april 2019 - volume 29 - issue 4 - journal of

JOUR

NALOF Perioperative

Practice

Apri l 2019 - Vo lume 29 - I ssue 4 - ISSN 1750-4589

Primary post-partum haemorrhage - Causation and Management

The presence of a Surgical Care Practitioner in the perioperative team is of benefit both to the patient and the consultant-led extended surgical team

Nurses’ knowledge about perioperative care of patients with neurological diseases

Psychometric evaluation of the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery and postoperative behavior and recovery in children undergoing tonsil surgery

Neurectomy for trigeminal neuralgia

Centre section: Newsletter

IN THIS ISSUE

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Volume 29 Number 4 April 2019

ContentsFrom the PresidentLet’s put a stop to smoking in theatres 67

Tracey Williams

From the EditorHow time flies 68

Julie Quick

Book ReviewIt’s Never Easy These Days 69

Leontia Hoy

News Update 70

Viewpoint

A personal view of the harmful effects of diathermy smoke 73

Kathy Nabbie

ReviewPrimary post-partum haemorrhage – Causation and management 75

Gareth Benson

Clinical FeaturesThe presence of a Surgical Care Practitioner in the perioperative team is of benefit both to the patient and theconsultant-led extended surgical team 81

Gabriel Rene M. Campaner

Nurses’ knowledge about perioperative care of patients with neurological diseases 87

Evagelia Laopoulou, Petros Papagiorgis, Chrysa Chrysovitsanou, Chrysoula Tsiou, Sotirios Plakas and Georgia Fouka

Original ArticlePsychometric evaluation of the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery andpostoperative behavior and recovery in children undergoing tonsil surgery 94

Ulrica Nilsson, Elisabeth Ericsson, Mats Eriksson, Ewa Idvall and Ann-Cathrine Bramhagen

Surgery of the PastNeurectomy for trigeminal neuralgia 102

Professor Harold Ellis

AfPP Board of TrusteesPresidentTracey Williams

Senior Lecturer in Operating Department Practice and Nursing Studies,

University of Central Lancashire (Trustee)

Vice PresidentJulie Peirce-Jones

Senior Lecturer in Operating Department Practice,

University of Central Lancashire (Trustee)

Elected TrusteesAngela Cobbold, Course Leader Operating Department Practice, University of Suffolk,

Ipswich (Trustee)

John Dade, Lecturer in Operating Department Practice, University of Leicester (Trustee)

Chloe Rich, Lecturer in Operating Department Practice, Oxford Brookes University

(Trustee)

Chief ExecutiveDawn L Stott

Editorial AdministratorGina Graydon

Email: [email protected]

Tel: 01423 882949

The Association for Perioperative Practice

Daisy Ayris House

42 Freemans Way

Harrogate, HG3 1DH

Reception: 01423 881300

Membership: 01423 881300 (Option 1)

Events: 01423 882969

Website: www.afpp.org.uk


Professional Advisory ServiceFor members of AfPP needing advice on professional and clinical issues:


Telephone: 01423 881300

If you are not a member, please contact our membership helpline on 01423 881300

Manuscripts submitted for consideration by the Editor must be the original work of the

author and not under consideration by any other publication. Advertisements or other

inserted material are accepted subject to current terms and conditions.

Acceptance of an advertisement does not signify endorsement of the products or

services by AfPP.

EditorJulie Quick, Senior Lecturer, Faculty of Health, Education and Life

Sciences, Birmingham City University

Associate EditorCarolina Britton, Lead Education, Theatres & Peri-ops, Cambridge

University Hospitals

Daphne Martin, Lecturer (Education), Pathway Leader Specialist Practice

in Anaesthetic Nursing, School of Nursing and Midwifery, Queen’s

University Belfast

Editorial BoardHannah Abbott, Associate Professor and Associate Head of School,

Faculty of Health, Education & Life Sciences, Birmingham City University

Jenny Abraham, Advanced Perioperative Specialist Practitioner,

University Hospitals Coventry and Warwickshire NHS Trust

Theodoros Aslanidis, Consultant-researcher, Intensive Care Unit, St.

