in relation to pediatric tonsil surgery: A survey of the multidisciplinary team2017In: International Journal of Pediatric Otorhinolaryngology, ISSN 0165-5876, E-ISSN 1872-8464, Vol. 101, p. 123-131Article in journal (Refereed)
    Abstract [en]

    Background: Pain management in children after tonsil surgery is essential, and optimal pain treatment has been discussed for many years. Data from the National Tonsil Register in Sweden (NTRS) and a national mapping system have demonstrated the need for national pain treatment guidelines for pediatric tonsil surgery. As a result, Swedish national guidelines, together with updated patient information on the website tonsilloperation.se, were developed and implemented in 2013.

    Objectives The objective of this study was to evaluate the professionals’ opinions of and adherence to pain treatment guidelines for pediatric tonsil surgery patients in a two-year follow-up.

    Method: This descriptive cross-sectional study was based on data from an inter-professional questionnaire, which was validated by an expert group using a content validity index (S-CVI 0.93). The questionnaire was sent to all Swedish ear, nose and throat (ENT) departments (n=49) that the NTRS identified as performing tonsil surgery on children younger than 18 years of age. In each clinic, we asked for responses from staff in each of the following professions: ENT physicians, anesthesia physicians, registered nurse anesthetists, and registered nurses in the ENT departments.

    Results: Respondents from 48 ENT departments participated, and 139/163 (85%) completed questionnaires were returned. The guidelines were reported as being clear, ensuring patient safety and providing optimal pharmacological treatment. Treatment was given according to the guidelines: Half of the departments gave pre- or intraoperative treatment with clonidine, betamethasone and high-dose paracetamol (acetaminophen). A multimodal pain approach (paracetamol and COX inhibitors) after hospital discharge was prescribed by all departments after tonsillectomy and, more extensively, after tonsillotomy. One-third of the departments prescribed paracetamol with a higher normal dose for the first three postoperative days. Half of the departments prescribed rescue analgesics, clonidine or opioids after tonsillectomy. None of the departments prescribed codeine or tramadol, drugs that are discouraged in the guidelines. The majority of the departments used the website tonsilloperation.se to provide information to the patients and their caregivers.

    Conclusion: The respondents' opinions of and the ENT departments adherence to the Swedish national guidelines were considered to be good. The national implementation process in Sweden has impacted the manner in which ENT departments treat pain after tonsil surgery.

  • 14.
    Alm, Fredrik
    et al.
    Örebro University, School of Health Sciences.
    Jaensson, Maria
    Örebro University, School of Health Sciences.
    Lundeberg, Stefan
    Astrid Lindgrens Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.
    Hemlin, Claes
    Sollentuna Specialist Clinic, Stockholm, Sweden.
    Hessén-Söderman, Anne-Charlotte
    Department of Otorhinolaryngology, Aleris Sabbatsberg, Stockholm, Sweden; Division of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
    Nerfeldt, Pia
    Karolinska University Hospital, Huddinge, Sweden.
    Odhagen, Erik
    Department of Otorhinolaryngology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Sunnergren, Ola
    Department of Otorhinolaryngology, Ryhov County Hospital, Jönköping, Sweden; Futurum-The Academy for health and care, County Council, Jönköping, Sweden.
    Stalfors, Joacim
    Sahlgrenska Universitety Hospital, Göteborg, Sweden.
    Ericsson, Elisabeth
    Örebro University, School of Health Sciences.
    Adherence to Swedish Guidelines for Pain Treatment in Tonsil Surgery in Pediatric Patients2016Conference paper (Refereed)
    Abstract [en]

    Objective: As shown by data from the National Tonsil Surgery Register in Sweden, tonsil surgery often causes severe pain that lasts for many days. The register data demonstrate the necessity for better evidence-based pain treatment guidelines for tonsil surgery. The guidelines, introduced in 2013, consist of both pharmacological and non-pharmacological recommendations. In the guidelines, a multimodal analgesic approach and combination of analgesics are recommended to provide effective pain treatment with limited side effects. Two national multi-professional education days on pain, pharmacology and the guidelines were offered. Web-based information about pharmacological treatment (www.tonsililloperation.se) was designed for patients and next-of-kin. The current aims were to describe adherence to the Swedish guidelines for pain treatment in tonsil surgery in pediatric patients < 18 years

    Method: An inter-professional questionnaire was developed, including questions linked to the relevant guidelines. The questions came from a national mapping before the guidelines were designed. The items were discussed by an expert group, and content validity was evaluated using the content validity index.ENT-and anesthesia physicians and nurses from all 50 ENT clinics in Sweden were enrolled.

    Results: Most clinics had received the guidelines, but there was a discrepancy between the professions. More than half had perused the literature review performed before the guidelines were designed, and attended themulti-professional education day. Pre- and perioperative treatment usually included paracetamol, clonidine and betamethasone. A multimodal pain approach after discharge from hospital (tonsillectomy and tonsillotomy) was used, combining paracetamol with cox-inhibitors. Most clinics used paracetamol, with a higher dose for the first 3 days (healthy children and acceptable nutrition), and a reduced dose from day 4.In case of inadequate analgesia after tonsillectomy, oral clonidine or opioids were used. Several clinics followed the recommendation to use clonidine as first choice and secondly an opioid. No respondents prescribed codeine compared to 80% at the mapping before the guidelines were designed. The guidelines were experienced as clear, safe and sufficient. The web-based information was used by most of the clinics to improve quality of care and provide facilitating tools for patients, relatives and caregivers.

    Conclusion: Swedish guidelines for tonsil surgery provide practical evidence-based pain treatment recommendations. To achieve a change, multi-professional education is necessary. This needs to be repeated for a wider spread.

    Future research should include evaluation through pain diaries and questionnaires to next-of-kin and children. There should be matching of data from the quality registers at each clinic, with pain variables such as unplanned health care contacts due to pain, number of days with analgesics, and return to normal diet

  • 15.
    Alm, Fredrik
    et al.
    Örebro University, School of Health Sciences. Department of Anaesthesia and Intensive Care.
    Lundeberg, Stefan
    Astrid Lindgrens barnsjukhus, Karolinska universitetssjukhus, Stockholm.
    Stalfors, Joacim
    Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Sheikh Khalifa Medical City, Ajman, United Arab Emirates.
    Nerfeldt, Pia
    Karolinska Universitetssjukhuset, Huddinge.
    Ericsson, Elisabeth
    Örebro University, School of Health Sciences.
    Improving pain management after pediatric tonsil surgery – an ongoing project2018Conference paper (Refereed)
    Abstract [en]

    The National Tonsil Surgery Register in Sweden collects perioperative data from health care professionals and patient reported outcome measures 30 days and 6 months after surgery. Since 2009, patient-reported outcome measures, include questions related to pain.

    Objective: To illustrate the process of improvements, efforts, and the use of a quality register in pain, and pain management after tonsil surgery in Sweden.

    Method: Quantitative and qualitative research.

    Results: Registry data indicated unrelieved postoperative pain with a high proportion of health care contacts. This resulted in the implementation of the Swedish National Guidelines (2013), and patient information published on the website www.tonsilloperation.se. The guidelines recommend multimodal pain treatment with paracetamol combined with COX-inhibitors, and if necessary, oral clonidine rather than opioids as rescue analgesics. A national survey (2015) showed that Swedish ENT-professionals’ opinions of, and the ENT-departments adherence to the guidelines were good. According to the national registry data (2017), the implementation has resulted in longer use of post-operative analgesic and fewer contacts with healthcare. Simultaneously, registry data showed that operating methods and techniques, age, and indication for surgery affect the pain outcome. Results from age-oriented pain diaries and qualitative interviews (2017-2018) capture the children’s and caregivers’ perspectives on pain, and pain treatment. Preliminary results show that type of pain treatment affects the quality of the postoperative care and recovery.

    Conclusion: Pain management after tonsil surgery has been, and still is, a challenge for ENT-professionals and constant improvements are necessary.

  • 16.
    Alm, Fredrik
    et al.
    Örebro University, School of Health Sciences.
    Stalfors, Joacim
    Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Sheikh Khalifa Medical City, Ajman, United Arab Emirates.
    Nerfeldt, Pia
    Karolinska University Hospital, Huddinge, Sweden.
    Ericsson, Elisabeth
    Örebro University, School of Health Sciences.
    Patient reported outcome of pain after tonsil surgery: An analysis of 32,225 children from the National Tonsil Surgery Register in Sweden 2009-20162017Conference paper (Refereed)
    Abstract [en]

    Tonsil surgery is common surgical procedure in children and cause significant pain under postoperative recovery. The objective of this register study was to explore factors affecting pain after pediatric tonsil surgery, using patient-reported outcomes from questionnaires in the National Tonsil Surgery Registry in Sweden, 30 days after surgery. A total of 32,225 tonsil surgeries on children (aged 1-18 years) during January 2009- November 2016 were included; 13,904 tonsillectomies with or without adenoidectomy (TE±A) and 18,321 tonsillotomies with or without adenoidectomy (TT±A). In surgery cases of indication obstruction, the TT±A stopped taking painkillers and returned to normal eating habits sooner, and had less contact with health care services due to pain, compared to TE±A. After TE±A, the indication infection group had more days on analgesics and more contacts with health care services due to pain, compared to the indication obstruction group. TE±A with cold-dissection technique resulted in fewer days on painkillers compared to warm-technique, and reduced the number of contacts with health care services due to pain. Older children were affected by more days of morbidity than the younger ones, but there was no gender difference after adjustment for age, dissection technique and hemostasis technique. Implementation of national guidelines for pain treatment (2013) and patient information on the website tonsilloperation.se seems to have increased the days on analgesics after surgery. Pain after tonsil surgery depends on the surgical procedure and technique, as well as factors such as the patient’s age and surgical indication. More studies including pain interventions are needed to improve the care of tonsillectomy patients.

