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  • 1.
    Allvin, Renee
    et al.
    Örebro University, Department of Clinical Medicine. Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro; Centre for Evidence Based Medicine and Assessment of Medical Technology, Örebro.
    Ehnfors, Margareta
    Örebro University, Department of Nursing and Caring Sciences.
    Rawal, Narinder
    Örebro University, Department of Clinical Medicine. Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro.
    Idvall, E.
    Research Section, Kalmar County Council, Kalmar; Department of Medicine and Health, Linköping University, Linköping.
    Experiences of the postoperative recovery process: an interview study2008In: The open nursing journal, ISSN 1874-4346, Vol. 2, p. 1-7Article in journal (Refereed)
    Abstract [en]

    Few researchers have described postoperative recovery from a broad, overall perspective. In this article the authors describe a study focusing on patient and staff experiences of postoperative recovery using a qualitative descriptive design to obtain a description of the phenomenon. They performed 10 individual interviews with patients who had undergone abdominal or gynecological surgery and 7 group interviews with registered nurses working on surgical and gynecological wards and in primary care centers, surgeons from surgical and gynecological departments, and in-patients from a gynecological ward. The authors analyzed data using qualitative content analysis. Postoperative recovery is described as a Dynamic Process in an Endeavour to Continue With Everyday Life. This theme was further highlighted by the categories Experiences of the core of recovery and Experiences of factors influencing recovery. Knowledge from this study will help caregivers support patients during their recovery from surgery.

  • 2.
    Allvin, Renée
    et al.
    Örebro University, Department of Clinical Medicine.
    Ehnfors, Margareta
    Örebro University, Department of Nursing and Caring Sciences.
    Rawal, Narinder
    Örebro University, Department of Clinical Medicine.
    Idvall, Ewa
    Experiences of the postoperative recovery process: an interview study2008In: The open nursing journal, ISSN 1874-4346, Vol. 2, p. 1-7Article in journal (Refereed)
    Abstract [en]

    Few researchers have described postoperative recovery from a broad, overall perspective. In this article the authors describe a study focusing on patient and staff experiences of postoperative recovery using a qualitative descriptive design to obtain a description of the phenomenon. They performed 10 individual interviews with patients who had undergone abdominal or gynecological surgery and 7 group interviews with registered nurses working on surgical and gynecological wards and in primary care centers, surgeons from surgical and gynecological departments, and in-patients from a gynecological ward. The authors analyzed data using qualitative content analysis. Postoperative recovery is described as a Dynamic Process in an Endeavour to Continue With Everyday Life. This theme was further highlighted by the categories Experiences of the core of recovery and Experiences of factors influencing recovery. Knowledge from this study will help caregivers support patients during their recovery from surgery.

  • 3.
    Allvin, Renée
    et al.
    Örebro University, Department of Clinical Medicine.
    Ehnfors, Margareta
    Örebro University, Department of Nursing and Caring Sciences.
    Rawal, Narinder
    Örebro University, Department of Clinical Medicine.
    Svensson, Elisabeth
    Örebro University, Swedish Business School at Örebro University.
    Idvall, Ewa
    Development of a questionnaire to measure patient-reported postoperative recovery: content validity and intra-patient reliability2009In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 15, no 3, p. 411-419Article in journal (Refereed)
    Abstract [en]

    Aims and objectives. In this study we describe the development of a short, easy-to-use questionnaire to measure postoperative recovery and evaluate its content validity and intra-patient reliability.   The questionnaire is designed to evaluate the progress of postoperative recovery and the long-term follow-up of possible effects of interventions during recovery.

    Method. The study involved four steps. 1) A conceptualisation and item definitions were based on a theoretical framework and a description of patients' postoperative recovery from the perspective of patients, registered nurses and surgeons. 2) Content validity of items was tested through expert judgements. 3) A test run of the questionnaire was performed to confirm its feasibility and workload requirement. 4) The stability of the questionnaire was evaluated through intra-patient reliability assessment.

    Results. As a result of the operationalisation process of the concept postoperative recovery, five dimensions (physical symptoms, physical functions, psychological, social, activity) and 19 items were identified. Each item was formulated as a statement in the questionnaire. Content validity was judged to be high. After the pre-test of the questionnaire a revision with refinements in the layout was made. The vast majority of items showed a high level of intra-patient reliability.

    Conclusion. Based on a theoretical framework and empirical data, we developed a short and easy-to-use tentative questionnaire to measure patient-reported postoperative recovery. Initial support for content validity was established. The vast majority of items showed a high level of test-retest reliability.