Paul General Hospital, Greece

Nerys Bolton, Staff Tutor for the South East and London, The Open

University, Faculty of Wellbeing, Education and Language Studies,

School of Health, Wellbeing and Social Care, Milton Keynes

Victoria Cadman, Lecturer in Operating, Department Practice, Sheffield

Hallam University

Sonya Clarke, Senior Lecturer (Education), Professional Lead for

Childrens Nursing, Pathway Leader for Orthopaedic/Trauma Nursing,

School of Nursing and Midwifery, Queen’s University Belfast

Angela Cobbold, Course Leader Operating Department Practice,

University of Suffolk, Ipswich

Linda M Cooper, Decontamination Services Manager, Belfast Health and

Social Care Trust

Ann Cousley, Retired Anaesthetic Nurse Specialist

Felicia Cox, Lead Nurse Pain Management, Royal Brompton & Harefield

NHS Foundation Trust

Maria Coyle, Clinical Education Facilitator, Theatres and Recovery, Royal

Victoria Hospital, Belfast Health and Social Care Trust

Pauline Daniels, Lecturer, School of Nursing and Midwifery, Queen’s

University Belfast, UK

Luke Ewart, Senior Lecturer, ODP programme Director, Canterbury Christ

Church University, Chatham Maritime, Kent

Mona Guckian Fisher, Independent Healthcare Consultant

Dr Theofanis Fotis, Principal Lecturer, School of Health Sciences,

University of Brighton

Eleanor Freeman, Sister Theatres, Queen Elizabeth Hospital, Gateshead,

Tyne and Wear

Lois Hamlin, Retired Lecturer, Director, Postgraduate Nursing Programs,

University of Technology, Sydney, Australia

Leontia Hoy, Course Director, BSc Hons/Graduate Diploma/Post

Graduate Diploma-Specialist Practice, School of Nursing, Queen’s

University Belfast

Clare Hughes, Midwifery Lecturer (Education), Queen’s University Belfast

Nimmy John, Anaesthetic Nurse Specialist, Belfast Health and Social

Care Trust

Adrian Jones, Orthopaedic Surgical Care Practitioner, Orthopaedic

Department, Norfolk & Norwich University Hospital

Dr Moyra Journeaux, Senior Lecturer, Nursing and Midwifery Higher

Education Department, Jersey

Hiroka Komori, Senior Clinical Fellow, Department of Transplant Surgery,

Cambridge NHS Trust (Addenbrookes)

Laurence Leonard, Lecturer (Infections and Infection Control), School of

Nursing and Midwifery, Queen’s University Belfast

Georgina Lewis, Surgical Care Practitioner (Gynae), Gloucestershire

Hospitals NHS Trust

Sue Lord, Team Leader, General, Vascular and Laparoscopic, Princess

Alexandra Hospital NHS Trust

Helen Lowes, Senior Lecturer and Business Development Lead for

Operating Department Practice, Sheffield Hallam University

Jun Ma, Deputy Chief Neurosurgery, Neurosurgery Department, Beijing

Tiantan Hospital affiliated to Capital Medical University

Andy Mardell, Retired Practice Education Nurse, Cardiff & Vale University

Health Board, University Hospital of Wales, Cardiff

Shirley Martin, Surgical Care Practitioner and Robotics Specialist Nurse,

St Mary’s NHS Trust

Greg McConaghie, Clinical Fellow in Orthopaedics, Queen’s Medical

Centre, Nottingham

Daniel Morgan, Operating Departmental Practitioner, the Royal Marsden

Hospital

Amanda Parker, Retired Director of Nursing, Western Sussex Hospitals

NHS Foundation Trust

Susan Pirie, Senior Charge Nurse, Theatres, Aberdeen Maternity

Hospital, NHS Grampian

Clare Prue, Registered Nurse, NW Spinal Lead, Ramsay Health

Paul Rawling, Senior Lecturer, ODP Education, Edge Hill University,

Ormskirk

Bill Robertson-Smith, Surgical Care Practitioner, Northampton General

Hospital

Daniel Rodger, Senior Lecturer in Perioperative Practice, London South

Bank University

Brian Smith, HE Consultant, HEA National Teaching Fellow, Registered

ODP

Dr Susan Tame, Former Lecturer, Faculty of Health and Social Care,

University of Hull

Dezita Taylor-Robinson, ODP, Senior Lecturer FdSc Surgical Care,

Birmingham City University

Dr Linda Walker, Clinical Board Director of Nursing, Cardiff and Vale

University Health Board

Mr Jonathan JE White, Registrar in Trauma & Orthopaedics, East

Midlands North Deanery

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From the President

Let’s put a stop to smoking in theatres

As theatre practitioners we are concerned with the health andsafety of our patients. We are also concerned with the healthand safety of our colleagues and ourselves. Everything we do isgoverned by standards, guidelines and policies all aimed atpromoting high quality care delivery whilst minimising risk. Sowhy is it that every day theatre practitioners and patients areput at risk from inhaling smoke plume?

There is limited published data, but it does signify thatdedicated smoke evacuation/extraction devices are effectiveat reducing the levels of surgical smoke during surgicalprocedures. Guidelines recommend the use of smokemanagement systems and there are numerous products onthe market available to support this, yet the utilisation of suchsystems is inconsistent. Some organisations have clearpolicies in place and compliance is reported as being 100%.Others have nothing or have inconsistency in utilisationbetween theatres and disciplines or even teams.