  • 17.
    Alm, Fredrik
    et al.
    Örebro University, School of Health Sciences. Department of Anaesthesia and Intensive Care.
    Stalfors, Joacim
    Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden Sheikh Khalifa Medical City, Ajman, United Arab Emirates.
    Nerfeldt, Pia
    Karolinska Universitetssjukhuset, Huddinge.
    Ericsson, Elisabeth
    Örebro University, School of Health Sciences.
    Patient reported outcome of pain after tonsil surgery: An analysis of 32,225 children from the National Tonsil Surgery Register in Sweden 2009-20162017Conference paper (Refereed)
    Abstract [en]

    The objective of this register study was to explore factors affecting pain after pediatric tonsil surgery, using patient-reported outcomes from questionnaires in the National Tonsil Surgery Registry in Sweden, 30 days after surgery.

    Material and method: A total of 32,225 tonsil surgeries on children (aged 1-18 years) during 2009-2016 were included; 13,904 tonsillectomies with or without adenoidectomy (TE±A) and 18,321 tonsillotomies with or without adenoidectomy (TT±A). Pain was evaluated by using patient-reported outcomes from questionnaires in the National Tonsil Surgery Registry in Sweden, 30 days after surgery. Results: In surgery cases of indication obstruction, the TT±A stopped taking painkillers and returned to normal eating habits sooner, and had less contact with health care services due to pain, compared to TE±A. After TE±A, the indication infection group had more days on analgesics and more contacts with health care services due to pain, compared to the indication obstruction group. TE±A with cold-dissection technique resulted in fewer days on painkillers compared to warm-technique, and reduced the number of contacts with health care services due to pain. Older children were affected by more days of morbidity than the younger ones, but there was no gender difference after adjustment for age, dissection technique and hemostasis technique. Implementation of national guidelines for pain treatment (2013) and patient information on the website tonsilloperation.se seems to have increased the days on analgesics after surgery.

    Conclusion: Pain after tonsil surgery depends on the surgical procedure and technique, as well as factors such as the patient’s age and surgical indication.

  • 18.
    Alm, Fredrik
    et al.
    Örebro University, School of Health Sciences. Department of Anaesthesia and Intensive Care, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Stalfors, Joacim
    Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Sheikh Khalifa Medical City, Ajman, United Arab Emirates.
    Nerfeldt, Pia
    Department of Otorhinolaryngology, Karolinska University Hospital, Stockholm, Sweden; Division of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden.
    Ericsson, Elisabeth
    Örebro University, School of Health Sciences.
    Patient reported pain-related outcome measures after tonsil surgery: an analysis of 32,225 children from the National Tonsil Surgery Register in Sweden 2009–20162017In: European Archives of Oto-Rhino-Laryngology, ISSN 0937-4477, E-ISSN 1434-4726, Vol. 274, no 10, p. 3711-3722Article in journal (Refereed)
    Abstract [en]

    The objective of this study was to describe factors affecting pain after pediatric tonsil surgery, using patient reported pain-related outcome measures (pain-PROMs) from the National Tonsil Surgery Register in Sweden. In total, 32,225 tonsil surgeries on children (1 to\18 years) during 2009–2016 were included; 13,904 tonsillectomies with or without adenoidectomy (TE ± A), and 18,321 tonsillotomies with or without adenoidectomy (TT ± A). Adjustments were made for variables included in the register to compensate for contributable factors in the analysis. When compared to TE ± A for surgical indication obstruction, TT ± A resulted in lower pain-PROMs, shorter use of postoperative analgesics, earlier return to regular food intake, and lower risk for contact with health care services due to pain. Children who underwent TE ± A because of obstruction problems stopped taking painkillers and returned to normal eating habits sooner, compared to children who underwent TE ± A for infectious indications. In both indication groups, TE ± A performed with hot rather than cold technique (dissection and haemostasis) generally resulted in higher pain-PROMs. Older children reported more days on analgesics and a later return to regular food intake after TE ± A than younger ones. No clinically relevant difference between sexes was found. Between 2012 and 2016 (pre-and post-implementation of Swedish national guidelines for pain treatment), the mean duration of postoperative analgesic use had increased. In conclusion, TE ± A caused considerably higher ratings of pain-related outcome measures, compared to TT ± A. For TE ± A, cold surgical techniques (dissection and haemostasis) were superior to hot techniques in terms of pain-PROMs. Older children reported higher pain-PROMs after TE ± A than younger ones.

  • 19.
    Andersson, Elin
    et al.
    Department of Anaesthesiology and Intensive Care, Östergötlands Läns Landsting, Linköping, Sweden.
    Kroon, Anna
    Department of Anaesthesiology and Intensive Care, Östergötlands Läns Landsting, Linköping, Sweden.
    Ericsson, Elisabeth
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden; Department of Anaesthesiology and Intensive Care, Östergötlands Läns Landsting, Linköping, Sweden.
    Nationell kartläggning av farmakologiska rutiner och information i samband med tonsilloperation2013Conference paper (Other academic)
    Abstract [sv]

    Studien är en del i ett större nationellt projekt med syfte att kartlägga smärtbehandling vid tonsillkirurgi i samband med utformning av nationella farmakologiska riktlinjer. De vanligaste postoperativa komplikationerna vid tonsillkirurgi är postoperativt illamående och kräkningar (PONV), smärta, blödning och dehydrering. Tonsillkirurgin utförs idag antingen som dagkirurgiskt ingrepp eller som slutenvårdsingrepp med en vårdtid på ca ett dygn. Därmed sker den postoperativa vården i hemmet. Ett flertal studier har beskrivit patienternas upplevelse av höggradig smärta efter tonsillkirurgi. Obehandlad smärta leder till svårigheter att svälja och därmed otillräckligt dryckes- och matintag, vilket leder till dehydrering, ökad blödningsbenägenhet, sämre läkningsförmåga samt negativa  postoperativa beteendeförändringar hos barnet.

    Syftet var att i en nationell studie kartlägga farmakologiska rutiner och informationen i samband med tonsilloperation hos barn och ungdomar.

  • 20.
    Andersson, Elin
    et al.
    Anestesi- och Operationskliniken, Universitetssjukhuset, Linköping, Sverige.
    Kroon, Anna
    Anestesi- och Intensivvårdskliniken, Vrinnevisjukhuset, Norrköping, Sverige.
    Ericsson, Elisabeth
    Hälsouniversitet, Linköpings universitet, Linköping, Sverige; Anestesi- och Operationskliniken, Universitetssjukhuset, Linköping, Sverige.
    Nationell kartläggning av farmakologiska rutiner och information i samband med tonsilloperation2012In: Nationellt kvalitetsregister Öron-, Näs- och Halssjukvård: Årsrapport 2012, Hisings Kärra: Nationellt kvalitetsregister för Öron-, Näs- och Halssjukvård. , 2012, p. 77-81Chapter in book (Other academic)
    Abstract [sv]

    Studien är en del i ett större nationellt projekt med syfte att kartlägga smärtbehandling vid tonsillkirurgi i samband med utformning av nationella farmakologiska riktlinjer. De vanligaste postoperativa komplikationerna vid tonsillkirurgi är postoperativt illamående och kräkningar (PONV), smärta, blödning och dehydrering. Tonsillkirurgin utförs idag antingen som dagkirurgiskt ingrepp eller som slutenvårdsingrepp med en vårdtid på ca ett dygn. Därmed sker den postoperativa vården i hemmet. Ett flertal studier har beskrivit patienternas upplevelse av höggradig smärta efter tonsillkirurgi. Obehandlad smärta leder till svårigheter att svälja och därmed otillräckligt dryckes- och matintag, vilket leder till dehydrering, ökad blödningsbenägenhet, sämre läkningsförmåga samt negativa  postoperativa beteendeförändringar hos barnet.

    Syftet var att i en nationell studie kartlägga farmakologiska rutiner och informationen i samband med tonsilloperation hos barn och ungdomar.