  • 4.
    Allvin, Renée
    et al.
    Örebro University, Department of Clinical Medicine.
    Svensson, Elisabeth
    Örebro University, Swedish Business School at Örebro University.
    Rawal, Narinder
    Örebro University, Department of Clinical Medicine.
    Ehnfors, Margareta
    Örebro University, Department of Nursing and Caring Sciences.
    Kling, Anna-Maria
    Statistical and Epidemiology Unit, Örebro University Hospital, Örebro, Sweden.
    Idvall, Ewa
    The Postoperative Recovery Profile (PRP): a multidimensional questionnaire for evaluation of recovery profiles2011In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 17, no 2, p. 236-243Article in journal (Refereed)
    Abstract [en]

    Background. The previously developed Postoperative Recovery Profile (PRP) questionnaire is intended for self-assessment of general recovery after surgery. The aim of this study was to further evaluate the questionnaire regarding the construct validity and ability to discriminate recovery profiles between groups. Furthermore, the item variables of greatest importance during the progress of recovery were investigated.

    Methods. Postoperative recovery was assessed during the period from discharge to 12 months after lower abdominal- and orthopedic surgery. Construct validity was evaluated by comparing the assessments from the PRP-questionnaire and a global recovery scale. Recovery profiles of the diagnose groups were displayed by the cumulative proportion recovered participants over time. The importance of item variables was investigated by ranking ordering.

    Results. A total of 158 patients were included. The result showed that 7.6 % of all possible pairs were disordered when comparing the assessments from the PRP questionnaire and the global recovery scale. Twelve months after discharge 51 % participants in the abdominal group were fully recovered, as compared with the 73%, in the orthopedic group (95% CI: 6 % to 40 %). The item variable pain appeared as top five at eight measurement occasions of eight possible in both the abdominal and the orthopedic groups. The importance of the items was emphasized.

    Conclusions. The PRP questionnaire allows for evaluation of the progress of postoperative recovery, and can be useful to assess patient-reported recovery after surgical treatment. Knowledge about recovery profiles can assist clinicians in determining the critical time points for measuring change.

  • 5.
    Axelsson, Kjell
    et al.
    Örebro University, School of Health and Medical Sciences.
    Gupta, Anil
    Örebro University, School of Health and Medical Sciences.
    Johanzon, Eva
    Berg, Elisabeth
    Ekbäck, Gustav
    Rawal, Narinder
    Enström, Peter
    Nordensson, Ulf
    Intraarticular administration of ketorolac, morphine, and ropivacaine combined with intraarticular patient-controlled regional analgesia for pain relief after shoulder surgery: a randomized, double-blind study2008In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 106, no 1, p. 328-333Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In this study we assessed the efficacy of intraarticular regional analgesia on postoperative pain and analgesic requirements. METHODS: Fifty-one patients undergoing shoulder surgery (Bankart) were recruited into this double-blind study. At the end of the operation, patients were randomized to three groups to receive intraarticularly via a catheter: Group 1: ropivacaine 90 mg (9 mL), morphine 4 mg (10 mL), and ketorolac 30 mg (1 mL) (total volume 20 mL); Groups 2 and 3: saline (20 mL). In addition, Groups 1 and 3 received 1 mL saline IV while Group 2 received ketorolac 30 mg (1 mL) IV. Postoperatively, Group 1 received pain relief using 10 mL 0.5% ropivacaine on demand via the intraarticular catheter while Groups 2 and 3 received 10 mL of saline intraarticularly. Group 3 was the Control group. RESULTS: Postoperative pain at rest and on movement were lower in Group 1 than in Groups 2 and 3 during the first 30 and 120 min, respectively. The time to first request for local anesthetic infusion was longer in Group 1 than in Groups 2 and 3 (P < 0.001). The median morphine consumption during the first 24 postoperative hours was less in Groups 1 and 2 than in Group 3 (P < 0.001). There was no significant difference in analgesic consumption between Group 1 and Group 2. The median satisfaction score was higher in Group 1 compared with Groups 2 (P < 0.05) and 3 (P < 0.001). CONCLUSIONS: A combination of intraarticular ropivacaine, morphine, and ketorolac followed by intermittent injections of ropivacaine as needed provided better pain relief, less morphine consumption, and improved patient satisfaction compared with the control group. The group that received IV ketorolac consumed less morphine and was more satisfied with treatment than patients in the control group.