There is no doubt that the plume created, when usingelectrosurgery during procedures, contains over 150 differentchemicals, carcinogens, prions, bacteria, viruses and viablecells. Unfortunately, there is insufficient data to allowconclusions to be drawn on reported respiratory ill healthsymptoms linked with surgical smoke exposure (Beswick &Evans 2012).

Nonetheless, chronic irritation caused by surgical smoke can leadto respiratory irritation, exacerbation of asthma, headaches,nausea, mucous membrane irritations and skin irritations(Eickmann et al 2011). What is lacking is definitive proof thatbreathing in this noxious substance causes harm. Perhaps this iswhy there is some reluctance around using containment systems.

Personally, I choose not to smoke cigarettes. So why is it thatwhen I am in an operating theatre where diathermy is beingused, I am sometimes forced to inhale the resultant smokeproduced. Hill et al (2012) showed that the surgical smokegenerated during plastic surgery procedures, in one day,was equivalent to smoking 27 to 30 unfiltered cigarettes.

Smoking has been banned in enclosed public places so whyshould it be permissible to inhale smoke in the work place?

Theatre practitioners are not the only ones at risk. There also isa risk to patients. Not only can they be exposed to breathing inthe smoke but during certain laparoscopic procedures theymay absorb it into their blood stream. If allowed to accumulate,the surgical smoke can also be a hinderance during theseprocedures as it can affect the visualisation of organs andtissues. This can be addressed by releasing the smoke througha port into the atmosphere where guess what? We are againexposed to breathing it in!

We have a duty of care to our patients and each other todeliver high quality care and eliminate or reduce risk whereverpossible. AfPP member Kathie Nabbie has instigated a secondpetition to mandate the use of smoke management systemsand we require 10,000 signatures before the government willrespond. At 100,000 signatures, this petition will beconsidered for debate in Parliament. As I write this we have justover 2000 signatures. I am asking you all to support this andsign but also ask your friends, neighbours and relatives to signit too. We have the power to lobby for change and we owe it toourselves to protect our health, so let's do it.

Please sign the petition to make smoke evacuationcompulsory, visit https://petition.parliament.uk/petitions/237619

Tracey WilliamsPresident AfPP

Find AfPP on Facebookwww.facebook.com/safersurgeryuk

@SaferSurgeryUK

References

Beswick A, Evans G 2012 Evidence for exposure and harmfuleffects of diathermy plumes (surgical smoke) Evidencebased literature review Prepared by the Health and SafetyLaboratory for the Health and Safety Executive

Eickmann I, Falcy M, Fokuhl RNI, Rüegger M 2011 Surgicalsmoke: Risks and preventive measures http://prevencion.umh.es/files/2012/04/2-surgical_smoke.pdf

Hill DS, O'Neill JK, Powell RJ, Oliver DW 2012 Surgical smoke -a health hazard in the operating theatre: a study to quantifyexposure and a survey of the use of smoke extractorsystems in UK plastic surgery units. Journal of PlasticReconstructive & Aesthetic Surgery 65 (7) 911–6.

Journal of Perioperative Practice

2019, Vol. 29(4) 67

! The Author(s) 2019

Article reuse guidelines:

sagepub.com/journals-permissions

DOI: 10.1177/1750458919840184

journals.sagepub.com/home/ppj

https://petition.parliament.uk/petitions/237619


http://prevencion.umh.es/files/2012/04/2-surgical_smoke.pdf

http://prevencion.umh.es/files/2012/04/2-surgical_smoke.pdf

http://uk.sagepub.com/en-gb/journals-permissions

http://dx.doi.org/10.1177/1750458919840184


From the Editor

How time flies

The photograph above was taken when I started mynurse training 30 years ago this month, it also coincideswith life-changing events that forged my interest in theperioperative environment. The day after this photo wastaken, a family member was admitted for emergencycardiac surgery. Although traumatic at the time, thisexperience fostered my interest in surgery and when Iqualified as a Registered General Nurse, I knew therewas only one speciality for me and I moved straight intothe operating theatre, fascinated by the surgeries thatcould be performed and the one-to-one care Icould provide.

A few years after I qualified, I started work in an ENTtheatre and I remember feeling quite thankful that I hadundergone my tonsillectomy as a young child before Isaw how tonsils were removed. The brutality of tonsilsnares and guillotines was a complete shock – nowonder I was in so much pain after surgery! Over thepast three decades, new, safer techniques haveemerged; however, Ulrica Nilsson and her teamcompared postoperative behaviour and recovery inchildren undergoing tonsillectomy and in this editionindicate that pain in children undergoing tonsil surgery isstill poorly managed.