  • 21.
    Andersson, Elin
    et al.
    Anestesi- och intensivvårdskliniken, Universitetsjukhuset, Östergötlands Läns Landsting, Linköping, Sverige.
    Kroon, Anna
    Anestesi- och intensivvårdskliniken VIN, Östergötlands Läns Landsting, Norrköping, Sverige.
    Ericsson, Elisabeth
    Department of Health and Medical care, Linköping University, Linköping, Sverige.
    Nationell kartläggning av farmakologiska rutiner och information i samband med tonsilloperation2013In: Ventilen, ISSN 0348-6257, Vol. 4, no 48, p. 16-17Article in journal (Other academic)
    Abstract [sv]

    Studien är en del i ett större nationellt projekt med syfte att kartlägga smärtbehandling vid tonsillkirurgi i samband med utformning av nationella farmakologiska riktlinjer. De vanligaste postoperativa komplikationerna vid tonsillkirurgi är postoperativt illamående och kräkningar (PONV), smärta, blödning och dehydrering. Tonsillkirurgin utförs idag antingen som dagkirurgiskt ingrepp eller som slutenvårdsingrepp med en vårdtid på ca ett dygn. Därmed sker den postoperativa vården i hemmet. Ett flertal studier har beskrivit patienternas upplevelse av höggradig smärta efter tonsillkirurgi. Obehandlad smärta leder till svårigheter att svälja och därmed otillräckligt dryckes- och matintag, vilket leder till dehydrering, ökad blödningsbenägenhet, sämre läkningsförmåga samt negativa  postoperativa beteendeförändringar hos barnet.

    Syftet var att i en nationell studie kartlägga farmakologiska rutiner och informationen i samband med tonsilloperation hos barn och ungdomar.

  • 22.
    Bramhagen, Ann-Cathrine
    et al.
    Faculty of Health and Society, Department of Care Science, Malmö University, Malmö, Sweden.
    Eriksson, Mats
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Ericsson, Elisabeth
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Nilsson, Ulrica
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Harden, Sue
    CSN, e-Learning/Content Developer, Skåne University Hospital, Malmö, Sweden.
    Idvall, Ewa
    Faculty of Health and Society, Department of Care Science, Malmö University, Malmö, Sweden.
    Self-reported post-operative recovery in children: development of an instrument2016In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 22, no 2, p. 180-188Article in journal (Refereed)
    Abstract [en]

    Rationale, aims and objectives: According to the United Nations (1989) , hildren have the right to be heard and to have their opinions respected. Since post-operative recovery is an individual and subjective experience and patient-reported outcome measures are considered important, our aim was to develop and test an instrument to measure self-reported quality of recovery in children after surgical procedures.

    Methods: Development of the instrument Postoperative Recovery in Children (PRiC) was influenced by the Quality of Recovery-24, for use in adults. Eighteen children and nine professionals validated the items with respect to content and language. A photo question- naire was developed to determine whether the children’s participation would increase compared with the text questionnaire. The final instrument was distributed consecutively to 390 children, ages 4–12 years, who underwent tonsil surgery at four hospitals in Sweden.

    Results: A total o f238 children with a mean age of 6.5 years participated. According to the parents, 23% circled the answers themselves and 59% participated to a significant degree. However, there was no significant difference in participation between those who received a photo versus a text questionnaire. Psychometric tests of the instrument showed that Cronbach’s alpha for the total instrument was 0.83 and the item-total correlations for 22 of the items were ≥0.20.

    Conclusion: Our results support use of the PRiC instrument to assess and follow-up on children’s self-reported post-operative recovery after tonsil operation, both in clinical praxis as well in research. 

  • 23.
    Brattwall, Metha
    et al.
    Sahlgrenska Universitetssjukhuset, Göteborg, Sweden.
    Lundeberg, Stefan
    Astrid Lindgrens barnsjukhus, Karolinska universitetssjukhuset, Stockholm, Sweden.
    Ericsson, Elisabeth
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Behandling av smärta och illamående i samband med tonsilloperation: Nya riktlinjer för farmakologiskbehandling till barn och ungdomar2014In: Läkartidningen, ISSN 0023-7205, Vol. 41, p. 1775-1777Article in journal (Refereed)
  • 24.
    Ericsson, Elisabeth
    Örebro University, School of Health Sciences.
    Anestesiologisk omvårdnad i samband tonsillkirurgi: att vara steget före2016Conference paper (Other academic)
    Abstract [sv]

    Vid en av de mest vanligaste kirurgin på barn är målet att minimera eller eliminera obehag, underlätta återhämtning och undvika komplikationer. I Sverige utförs ca 12000 tonsilloperationer varje år varav ca 10000 på barn och unga vuxna och oftast i dagkirurgi. Det innebär att större delen av den postoperativa återhämtningen sker i hemmet. Data från svenska kvalitetsregistret tonsilloperation visar att var fjärde patient kontaktar vården på grund av otillräcklig smärtlindring. Processen med att minimera obehag i samband med operation startar redan i samband med planeringen av kirurgin. Hög preoperativ oro är i sin tur associerat ökad grad av postoperativ smärta. Tonsilloperation kan medföra svår och långvarig smärta samt hög frekvens av illamående. Otillräcklig smärtbehandling i samband med tonsillkirurgi leder till svårigheter att svälja dryck och mat kan leda till dehydrering vilket i sin tur leder till risker i den farmakologiska smärtbehandlingen och ökade risker vid postoperativa blödningar Återhämtning påverkas starkt av fysiska symtom, känslomässiga reaktioner under dygnets alla timmar efter tonsilloperation. Tidigare kartläggning i Sverige har visat bristande konsensus i omhändertagandet av barn som genomgår tonsillkirurgi, vilket föranlett utvecklingen och implementeringen av nationella riktlinjer för behandling av smärt- och illamående samt utveckling av websaiten tonsilloperation.se till närstående och barn/ungdomar. Multidisciplinär utvärdering visar att läkare och sjuksköterskor inom ÖNH och Anestesi inte har samma utgångspunkt inom den farmakologiska och icke farmakologiska omhändertagandet vilket riskerar att närstående och barn får mixad budskap i samband med tonsillkirurgi. Presentation behandlar dessa aspekter utifrån aktuell forskning och hur vi kan ligga steget före samt vikten av teamarbete inom den pre och postoperativa omhändertagandet för att ge god och säker vård. Målgruppen är inom tonsillkirurgi, men går lätt att placera i samband med annan kirurgi på friska barn och ungdomar.

  • 25.
    Ericsson, Elisabeth
    School of Health Science, Jönköping University, Jönköping, Sweden.
    Bemötande av barn inför anestesi2010Conference paper (Other (popular science, discussion, etc.))
    Abstract [sv]

    Barn upplever anestesiinduktionen som mycket ångestfylld och stressad situation. Stark preoperativ oro visar sig hos 50-60% av de barn som skall genomgå anestesi och operation. Oro hos barn före och i samband med anestesiinduktionen kan resultera i, sämre medverkan vid anestesiinduktionen, ett agiterat uppvaknade, ökad postoperativ smärta/ analgetikabehov samt negativa beteendeförändringar i det postoperativa skedet. Presentationen kommer att belysa resultat från egna och andras forskning angående beteende, kommunikation, information/förberedelser, skattning av barns oro, föräldramedverkan och premedicinering.

  • 26.
    Ericsson, Elisabeth
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Farmakologisk smärtbehandling (& illamående) i samband med tonsilloperation2012Conference paper (Refereed)
  • 27.
    Ericsson, Elisabeth
    Linköping University, Linköping, Sweden.
    Health and well-being of children and young adults in relation to surgery of the tonsils2007Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    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.

    List of papers
    1. Pediatric Tonsillotomy with Radiofrequency Technique: Less Morbidity and Pain
    Open this publication in new window or tab >>Pediatric Tonsillotomy with Radiofrequency Technique: Less Morbidity and Pain
    2004 (English)In: The Laryngoscope, ISSN 0023-852X, E-ISSN 1531-4995, Vol. 114, no 5, p. 871-877Article in journal (Refereed) Published
    Abstract [en]

    OBJECTIVE: To compare two techniques for pediatric tonsil surgery with respect to pain and postoperative morbidity. The two methods were the partial tonsil resection using radiofrequency (RF) technique (tonsillotomy [TT]) versus traditional tonsillectomy (TE).

    STUDY DESIGN: Prospective clinical randomized study in one tertiary care ENT clinic and two secondary care clinics.

    METHOD: One hundred fifty children, between 5 and 15 years of age, were randomized to either TT with RF using the Surgitron Ellman, 1.7 MHz, or regular TE. Randomization was performed from the waiting list, including children with both a history of obstructive problems and recurrent tonsillitis. The TT was performed with a specially made sling electrode using a cut/coagulation mode.

    RESULTS: Forty-nine children were operated on with TT and 43 with TE. There was significantly less bleeding in the TT group, although two cases of primary postoperative bleeding occurred among the TT children and one in the TE group. The pain recordings showed significantly less pain for the TT children from the second hour postoperatively onward, and the TT children were pain free and in school 3 days earlier than the TE group. The TT group had less need of the prescribed drugs (diclofenac and paracetamol). After 9 days, 73% of the TT children were completely healed, but only 31% of the TE children. By that time, the TE children had lost a mean of 660 g, and the TT children had gained 127 g. The effect on snoring was the same for both groups.

    CONCLUSION: RF appears to be a safe and reliable method for tonsil surgery with much less postoperative morbidity than regular TE.