  • 6.
    Jildenstål, Pether K.
    et al.
    Department of Anesthesiology and Intensive Care, University Hospital, Örebro, Sweden.
    Hallén, Jan L.
    Department of Anesthesiology and Intensive Care, University Hospital, Örebro, Sweden.
    Rawal, Narinder
    Department of Anesthesiology and Intensive Care, University Hospital, Örebro, Sweden.
    Berggren, Lars
    Department of Anesthesiology and Intensive Care, University Hospital, Örebro, Sweden; Centre for Assessment of Medical Technology (CAMTÖ), Region Örebro County, Örebro, Sweden.
    Does depth of anesthesia influence postoperative cognitive dysfunction or inflammatory response following major ENT surgery?2012In: Journal of Anesthesia & Clinical Research, ISSN 2155-6148, Vol. 3, no 6, p. 220-Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to evaluate the role of depth of anesthesia on POCD after major ENT surgery and to assess changes in postoperative inflammatory markers in patients undergoing major ENT surgery. Thirty two patients aged 40 to 94 yrs, scheduled for surgery under general anesthesia were randomly assigned to one of two groups. In group A (AEP group) depth of anesthesia (DOA) was measured with auditory evoked potential (AEP). In the control group (group C) DOA was monitored according to clinical signs. Cognitive function was evaluated using Mini-Mental State Examination (MMSE), Confusion Assessment Method (CAM) and Cognitive Failure Questionnaire (CFQ). Inflammatory markers were measured before and after anesthesia. Perioperative requirements for desflurane and fentanyl were significantly lower in group A. On the first postoperative day MMSE changes indicating POCD were noted in 1 patient in group A and 7 patients in group C (P<0.03). One month follow up did not show any difference between the groups regarding POCD. Our study indicates that AEP-guided anesthesia allows dose reduction of anesthetic agents including opioids leading to better cardiovascular stability and less early POCD. Anesthesia depth did not influence the inflammatory response to surgery.

  • 7.
    Jildenstål,, Pether K.
    et al.
    Department of Anaesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Hallén, Jan L.
    Department of Anaesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Rawal, Narinder
    Department of Anaesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Gupta, Anil
    Department of Anaesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden; Department of Anaesthesiology, Linköping University, Linköping, Sweden.
    Berggren, Lars
    Department of Anaesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden: Centre for Assessment of Medical Technology, Örebro University Hospital, Örebro, Sweden.
    Effect of auditory evoked potential-guided anaesthesia on consumption of anaesthetics and early postoperative cognitive dysfunction: a randomised controlled trial2011In: European Journal of Anaesthesiology, ISSN 0265-0215, E-ISSN 1365-2346, Vol. 28, no 3, p. 213-219Article in journal (Refereed)
    Abstract [en]

    Background: Post-operative cognitive dysfunction (POCD) after non-cardiac surgery is a well known problem in some categories of patients. This study aims to evaluate the influence of auditory evoked potential (AEP)-guided anaesthesia on the requirement for anaesthetic drugs and their influence on POCD.

    Methods: Four hundred and fifty patients aged between 18 and 92 years scheduled for ophthalmic surgery under general anaesthesia were assigned randomly to one of two groups. In group A (AEP group), the depth of anaesthesia (DoA) was aimed at an AEP index (AAI) between 15 and 25. In group C (control group), DoA was guided by clinical signs. Hypotension was treated with fluids and vasopressors using a standardised algorithm. A mini-mental test and the Cognitive Failure Questionnaire were used to evaluate cognitive function.

    Results: Anaesthetic drug requirements were significantly lower in group A than in group C: propofol 92.526.5 vs. 103.839.5mg (P¼<0.001) and desflurane end-tidal concentration 2.50.58 vs. 3.30.79% (P<0.001). In group A, 36 patients (16%) received additional fluids and vasopressors compared to 65 patients (29%) in group C (P<0.01). AAI values differed significantly between the groups: 18 (11–21) in group A vs. 12 (10–19) in group C (P<0.001). The number of patients with POCD was 16 in group C compared to two in group A (P<0.001) at day 1 post-operation.

    Conclusion: AEP monitoring allows dose reduction of anaesthetic agents, leading to better cardiovascular stability and decreased requirements for intra-operative fluids and vasopressors. Cognitive decline seen following minor ophthalmic surgery, even when anaesthesia is assessed clinically, is short-lived with no long-term sequelae.