    Keywords
    Tonsils, tonsil surgery, RF surgery, snoring, sleep apnea
    National Category
    Otorhinolaryngology
    Identifiers
    urn:nbn:se:oru:diva-40826 (URN)10.1097/00005537-200405000-00016 (DOI)000221537900016 ()15126747 (PubMedID)2-s2.0-2442423346 (Scopus ID)
    Available from: 2007-05-21 Created: 2015-01-11 Last updated: 2017-12-05Bibliographically approved
    2. Pre-surgical Child Behavior Ratings and Pain Management after Two Different Techniques of Tonsil Surgery
    Open this publication in new window or tab >>Pre-surgical Child Behavior Ratings and Pain Management after Two Different Techniques of Tonsil Surgery
    2006 (English)In: International Journal of Pediatric Otorhinolaryngology, ISSN 0165-5876, E-ISSN 1872-8464, Vol. 70, no 10, p. 1749-1758Article in journal (Refereed) Published
    Abstract [en]

    Objective

    The purpose of this investigation was to compare child behavior before surgery with experience of pain and anxiety in relation to two techniques of tonsil surgery, to relate previous experiences of surgery/tonsillitis with anxiety and pain, and to compare the children's, parent's and nurse's rating of pain.

    Method

    Ninety-two children (5–15 years) with sleep-disordered breathing (SDB) and with or without recurrent tonsillitis were randomized to partial tonsil resection/tonsillotomy (TT) or full tonsillectomy (TE). Measures: Parents: Child Behavior Checklist (CBCL). Children: State-Trait-Anxiety Inventory for Children (STAIC) and seven-point Faces Pain Scale (FPS). Parents/staff: seven-point Verbal Pain Rating Scale (VPRS). Pain relievers were opoids, paracetamol and diclophenac.

    Results

    These children with SDB scored significantly higher on CBCL than did normative groups, but no connection was observed between CBCL rating and experience of pain. There was no relation between pre-operative anxiety and pain. The post-operative anxiety level (STAIC) correlated with pain. The TE-group scored higher on STAIC after surgery. Previous experience of surgery or tonsillitis did not influence post-operative pain. The TE-group rated higher experience of pain despite more medication. The nurses scored pain lower than the parents/children and under-medicated.

    Conclusion

    SDB may influence children's behavior, but with no relation to post-operative pain. The surgical method predicts pain better than does the child's behavior rating. The nurses underestimated the pain experienced by the child.

    Keywords
    Children; Post-operative pain; Anxiety; Behavior; Tonsil surgery; Anesthesia
    National Category
    Otorhinolaryngology
    Identifiers
    urn:nbn:se:oru:diva-40832 (URN)10.1016/j.ijporl.2006.05.017 (DOI)000240782400010 ()16814402 (PubMedID)2-s2.0-33747891695 (Scopus ID)
    Available from: 2007-05-21 Created: 2015-01-11 Last updated: 2017-12-05Bibliographically approved
    3. Pediatric Tonsillotomy with the Radiofrequency Technique: Long-term Follow-up
    Open this publication in new window or tab >>Pediatric Tonsillotomy with the Radiofrequency Technique: Long-term Follow-up
    2006 (English)In: The Laryngoscope, ISSN 0023-852X, E-ISSN 1531-4995, Vol. 116, no 10, p. 1851-1857Article in journal (Refereed) Published
    Abstract [en]

    Objectives: Compare the effects of partial tonsil resection using a radiofrequency technique, tonsillotomy (TT), with total tonsillectomy (TE, blunt dissection) after 1 and 3 years. Compare frequency of relapse in snoring or infections and possible long-term changes in behavior among TT children with those in TE children.

    Method: Ninety-two children (5-15 yr) randomized to TT (n = 49) or TE (n = 43) groups because of obstructive problems with or without recurrent tonsillitis. One year after surgery, general health, degree of obstruction, history of infections, and behavior were investigated using two questionnaires, the Qu1 and Child Behavior Checklist, as well as an ENT visit. After 3 years, two questionnaires, Qu2 and the Glasgow Children's Benefit Inventory, were answered by mail.

    Results: After 1 year, both groups were in good health. The effect on snoring and total behavior was the same for both groups, and the rate of recurrence of infections was not higher in the TT group. After 3 years, two children in the TT group were tonsillectomized (4%, 2/49), one because of peritonsillitis and another because of increased snoring. Otherwise, no differences existed between the groups in general health, snoring, or number of infections.

    Conclusion: Removing only the protruding parts of the tonsils has the same beneficial long-term effect on obstructive symptoms and recurrent throat infections as complete TE in the majority of cases. The need for re-operation is low; therefore, it appears inadvisable to follow the current common practice of routinely removing the whole tonsil given its higher morbidity and risk for serious complications.

    Keywords
    Tonsil surgery, tonsillotomy, snoring, behavior, reduced morbidity, immunology, long-term follow-up
    National Category
    Otorhinolaryngology
    Identifiers
    urn:nbn:se:oru:diva-40827 (URN)10.1097/01.mlg.0000234941.95636.e6 (DOI)000240933900026 ()17003713 (PubMedID)2-s2.0-33749437091 (Scopus ID)
    Available from: 2007-05-21 Created: 2015-01-11 Last updated: 2019-08-29Bibliographically approved
    4. Tonsil Surgery in Youths – Good Results with Less Invasive Method
    Open this publication in new window or tab >>Tonsil Surgery in Youths – Good Results with Less Invasive Method
    2007 (English)In: The Laryngoscope, ISSN 0023-852X, E-ISSN 1531-4995, Vol. 117, no 4, p. 654-661Article in journal (Refereed) Published
    Abstract [en]

    Objective: Comparison of two types of tonsil surgery for 16- to 25-year-old patients, with respect to primary morbidity, snoring, and recurrent infections after 1 year. Teenagers and young adults are a significant proportion (26%) of the population that receive tonsil surgery each year and appear to suffer more pain than younger children. Recurrent tonsillitis, in combination with obstructive problems, is the main indication for surgery.

    Method: One hundred fourteen patients 16 to 25 years of age were randomized to tonsillotomy (TT) with radiosurgery (RF) (Ellman International) or to cold tonsillectomy (TE). Pain and analgesics were logged until patients were pain free.

    Results: Thirty-two patients were operated on with TT and 44 with TE. The TT group had less blood loss during surgery and no postoperative bleedings, compared with the TE group (2 primary and 4 late hemorrhages). The TT group recorded significantly less pain from the first day, had less need of analgesics (diclofenac and paracetamol), and were pain free and in school/at work 4 days earlier than the TE group. After 7 days, the TE patients had lost a mean of 1.8 kg compared with TT, with no significant weight loss. After 1 year, both groups were satisfied. The positive effect on snoring was the same for both groups. There were few throat infections in both groups.

    Conclusion: TT with RF is an effective method for tonsil surgery for many teenagers and young adults, with much less postoperative morbidity than regular TE. Long-term follow-up is necessary.

    Keywords
    Tonsillotomy, tonsillectomy, radiofrequency surgery, postoperative pain, snoring, recurrent tonsillitis
    National Category
    Otorhinolaryngology
    Identifiers
    urn:nbn:se:oru:diva-40838 (URN)10.1097/mlg.0b013e318030ca69 (DOI)000245377400018 ()17415136 (PubMedID)2-s2.0-34147128609 (Scopus ID)
    Available from: 2007-05-21 Created: 2015-01-11 Last updated: 2017-12-05Bibliographically approved
    5. Long-Term Improvement of Quality of Life as a Result of Tonsillotomy (With Radiofrequency Technique) and Tonsillectomy in Youths
    Open this publication in new window or tab >>Long-Term Improvement of Quality of Life as a Result of Tonsillotomy (With Radiofrequency Technique) and Tonsillectomy in Youths
    2007 (English)In: The Laryngoscope, ISSN 0023-852X, E-ISSN 1531-4995, Vol. 117, no 7, p. 1272-1279Article in journal (Refereed) Published
    Abstract [en]

    Objective: This is a 1 year follow-up to compare the effects of partial tonsil resection using the radiofrequency technique (RF) tonsillotomy (TT) with total tonsillectomy (TE) (blunt dissection). Obstructive symptoms, tendency for infections, and health-related quality of life (HRQL) were studied and compared with the HRQL data from a normal population.

    Method: The study group consisted of 74 patients (16-25 yr old) randomized to TT (n = 31) or TE (n = 43) with obstructive throat problems with or without recurrent tonsillitis. The Short Form 36 (SF-36) and EuroQul Visual Analogue Scale were used to evaluate HRQL. A questionnaire investigated the degree of obstruction and history of infections.

    Results: Preoperatively, both groups reported significantly lower HRQL in all dimensions of the SF-36 compared with the normal population (P < .05-P < .001). After 1 year, a large improvement (P < .01-P < .001) in both groups in HRQL was found. No differences were found when these groups were compared with the normal population or between the study groups. The effect on snoring was the same for both groups, and the rate of recurrence of infections was low and not any higher in the TT group.

    Conclusion: Preoperative obstructive problems in combination with recurrent tonsillitis have a negative impact on HRQL. Both the TT and TE groups demonstrated large improvements on HRQL, infections, and obstructive problems 1 year after surgery, indicating that the surgical methods are equally effective. With its reduced postoperative complications, less pain, shorter recovery time, and cost reduction, TT with RF should be considered the method of choice.

    Keywords
    tonsillotomy, tonsillectomy, health-related quality of life, Short Form 36, snoring, recurrent tonsillitis
    National Category
    Otorhinolaryngology
    Identifiers
    urn:nbn:se:oru:diva-40810 (URN)10.1097/MLG.0b013e31805559e1 (DOI)000247763700027 ()17603326 (PubMedID)2-s2.0-34347347298 (Scopus ID)
    Available from: 2007-05-21 Created: 2015-01-11 Last updated: 2017-12-05Bibliographically approved
  • 28.
    Ericsson, Elisabeth
    Hälsouniversitetet, Linköpings universitet, Linköping.
    Health and well-being of children and young adults in relation to surgery of the tonsils2007In: Svensk ÖNH-tidskrift, ISSN 1400-0121, Vol. 2, p. 42-45Article in journal (Other (popular science, discussion, etc.))
    Abstract [en]

        

  • 29.
    Ericsson, Elisabeth
    School of Health Science, Jönköping University, Jönköping, Sweden.
    Improvement of Quality of Life by Tonsillotomy & Tonsillectomy in Children and Youths2009In: 1st Meeting of the European Academy of ORL - HNS, Mannheim, Tyskland  27-30 juni, 2009, 2009Conference paper (Refereed)
    Abstract [en]

    Background: There has been increasing evidence over the last few years that paediatric sleep-disordered breathing is associated with behavioural and neurocognitive problems as well as with poor school performance, failure to thrive and poor health related quality of life (HRQL). Several studies indicate that both behaviour and quality of life improve after tonsillectomy (TE) in children with sleep-disordered breathing (SDB). However, TE causes considerable pain and morbidity which often lasts more than seven days. Postoperative pain is poorly managed and under-treatment of pain leads to increased morbidity and postoperative behavioural changes. Tonsillotomy (TT) for obstructive symptoms has re-appeared with focus on reduction of postoperative morbidity. Removing only the protruding parts of the tonsils seems to have the same beneficial long-term effect on obstructive symptoms due to hypertrophic tonsils.

    Material and Method: Children and youths have been studied in relation to tonsil surgery with the goal of improving care and comparisons have been made between TT and TE.

    The first part of this presentation will cover three randomized trials of children and youth  4 to 25 years old with respect to pain and morbidity and with six months to three years follow-up including assessment of HRQL.

    The second part presents preliminary results from a Swedish national study of a sample of 550 children (4-15 yrs) to determine the impact on HRQL before and six months after TT or TE.

    In the studies, the impact on HRQL was evaluated in the younger age group using the Obstructive Sleep Apnea-18 (OSA-18), Glasgow Children´s Benefit Inventory (GCBI); their behavioural and emotional problems were assessed using the Child Behaviour Checklist (CBCL). In the age group 16-25 yrs, the HRQL was measured using the SF-36.

    Results: In the TT groups, the children recorded less pain from the first day after surgery onwards, used fewer doses of painkillers, and were pain-free 3 days (5-15yrs)/4 days (16-25 yrs) earlier than the children/youths in the TE group. For most TT patients, the combination of Paracetamol and Diclophenac was sufficient for analgesia. However, most of the TE patients with that medication had considerable pain and 50% still experienced substantial pain after one week. Before surgery, HRQL was registered as much lower among patients with obstruction problems when compared to the reference sample. Surgery with either tonsillotomy or tonsillectomy was associated with a marked improvement of the quality of life both for children with severe obstructive sleep related distress or with milder sleep disordered breathing.

     

    Conclusion: TT is a safe method, which causes less pain and postoperative morbidity than regular TE. Children and young adults with tonsillar hypertrophy and different degrees of obstructive sleep related distress all show a negative impact on HRQL and behaviour. All improve dramatically after a tonsillar operation—equally after TT as compared to TE.

  • 30.
    Ericsson, Elisabeth
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Nationella riktlinjer för farmakologisk behandling av smärta och illamående i samband med tonsillotomi och tonsillektomi på barn och ungdomar (<18 år)2013Conference paper (Other academic)
    Abstract [sv]

    Premedicinering kan göras enligt sjukhusets vanliga rutiner. En möjlig kombination som oral premedicinering (= start av multimodal smärtbehandling) är paracetamol (40 mg/kg), klonidin (2–3 mikrog/kg) och betametason (0,2 mg/kg, max 8 mg) enligt kroppsvikt eller 4 mg vid vikt under 50 kg, 8 mg vid vikt över 50 kg som ges cirka 90 minuter innan anestesistart.

    Alternativt ges ovanstående läkemedel i samband med inledningen av anestesin men med doseringsförslag som anges under smärtbehandling per operativt nedan.

    Smärtbehandling peroperativt

    Paracetamol bör ges intravenöst (20 mg/kg) och intravenöst betametason (0,2 mg(kg) om inte det ingått i premedicineringen. Vid slutet av operationen ges en dos av COX hämmare (diklofenak 1 mg/kg rektalt eller intravenöst, alternativt ibuprofen 5–7 mg/kg rektalt). Om klonidin inte givits som premedicinering kan en intravenös dos ges vid inledningen av anestesin, 1 mikrog/kg intravenöst. Med klonidin kan övriga underhållsanestetika ofta reduceras med cirka 25%. För att minska den tidiga smärtan kan också kompresser indränkta med bupivacain 5 mg/ml läggas på sårområdet i cirka 5 minuter.

    Initial postoperativ smärta behandlas med intravenösa opioider, paracetamol och klonidin titrerat till för individen acceptabel smärtnivå. Smärtskattning ska göras med ålderadekvat instrument.

    Illamående, profylax och behandling

    I samband med anestesiinledningen ges betametason samt vid indikation ondansetron 0,1 mg/kg för att förbygga postoperativt illamående. Behandling kan ske med ondansetron 0,1 mg/kg, prometazin 0,1 mg/kg (licenspreparat) eller droperidol 30 mikrog/kg. En kombination av antiemetika ger bättre effekt. En fördel är att inducera anestesin med propofol om intravenös infart finns.

    Smärtbehandling i hemmet

    Paracetamol 24 mg/kg x 4 i tre dygn och därefter minska till 18 mg/kg x 4 (paracetamolmixturen är 24 mg/ml vilket innebär att den initiala behandlingen blir 1 ml/kg x 4 om mixturen används). Kombinera paracetamol med COXhämmare ibuprofen 5–7mg/kg x 4 eller diklofenak 1–1,5 mg/kg x 3. Vid blödningsrisk kan selektiv COX-2 hämmare användas, celecoxib 2 mg/kg x 2, som alternativ till ibuprofen och diklofenak. COX hämmare och paracetamol utgör basen i analgetikabehandlingen och ska ges regelbundet.

    För ytterligare smärtbehandling kan t. ex klonidin ges i dosen 1–2 mikrog/kg x 3 per os. Opioider kan behövas i vissa fall men insättning bör göras efter kontakt med ÖNH kliniken. Ur praktisk synvinkel rekommenderas att doser av klonidin- eller opioidmixtur (oxikodon eller morfin) dras upp i sprutor med engångsdoser när analgetika skickas med vid utskrivningen. Antalet doser som skickas hem med patienten bestäms av behovet och lokala rutiner. När smärtan avklingar kan man börja sätta ut analgetika: först opioider, därefter klonidin, paracetamol och sist COX hämmare. (Enstaka doser av COX hämmare ger en bättre analgetisk effekt än enstaka doser av paracetamol).

    Smärtbehandling kan behövas upp till 2–3 veckor efter tonsillektomi, och drygt en vecka efter tonsillotomi. Vid tonsillotomi räcker det oftast med paracetamol kombinerat med COX-hämmare. Som förslag i nationella riktlinjer föreslås en behandlingslängd med COX-hämmare i kombination med paracetamol i 3–5 dygn vid tonsillotomi och 5–8 dygn vid tonsillektomi.

  • 31.
    Ericsson, Elisabeth
    School of Health Science, Jönköping University, Jönköping, Sweden.
    Nationella riktlinjer och kvalitetsregister inom tonsillkirurgi2009Conference paper (Other academic)
    Abstract [sv]

    Elisabeth Ericsson presenterar sin nuvarande forskning som berör barn och ungdomar i samband med anestesi och operation, med avsikt att komma fram till optimala förhållanden när det gäller att minimiera oro och förbättra smärtbehandling. Presentation av arbetet med nationella riktlinjer och kvalitetsregistret inom tonsillkirurgi; operationsindikationer, information och smärtbehandling. Resultat presenteras om validering av OSA-18 hälsorelaterat livskvalitetsinstrument för barn med obstruktionsbesvär

  • 32.
    Ericsson, Elisabeth
    Department of Health and Medical care, Linköping University, Linköping, Sweden.
    Processen med utformning av nationella farmakologiska riktlinjer i samband med tonsilloperation2013In: Ventilen, ISSN 0348-6257, Vol. 4, no 48, p. 17-Article in journal (Other academic)
  • 33.
    Ericsson, Elisabeth
    HHJ. CHILD, Högskolan i Jönköping, Jönköping.
    Validering av OSA-18 på en svensk barnpopulation2009In: Svensk ÖNH-tidskrift, ISSN 1400-0121, Vol. 16, no 4, p. 16-19Article in journal (Other academic)
  • 34.
    Ericsson, Elisabeth
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Vägen till webbaserad information vid tonsilloperation2012Conference paper (Refereed)
  • 35.
    Ericsson, Elisabeth
    et al.
    Avd. f omvårdnad, Institutionen för medicin och hälsa, Linköpings universitet, Linköping, Sverige.
    Brattwall, Metha
    Anestesi och intensivvårdskliniken, Sahlgrenska Universitetssjukhuset, Mölndal, Sverige.
    Lundeberg, Stefan
    Smärtbehandlingsenheten, Astrid Lindgrens Barnsjukhus, Stockholm, Sverige.
    Farmakologisk behandling av smärta och illamående i samband med tonsillotomi och tonsillektomi på barn och ungdomar2013In: Nationellt kvalitetsregister Öron-, Näs- och Halssjukvård: Årsrapport 2012, Hisings Backa: Nationellt kvalitetsregister för öron-, näs- och halssjukvård , 2013, p. 64-71Chapter in book (Other academic)
    Abstract [sv]

    Premedicinering kan göras enligt sjukhusets vanliga rutiner. En möjlig kombination som oral premedicinering (= start av multimodal smärtbehandling) är paracetamol (40 mg/kg), klonidin (2–3 mikrog/kg) och betametason (0,2 mg/kg, max 8 mg) enligt kroppsvikt eller 4 mg vid vikt under 50 kg, 8 mg vid vikt över 50 kg som ges cirka 90 minuter innan anestesistart.