  • 8. Joshi, Girish P.
    et al.
    Kehlet, Henrik
    Rawal, Narinder
    Örebro University, School of Health and Medical Sciences.
    Evidence-based guidelines for postoperative pain management2007In: Regional anesthesia and pain medicine, ISSN 1098-7339, E-ISSN 1532-8651, Vol. 32, no 2, p. 173-Article in journal (Refereed)
  • 9. Langford, Richard M.
    et al.
    Rawal, Narinder
    Örebro University, Department of Clinical Medicine.
    A new needle-free PCA system: the fentanyl iontophoretic transdermal system [Editorial]2006In: Acute Pain, ISSN 1366-0071, E-ISSN 1873-6319, Vol. 8, no 4, p. 151-153Article in journal (Other academic)
  • 10.
    Nilsson, Ulrica
    et al.
    Örebro University Hospital, Department of Anaesthesiology and Intensive Care, Örebro, Sweden.
    Unosson, Mitra
    Faculty of Health Science, Department of Medicine and Care, Division of Nursing Science, Linköping, Sweden.
    Rawal, Narinder
    Örebro University Hospital, Department of Clinical Medicine, Division of Anaesthesiology, Örebro, Sweden.
    Stress reduction and analgesia in patients exposed to calming music postoperatively: a randomized controlled trial2005In: European Journal of Anaesthesiology, ISSN 0265-0215, E-ISSN 1365-2346, Vol. 22, no 2, p. 96-102Article in journal (Refereed)
    Abstract [en]

    Background and objectives: This randomized controlled trial was designed to evaluate, first, whether intra- or postoperative music therapy could influence stress and immune response during and after general anaesthesia and second, if there was a different response between patients exposed to music intra- or postoperatively.

    Method: Seventy-five patients undergoing open hernia repair as day care surgery were randomly allocated to three groups: intraoperative music, postoperative music and silence (control group). Anaesthesia and postoperative analgesia were standardized and the same surgeon performed all the operations. Stress response was assessed during and after surgery by determining the plasma cortisol and blood glucose levels. Immune function was evaluated by studying immunoglobulin A (IgA) levels. Patients’ postoperative pain, anxiety, blood pressure (BP), heart rate (HR) and oxygen saturation were also studied as stress markers.

    Results: There was a significantly greater decrease in the level of cortisol in the postoperative music group vs. the control group (206 and 72 mmol L 1 decreases, respectively) after 2 h in the post anaesthesia care unit. The postoperative music group had less anxiety and pain and required less morphine after 1 h compared with the control group. In the postoperative music group the total requirement of morphine was significantly lower than in the control group. The intraoperative music group reported less pain after 1 h in the post anaesthesia care unit. There was no difference in IgA, blood glucose, BP, HR and oxygen saturation between the groups.

    Conclusion: This study suggests that intraoperative music may decrease postoperative pain, and that postoperative music therapy may reduce anxiety, pain and morphine consumption.

  • 11.
    Rawal, Narinder
    Örebro University, School of Health and Medical Sciences.
    Postoperative pain treatment for ambulatory surgery2007In: Best practice & research. Clinical anaesthesiology, ISSN 1753-3740, Vol. 21, no 1, p. 129-148Article in journal (Refereed)
    Abstract [en]

    One of the most significant changes in surgical practice during the last two decades has been the growth of ambulatory surgery. Adequate postoperative analgesia is a prerequisite for successful ambulatory surgery. Recent studies have shown that large numbers of patients suffer from moderate to severe pain during the first 24-48 hr. The success of fast-tracking depends to a considerable extent on effective postoperative pain management routines and the cost saving of outpatient surgery may be negated by unanticipated hospital admission for poorly treated pain. Depending on the intensity of postoperative pain current management includes the use of analgesics such as paracetamol, NSAIDs including coxibs and tramadol as single drugs or in combination as part of balanced (multimodal) analgesia. However, in the ambulatory setting many patients suffer from pain at home in spite of multimodal analgesic regimens. Sending patients home with perineural, incisional, and intra-articular catheters is a new and evolving area of postoperative pain management. Current evidence suggests that these techniques are effective, feasible and safe in the home environment if appropriate patient selection routines and organization for follow-up are in place.