    Alternativt ges ovanstående läkemedel i samband med inledningen av anestesin men med doseringsförslag som anges under smärtbehandling per operativt nedan.

    Smärtbehandling peroperativt

    Paracetamol bör ges intravenöst (20 mg/kg) och intravenöst betametason (0,2 mg(kg) om inte det ingått i premedicineringen. Vid slutet av operationen ges en dos av COX hämmare (diklofenak 1 mg/kg rektalt eller intravenöst, alternativt ibuprofen 5–7 mg/kg rektalt). Om klonidin inte givits som premedicinering kan en intravenös dos ges vid inledningen av anestesin, 1 mikrog/kg intravenöst. Med klonidin kan övriga underhållsanestetika ofta reduceras med cirka 25%. För att minska den tidiga smärtan kan också kompresser indränkta med bupivacain 5 mg/ml läggas på sårområdet i cirka 5 minuter.

    Initial postoperativ smärta behandlas med intravenösa opioider, paracetamol och klonidin titrerat till för individen acceptabel smärtnivå. Smärtskattning ska göras med ålderadekvat instrument.

    Illamående, profylax och behandling

    I samband med anestesiinledningen ges betametason samt vid indikation ondansetron 0,1 mg/kg för att förbygga postoperativt illamående. Behandling kan ske med ondansetron 0,1 mg/kg, prometazin 0,1 mg/kg (licenspreparat) eller droperidol 30 mikrog/kg. En kombination av antiemetika ger bättre effekt. En fördel är att inducera anestesin med propofol om intravenös infart finns.

    Smärtbehandling i hemmet

    Paracetamol 24 mg/kg x 4 i tre dygn och därefter minska till 18 mg/kg x 4 (paracetamolmixturen är 24 mg/ml vilket innebär att den initiala behandlingen blir 1 ml/kg x 4 om mixturen används). Kombinera paracetamol med COXhämmare ibuprofen 5–7mg/kg x 4 eller diklofenak 1–1,5 mg/kg x 3. Vid blödningsrisk kan selektiv COX-2 hämmare användas, celecoxib 2 mg/kg x 2, som alternativ till ibuprofen och diklofenak. COX hämmare och paracetamol utgör basen i analgetikabehandlingen och ska ges regelbundet.

    För ytterligare smärtbehandling kan t. ex klonidin ges i dosen 1–2 mikrog/kg x 3 per os. Opioider kan behövas i vissa fall men insättning bör göras efter kontakt med ÖNH kliniken. Ur praktisk synvinkel rekommenderas att doser av klonidin- eller opioidmixtur (oxikodon eller morfin) dras upp i sprutor med engångsdoser när analgetika skickas med vid utskrivningen. Antalet doser som skickas hem med patienten bestäms av behovet och lokala rutiner. När smärtan avklingar kan man börja sätta ut analgetika: först opioider, därefter klonidin, paracetamol och sist COX hämmare. (Enstaka doser av COX hämmare ger en bättre analgetisk effekt än enstaka doser av paracetamol).

    Smärtbehandling kan behövas upp till 2–3 veckor efter tonsillektomi, och drygt en vecka efter tonsillotomi. Vid tonsillotomi räcker det oftast med paracetamol kombinerat med COX-hämmare. Som förslag i nationella riktlinjer föreslås en behandlingslängd med COX-hämmare i kombination med paracetamol i 3–5 dygn vid tonsillotomi och 5–8 dygn vid tonsillektomi.

  • 36.
    Ericsson, Elisabeth
    et al.
    Department of Medical and Health Sciences, Linköping University, Linköping, Sverige.
    Brattwall, Metha
    Västra Götalandsregionen, Göteborg, Sverige.
    Lundeberg, Stefan
    Karolinska Institutet, Stockholm, Sverige.
    Grunddokument till nationella riktlinjer för farmakologisk behandling av smärta och illamående i samband med tonsillotomi och tonsillektomi på barn och ungdomar (<18 år)2013In: Svensk ÖNH-tidskrift, ISSN 1400-0121, Vol. 20, no 3, p. 18-26Article in journal (Other academic)
    Abstract [sv]

    I Sverige utförs 13000 tonsilloperationer varje år, över 50 % utförs på barn under 15 år. Tonsilloperation medför svår och långvarig smärta samt hög frekvens av illamående. Smärtan är ofta värst dag 3 till 5 efter tonsillektomi. Tonsillotomi ger generellt upphov till mindre smärta än tonsillektomi. Dehydrering och sämre näringsintag kan vara en orsak till större smärtproblematik vid tonsillektomier. Äldre barn som genomfört tonsilloperation skattar högre postoperativ smärta vilket kräver ökat behov av analgetika. Olika interventioner inklusive farmakologiska används för att behandla och förebygga smärta och illamående. De vanligaste systemiska analgetika som används är paracetamol, COX-hämmare samt opioider. Användande av opioider vid tonsillektomi på barn med och obstruktiv sömnapné kan ge upphov till allvarliga komplikationer 4. Alfa-2 adrenerga agonister som klonidin har en analgetisk effekt utan påverkan på andningsdriven. Klonidin kan vara ett bra komplement då paracetamol i kombination med COX-hämmare inte har tillräcklig analgetisk effekt. Olika regionala metoder med bl.a. lokalbedövningsmedel används också med viss effekt.

  • 37.
    Ericsson, Elisabeth
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Brattwall, Metha
    Anesthesia and Intensive Care, Sahlgrenska University Hospital, Mölndal, Sweden.
    Lundeberg, Stefan
    Pain treatment service, Astrid Lindgren Children's Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden .
    Swedish guidelines for the treatment of pain in tonsil surgery in pediatric patients up to 18 years2015In: International Journal of Pediatric Otorhinolaryngology, ISSN 0165-5876, E-ISSN 1872-8464, Vol. 79, no 4, p. 443-450Article in journal (Refereed)
    Abstract [en]

    Background: Surgery of the tonsils often causes severe pain lasting for many days as been shown by data from the National Tonsil Surgery Register in Sweden. Tonsillotomy is associated with fewer readmissions due to bleeding, number of days requiring analgesics and health care contacts due to pain compared to tonsillectomy. The register data demonstrate the necessity of better-evidenced based pain treatment guidelines for tonsil-surgery.

    Objectives: To develop evidenced based pain treatment guidelines for tonsil-surgery in Sweden.

    Methods: The evidence based guidelines were designed by an updated literature review and from the clinical expertise in the pediatric pain field, which thereafter were reviewed by ENT-doctors and anesthetists from each ENT-clinic in Sweden.

    Results: A multimodal pain treatment approach is advocated, including premedication and administration during anesthesia, with paracetamol (acetaminophen), clonidine and betamethasone. If not given as a premedication the combination can be administered intravenously in the initial phase of anesthesia. At the end of surgery, if no bleeding problems, cox-inhibitors can be given.After discharge from hospital, the recommendations for pain relief are paracetamol combined with cox-inhibitors (ibuprofen, diclofenac) and if needed oral clonidine in favor of opioids. When pain intensity decreases, discontinue the analgesic treatment in the following order: opioid, clonidine, paracetamol and at last ibuprofen. The need for analgesic treatment after tonsillectomy is usually 5-8 days, after tonsillotomy only 3-5 days.Parents are recommended to contact the hospital if the child has difficulties in drinking or eating adequately and/or suffers from pain despite taking the recommended medication regularly.

    Conclusions: Swedish guidelines for tonsil-surgery provide practical evidence-based pain treatment recommendations.

  • 38.
    Ericsson, Elisabeth
    et al.
    Linköpings universitet.
    Graf, Jonas
    Linköpings universitet.
    Hultcrantz, Elisabeth
    Linköpings universitet.
    Pediatric Tonsillotomy with the Radiofrequency Technique: Long-term Follow-up2006In: The Laryngoscope, ISSN 0023-852X, E-ISSN 1531-4995, Vol. 116, no 10, p. 1851-1857Article in journal (Refereed)
    Abstract [en]

    Objectives: Compare the effects of partial tonsil resection using a radiofrequency technique, tonsillotomy (TT), with total tonsillectomy (TE, blunt dissection) after 1 and 3 years. Compare frequency of relapse in snoring or infections and possible long-term changes in behavior among TT children with those in TE children.

    Method: Ninety-two children (5-15 yr) randomized to TT (n = 49) or TE (n = 43) groups because of obstructive problems with or without recurrent tonsillitis. One year after surgery, general health, degree of obstruction, history of infections, and behavior were investigated using two questionnaires, the Qu1 and Child Behavior Checklist, as well as an ENT visit. After 3 years, two questionnaires, Qu2 and the Glasgow Children's Benefit Inventory, were answered by mail.

    Results: After 1 year, both groups were in good health. The effect on snoring and total behavior was the same for both groups, and the rate of recurrence of infections was not higher in the TT group. After 3 years, two children in the TT group were tonsillectomized (4%, 2/49), one because of peritonsillitis and another because of increased snoring. Otherwise, no differences existed between the groups in general health, snoring, or number of infections.

    Conclusion: Removing only the protruding parts of the tonsils has the same beneficial long-term effect on obstructive symptoms and recurrent throat infections as complete TE in the majority of cases. The need for re-operation is low; therefore, it appears inadvisable to follow the current common practice of routinely removing the whole tonsil given its higher morbidity and risk for serious complications.

  • 39.
    Ericsson, Elisabeth
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Graf, Jonas
    Department of Anesthesia and Intensive Care, Linköping University, Linköping, Sweden; Division of Otorhinolaryngology, Department of Clinical and Experimental Medicine, Linköping University, Linköping.
    Lundeborg-Hammarström, Inger
    Division of Speech and Language Pathology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
    Hultcrantz, Elisabeth
    Division of Otorhinolaryngology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
    Tonsillotomy versus tonsillectomy on young children: 2 year post surgery follow-up2014In: Journal of Otolaryngology - Head & Neck Surgery, ISSN 1916-0216, Vol. 43, no 26Article in journal (Refereed)
    Abstract [en]

    Objectives: To study the long-term effect of tonsillotomy and tonsillectomy in young children after two years in comparison to the results after six months.

    Method: Children, age 4-5 with Sleep Disordered Breathing (SDB) and tonsil hyperplasia, were randomized to TE (32) or TT (35). TT was performed ad modum Hultcrantz with radiofrequency technique (Ellman). An adenoidectomy with cold steel was performed in the same session for 80% of cases. The patients were assessed prior to surgery, at six and 24 months postoperatively. Effects of surgery were evaluated clinically, through questionnaire (general health/snoring/ENT-infections), Quality of Life (QoL), survey of pediatric obstructive sleep apnea with OSA-18, and children’s behavior with the Child Behavior Checklist.

    Results: After two years there was still no difference between the groups with respect to snoring and frequency or severity of upper airway infections. Both TT and TE had resulted in large improvement in short and long term QoL and behavior. Three TT-children and one TE child had been re-operated due to recurrence of obstructive problems, the TE-child and one of the TT-children with adenoidectomy and two of the TT-children with tonsillectomy. Three of the TT-children had tonsil tissue protruding slightly out of the tonsil pouch and twelve TE-children had small tonsil remnants within the tonsil pouches, but with no need for surgery.

    Conclusion: Younger children have a small risk of symptom-recurrence requiring re-surgery within two years after TT. For the majority, the positive effect on snoring, infections, behavior and quality of life remain and is similar to TE.

  • 40.
    Ericsson, Elisabeth
    et al.
    School of Health Science, Jönköping University, Jönköping, Sweden.
    Hemlin, Claes
    Avdelningen för Otorhinolaryngologi, Aleris Sabbatsberg, Stockholm, Sweden.
    Hessen-Söderman, Ann-Charlotte
    Avdelningen för Otorhinolaryngologi, Karolinska Universitetssjukhuset, Solna, Sweden.
    Hultcrantz, Elisabeth
    Avdelningen för Otorhinolaryngologi, Inst för Kliniks och Experimentell Medicin, Hälsouniversitetet, Linköpings universitet, Linköping, Sweden.
    Månsson, Ingemar
    Avdelningen för Otorhinolaryngologi, Sahlgrenska Universitetssjukhuset, Göteborg, Sweden.
    Roos, Kristian
    Avdelningen för Otorhinolaryngologi, Capio Lundby sjukhus, Göteborg, Sweden.
    Stahlfors, Joacim
    Avdelningen för Otorhinolaryngologi, Sahlgrenska Universitetssjukhuset, Göteborg, Sweden.
    The role of information and instruction to children and parents in homemanagement after tonsil surgery: what is it helpful for them to know?2010Conference paper (Refereed)
    Abstract [en]

    OBJECTIVES

    To create national recommendations for information after tonsil surgery to improve the management ofchildren.

    METHODS

    1. A search of Medline addressing evidence on expectations and advice about medication and nonpharamacological techniques to relieve pain after tonsil surgery and 2. A questionnaire focusing on the routines for information before and after tonsil surgery was administrated to all ENT-clinics in Sweden with 99% response rate.

    RESULTS

    There is evidence that information has an empowering effect upon parents to feel more control over their child’s care. Lack of information leads to anxiety and increased perception of pain in the child. Children and parents who were given specific information related to pain and morbidity, reported less pain and were less anxious than those with no or insufficient information. Constructive information should be given gradually, starting preoperatively, to parents and children. A leaflet should contain sufficient information about what happens before, during and is to be expected after surgery, the risks and possible complications, and advice and recommendation of medication and non-pharmacological techniques. Results from the national enquiry (N=48) showed the provision of a variety of different written information from the various clinics, often insufficient. Based on these findings, an information leaflet for patients and a checklist based on the literature for the staff to use at discharge were developed (both will be available).

    CONCLUSIONS

    A checklist for the staff insures that parents and children get consistent advice. A leaflet provided before surgery helps children and parents with methods to relieve pain. This could decrease the number of complications and later consultations and give shorter recovery.

  • 41.
    Ericsson, Elisabeth
    et al.
    Hälsouniversitetet, Linköpings universitet, Linköping, Sweden.
    Hemlin, Claes
    Aleris Sabbatsberg Hospital, Stockholm, Sweden.
    Hessén Söderman, Anne- Charlotte
    Karolinska University Hospital, Stockholm, Sweden.
    Hultcrantz, Elisabeth
    Hälsouniversitetet, Linköpings universitet, Linköping, Sweden.
    Roos, Kristian
    Lundby Hospital, Göteborg, Sweden.
    Sunnergren, Ola
    County Hospital Ryhov, Jönköping, Sweden.
    Stalfors, Joacim
    Sahlgrenska University Hospital, Göteborg, Sweden.
    Webb-based information for tonsillar surgery2012Conference paper (Other academic)
  • 42.
    Ericsson, Elisabeth
    et al.
    Institutionen för medicin och hälsa, Avdelningen för omvårdnad, Linköpings universitet, Linköping.
    Hemlin, Claes
    Aleris Sabbatsberg, Stockholm .
    Hultcrantz, Elisabeth
    Institutionen för klinisk och experimentell medicin, Linköpings universitet, Linköping.
    Månsson, Ingemar
    Sahlgrenska Universitetssjukhuset, Göteborg.
    Roos, Kristian
    Capio Lundby Sjukhus, Göteborg.
    Stahlfors, Joacim
    Sahlgrenska Universitetssjukhuset, Göteborg.
    Weitz, Per
    Centrallasarettet, Västerås.
    Tonsilloperation: Nationella Medicinska Indikationer: Rapport från expertgruppen för tonsilloperation inom Svensk förening för Otorhinolaryngologi, Huvud- och halskirurgi 2009Report (Other academic)
  • 43.
    Ericsson, Elisabeth
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Hemlin, Claes
    Aleris Specialistvård, Stockholm, Sverige.
    Stalfors, Joacim
    Sahlgrenska Universitetssjukhuset, Göteborg, sverige.
    Hessén-Söderman, Anne-Charlotte
    Aleris Specialistvård, Stockholm, Sverige.
    Odhagen, Erik
    Södra Älvsborgs Sjukhus, Borås, Sverige.
    Sunnergren, Ola
    Länssjukhuset Ryhov, Jönköping, Sverige.
    Kvalitetsregistret för tonsilloperation2014In: Nationellt kvalitetsregister Öron- Näs och Halssjukvård - Årsrapport 2013: Du kan vara med och förbättra vården / [ed] Joacim Stalfors, Västra Götalandsregionen , 2014, , p. 100p. 34-97Chapter in book (Other academic)
  • 44.
    Ericsson, Elisabeth
    et al.
    Linköpings universitet.
    Hultcrantz, Elisabeth
    Linköpings universitet.
    Tonsil Surgery in Youths – Good Results with Less Invasive Method2007In: The Laryngoscope, ISSN 0023-852X, E-ISSN 1531-4995, Vol. 117, no 4, p. 654-661Article in journal (Refereed)
    Abstract [en]

    Objective: Comparison of two types of tonsil surgery for 16- to 25-year-old patients, with respect to primary morbidity, snoring, and recurrent infections after 1 year. Teenagers and young adults are a significant proportion (26%) of the population that receive tonsil surgery each year and appear to suffer more pain than younger children. Recurrent tonsillitis, in combination with obstructive problems, is the main indication for surgery.