  • 12.
    Rawal, Narinder
    Örebro University, School of Health and Medical Sciences.
    Regional techniques for management of postoperative pain2007In: PeriMed, Vol. 1, p. 26-34Article in journal (Other academic)
  • 13.
    Rawal, Narinder
    et al.
    Örebro University, School of Health and Medical Sciences.
    Langford, R. M.
    Current practices for postoperative pain management in Europe and the potential role of the fentanyl HCl iontophoretic transdermal system2007In: European Journal of Anaesthesiology, ISSN 0265-0215, E-ISSN 1365-2346, Vol. 24, no 4, p. 299-308Article in journal (Refereed)
    Abstract [en]

    Survey results continue to reveal that postoperative pain is insufficiently managed throughout Europe and the rest of the world. However, the efficient use of existing resources, as well as the introduction of novel technologies, may aid in its improvement. Use of an acute pain service has the potential to improve pain management through specialized patient care and utilization of effective analgesic techniques. Multimodal analgesic techniques, which include adjuvant non-opioids and/or regional analgesic techniques, can provide effective analgesia and reduce the amount of systemic opioids (or obviate the need) for postoperative pain management. Patient-controlled analgesia modalities may also offer improvements to pain management, as in practice they provide pain relief superior to the intermittent administration of bolus doses of opioids. A novel patient-controlled analgesia modality that has been approved by the European Medicines Evaluation Agency (EMEA) for the treatment of acute, moderate-to-severe pain is the needle-free, pre-programmed fentanyl HCl iontophoretic transdermal system. This system was shown in a recent US clinical trial to be comparable in efficacy to a standard regimen of morphine intravenous patient-controlled analgesia. Adverse events associated with the use of the fentanyl iontophoretic transdermal system are generally similar to those experienced by patients using intravenous morphine patient-controlled analgesia. Considerations regarding the selection of patients for treatment with the fentanyl iontophoretic transdermal system are similar to those with other patient-controlled analgesia modalities; sufficient upper limb mobility and alertness are required to operate the system. Utilization of the fentanyl iontophoretic transdermal system, together with the guidance of an effective acute pain service, may lead to improvements in postoperative pain management.

  • 14.
    Rebenius, Inga
    Örebro University, Department of Education.
    Talet om learner autonomy: språkinlärning, autonomi och ett demokratiskt medborgarskap - ett gränsland till moralfilosofi2007Doctoral thesis, monograph (Other academic)
    Abstract [en]

    The overall aim of this thesis is to clarify a number of meanings embedded in the discourse that frames the concept of learner autonomy and then place special emphasis on the concepts of autonomy and citizenship. In addition the thesis has three subgoals: to revitalize an early political dimension that aims at democratic citizenship, to investigate how the discourse of learner autonomy is expressed in national curricula and in syllabuses in English and French/German/Spanish for the Swedish upper secondary school and to clarify and discuss a number of possible didactic consequences of a revitalized concept of learner autonomy. One specific question asked is if such a revitalization can make the autonomous student visible as a rebellious autonomous student via a narrative. A red thread in the thesis is the pedagogical paradox: How can a goal such as autonomy be promoted when it is the institution that imposes autonomy on the students.

    The thesis is comprised of a textual analysis and a case study in the form of a narrative analysis. Both are placed within a critical-pragmatic approach. This approach is linked to a curriculum theory tradition that focuses on the selection of content as it is expressed in the Swedish official governing documents for education. The analysis can be described as a historical, language didactic, political – moral - philosophical and curricular contextualisation.

    Five meanings of the discourse of learner autonomy are constructed: Autonomy – a democratic citizenship, Autonomy – efficiency in language learning, The well-adjusted autonomous student, Autonomy, a social context and communication and Autonomy as critical awareness. ‘Autonomy – effi ciency in language learning’ and ‘The well-adjusted autonomous student’ are designated imposed autonomy based on Immanuel Kant. ‘Autonomy – a democratic citizenship’, ‘Autonomy, a social context and communication’ and ‘Autonomy as critical awareness’ are designated experienced autonomy-authenticity based on Charles Taylor. The five meanings are used as points of references in the analysis of the national curricula and syllabuses.

    The autonomous student is made visible as a rebellious autonomous student with the help of certain aspects of the concept of freedom, the meaning ‘Autonomy as critical awareness’ and my interpretation of Taylor’s ideas on freedom, autonomy and identity.

    The discourse that frames the concept of learner autonomy has had an impact on the syllabuses. It is primarily imposed autonomy that is expressed there, reaching a peak in 1989 in French/Spanish/German. The analysis of the curricula shows that there are parallels to the discourse of learner autonomy. In the overall goals both imposed autonomy and experienced autonomy-authenticity are expressed.

    Didactic consequences are discussed under six headings: the pedagogical paradox; the subject-object problematic; the learner as an individual, as a communicator, as a change agent and as a person; imposed autonomy – experienced autonomy-authenticity and the individual versus the collective.

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