    Method: One hundred fourteen patients 16 to 25 years of age were randomized to tonsillotomy (TT) with radiosurgery (RF) (Ellman International) or to cold tonsillectomy (TE). Pain and analgesics were logged until patients were pain free.

    Results: Thirty-two patients were operated on with TT and 44 with TE. The TT group had less blood loss during surgery and no postoperative bleedings, compared with the TE group (2 primary and 4 late hemorrhages). The TT group recorded significantly less pain from the first day, had less need of analgesics (diclofenac and paracetamol), and were pain free and in school/at work 4 days earlier than the TE group. After 7 days, the TE patients had lost a mean of 1.8 kg compared with TT, with no significant weight loss. After 1 year, both groups were satisfied. The positive effect on snoring was the same for both groups. There were few throat infections in both groups.

    Conclusion: TT with RF is an effective method for tonsil surgery for many teenagers and young adults, with much less postoperative morbidity than regular TE. Long-term follow-up is necessary.

  • 45.
    Ericsson, Elisabeth
    et al.
    Department of Medical and Health Sciences, Linköping University, Linköping, Sweden; Department of ENT - Head and Neck Surgery UHL, Östergötlands Läns Landsting, Linköping, Sweden.
    Hultcrantz, Elisabeth
    Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of ENT - Head and Neck Surgery UHL, Östergötlands Läns Landsting, Linköping, Sweden.
    Tonsil Surgery in Youths: Good Results With A Less Invasive Method2011Conference paper (Refereed)
  • 46.
    Ericsson, Elisabeth
    et al.
    School of Health Science, Jönköping University, Jönköping, Sweden.
    Hultcrantz, Elisabeth
    Department of Clinical and Experimental Medicine. Linköping University, Linköping, Sweden.
    Månsson, Ingemar
    Hälso- och sjukvårdsstyrelsen, Västra Götalandsregionen, Göteborg, Sweden, .
    Roos, Kristian
    Capio Lundby Sjukhus AB, Göteborg, Sweden .
    Stalfors, Joachim
    Sahlgrenska University Hospital, Göteborg, Sweden.
    Weitz, Per
    Central Hospital, Västerås, Sweden.
    Erfarenheter från kvalitetsregistret för tonsilloperation 1997-20082008In: Medicinska Riksstämman, Göteborg 26-28 nov, 2008, 2008Conference paper (Other academic)
    Abstract [sv]

    Bakgrund

    Kvalitetsregister för svensk ÖNH-sjukvård infördes successivt med början 1997, ett av registren ägnades tonsillektomi. Detta register har nu varit i bruk i drygt 10 år. Det kommer att avslutas med operationer utförda t.o.m. 081231. Registret beräknas komma att omfatta ca 50 000 ingrepp, det fortsätter sedan i modifierad form och med ny teknik för insamling av data. Med anledning av att en period för tonsilloperationsregistret nu avslutas, ges här en översiktlig rapport om erfarenheterna.

    Metod

    Kvalitetsregistret är tänkt att användas såväl på kliniknivå som på nationell nivå. På kliniknivå ska effekter och bieffekter av ingreppet jämföras dels med riksgenomsnittet och dels med sig själv över tid. På riksnivå kan förändringar i indikationer, operationsmetoder och organisatoriska förändringar m.m. studeras. Rapporten analyserar utvecklingen av det nuvarande tonsilloperationsregistret med fokus på den nationella nivån samt presenterar några rapporter som tillkommit i anslutning till registret.

    Resultat

    En översiktlig presentation ges av: ⋅ Registrets data på nationell bas ⋅ Hälso- och sjukvårdsrapport 2001 ⋅ Oväntad ålders- och könsfördelning ⋅ Oplanerade återbesök ⋅ Patienters upplevelse av komplikationer till tonsillektomi ⋅ Nationella indikationer för tonsilloperation ⋅ M.m.

    Sammanfattning

    En sammanfattning av utvecklingen av ett nationellt kvalitetsregister med 50 000 tonsilloperationer presenteras.

  • 47.
    Ericsson, Elisabeth
    et al.
    Linköpings universitet.
    Ledin, Torbjörn
    Linköpings universitet,.
    Hultcrantz, Elisabeth
    Linköpings universitet.
    Long-Term Improvement of Quality of Life as a Result of Tonsillotomy (With Radiofrequency Technique) and Tonsillectomy in Youths2007In: The Laryngoscope, ISSN 0023-852X, E-ISSN 1531-4995, Vol. 117, no 7, p. 1272-1279Article in journal (Refereed)
    Abstract [en]

    Objective: This is a 1 year follow-up to compare the effects of partial tonsil resection using the radiofrequency technique (RF) tonsillotomy (TT) with total tonsillectomy (TE) (blunt dissection). Obstructive symptoms, tendency for infections, and health-related quality of life (HRQL) were studied and compared with the HRQL data from a normal population.

    Method: The study group consisted of 74 patients (16-25 yr old) randomized to TT (n = 31) or TE (n = 43) with obstructive throat problems with or without recurrent tonsillitis. The Short Form 36 (SF-36) and EuroQul Visual Analogue Scale were used to evaluate HRQL. A questionnaire investigated the degree of obstruction and history of infections.

    Results: Preoperatively, both groups reported significantly lower HRQL in all dimensions of the SF-36 compared with the normal population (P < .05-P < .001). After 1 year, a large improvement (P < .01-P < .001) in both groups in HRQL was found. No differences were found when these groups were compared with the normal population or between the study groups. The effect on snoring was the same for both groups, and the rate of recurrence of infections was low and not any higher in the TT group.

    Conclusion: Preoperative obstructive problems in combination with recurrent tonsillitis have a negative impact on HRQL. Both the TT and TE groups demonstrated large improvements on HRQL, infections, and obstructive problems 1 year after surgery, indicating that the surgical methods are equally effective. With its reduced postoperative complications, less pain, shorter recovery time, and cost reduction, TT with RF should be considered the method of choice.

  • 48.
    Ericsson, Elisabeth
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Lundeberg, Stefan
    Astrid Lindgrens barnsjukhus, Karolinska universitetssjukhus, Stockholm, Sweden.
    Brattwall, Metha
    Sahlgrenska Universitetssjukhus, Göteborg, Sweden.
    Hemlin, Claes
    Aleris Specialistvård, Stockholm, Sweden.
    Hessén-Söderman, Anne-Charlotte
    Aleris Specialistvård, Stockholm, Sweden.
    Hultcrantz, Elisabeth
    Linköpings universitet, Linköping, Sweden.
    Odhagen, Erik
    Södra Älvsborgs Sjukhus, Borås, Sweden.
    Sunnergren, Ola
    Länssjukhuset Ryhov, Jönköping, Sweden.
    Stalfors, Joacim
    Sahlgrenska Universitetssjukhus, Göteborg, Sweden.
    Pharmacological treatment in children after tonsil-surgery: updated Swedish national guidelines2014Conference paper (Refereed)
  • 49.
    Ericsson, Elisabeth
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Lundeberg, Stefan
    Astrid Lindgrens barnsjukhus, Karolinska universitetssjukhus, Stockholm, Sweden.
    Brattwall, Metha
    Sahlgrenska Universitetssjukhus, Göteborg, Sweden.
    Hemlin, Claes
    Aleris Specialistvård, Stockholm, Sweden.
    Hessén-Söderman, Anne-Charlotte
    Aleris Specialistvård, Stockholm, Sweden.
    Odhagen, Erik
    Södra Älvsborgs Sjukhus, Borås, Sweden.
    Sunnergren, Ola
    Länssjukhuset Ryhov, Jönköping, Sweden.
    Stalfors, Joacim
    Sahlgrenska Universitetssjukhus, Göteborg, Sweden.
    National guidelines of pharmacological treatment in children: the implementations process2014Conference paper (Refereed)
  • 50.
    Ericsson, Elisabeth
    et al.
    Department of Medical and Health Science, Linköpings university, Linköping, Sverige.
    Lundeberg, Stefan
    Smärtbehandlingsenheten, Astrid Lindgrens Barnsjukhus, Stockholm, Sverige.
    Brattwall, Metha
    An/Op/IVA/Sc Sahlgrenska Universitetssjukhuset, Mölndal, Sverige.
    Stalfors, Joacim
    ÖNH-Kliniken, Sahlgrenska Universitetssjukhuset, Göteborg, Sverige.
    Hemlin, Claes
    ÖNH-Kliniken, Aleris Specialistvård Sabbatsberg, Stockholm, Sverige.
    Hessén-Söderman, Anne Charlotte
    ÖNH-Kliniken, Aleris Specialistvård Sabbatsberg, Stockholm, Sverige.
    Hultcrantz, Elisabeth
    Institutionen för klinisk och experimentell medicin, Linköpings universitet, Linköping, Sverige.
    Sunnergren, Ola
    ÖNH- Kliniken, Länssjukhuset Ryhov, Jönköping, Sverige.
    Odhagen, Erik
    ÖNH-Kliniken, Södra Älvsborgs Sjukhus, Borås, Sverige.
    Nationella riktlinjer för farmakologisk behandling av smärta och illamående i samband med tonsillotomi och tonsillektomi på barn och ungdomar (<18 år)2013In: Ventilen, ISSN 0348-6257, Vol. 4, no 48, p. 18-19Article in journal (Other academic)
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