I remember working as a scrub nurse in obstetrics withfondness. There is nothing more special than sharingthe birth of a baby with the new parents. It is unfortunate

that not all births go to plan. Post-partum haemorrhageis one of the most dangerous complications following abirth and requires emergency care by a multidisciplinaryteam. In his article this month, Gareth Benson looks atthe causes, as well as surgical and pharmaceuticalmanagement, of primary post-partum haemorrhage.

Although I regrettably never gained any experience incardiac surgery, I was privileged to perform somegeneral surgical procedures working in my last NHS roleas a Surgical Care Practitioner (SCP). Following on frommy own research in this area, Gabriel Campenerreminds us in his article that the presence of an SCP in asurgical team significantly improves the patientexperience while providing quality care and support forsurgical trainees.

I never got the opportunity to work in neurosurgery, sincethis type of surgery was usually performed in specialistunits. Consequently, many perioperative practitionersare not exposed to all neurological conditions and thecare that is required. Whilst Evagelia Laopoulou and herteam explore nurses' knowledge on caring for patientswith neurological disease in this edition, their articleidentifies the lack of knowledge that many practitionersoften have when caring for this group of patients.Continuing the neurosurgery theme, in his 'Surgery of thePast' series, Professor Harold Ellis, Emeritus Professor atSt Guys Hospital, London looks at the surgicaldevelopment in the treatment of trigeminal neuralgia –one of the most painful conditions of the face.

Reflecting on my own perioperative journey as well as myfamily's experiences reminds me how far surgery andanaesthetics has come over the past three decades.Technology has developed at a fast rate and we havehad to change to move with it. I feel honoured to havebeen part of this past generation of perioperativepractitioners who have striven to advance perioperativecare. Long may it continue!

Julie QuickSenior Lecturer

Faculty of Health, Education and Life Sciences,Birmingham City University



2019, Vol. 29(4) 68




DOI: 10.1177/1750458919837843


mailto:[email protected]


http://dx.doi.org/10.1177/1750458919837843


Book Review

It's Never Easy These Days

At a glance

Content. . .Ease of use. . .Value for money. . .

� Gareth HollbrookeTroubador, Leicester, 2015ISBN: 9781784622275PB, 272 pages, £9.99 (ebook available)

This comprehensive book has an original back storyabout the legacy of service delivery and administrativechanges within the UK's National Health Service whichtakes place over many decades.

The author starts off as a stores and supplies managerwith gradual promotion to senior administrator in anamalgamated trust of several hospitals. The text travelsthrough a 40 year time span from the pre-Griffiths era,covering NHS reorganisation, the internal market andmodernisation agenda to the current healthcare trustorganisation.

Each chapter is short with a glimpse of the complexitieswithin NHS management and administration in all itsdynamic and amusing forms. Chapters include: 'The WayWe Were', to 'Internal Market' and 'The Thatcher Years','Rent-a-Scope', 'Nurses, Neighbours, Car Parking Spacesand Spend, Spend, Spend!'

The true stories are both charming and amusingfocusing on an ever evolving public health service andits workforce, as well as the characters/personalities weall work with. One of the most original quotes from thebook is: 'The NHS in many respects is a very unforgivingorganisation and due to the rapid changes from the1990's onwards is not an easy environment to beconfident in'. How True!

This book is suitable for managers and administrators inprivate and public sectors, bearing in mind thatmanagement issues are similar the world over. Aninteresting, light and amusing read.

Leontia HoyCourse Director, BSc Hons/Graduate Diploma/Post Graduate

Diploma-Specialist, School of Nursing, Queen’s University Belfast


2019, Vol. 29(4) 69




DOI: 10.1177/1750458918816233



http://dx.doi.org/10.1177/1750458918816233


News

News Update

Government pledges overhaul to mentalhealth and wellbeing support for NHS staff

Plans to give staff immediate access to dedicatedmental health support will be considered as part of theupcoming workforce implementation plan.

The government is setting out new plans to providebetter mental health and wellbeing support to NHS staff.

The new support will be based on recommendations byHealth Education England (HEE) and could include:

• Post-incident support for NHS frontline staff, such aspeer group support or a more formal psychologi-cal assessment.

• A dedicated mental health support service giving con-fidential advice and support 24 hours a day.

• Fast-tracked mental health referrals for NHS employ-ees if requested as a priority from either a GP or anoccupational health clinician.

• Improved rest spaces for on-call staff and traineesduring and after their shifts, providing security,shower facilities and refreshments.

• An 'NHS workforce wellbeing guardian' in every NHSorganisation, responsible for championing mentalhealth and wellbeing support for staff.

HEE made the recommendations in its report on themental health and wellbeing of NHS staff and learners,commissioned by the Department of Health and SocialCare last year.

The recommendations will be considered as part ofthe 'workforce implementation plan', which will beled by NHS Improvement Chair Dido Harding andLeeds Teaching Hospitals Trust Chief ExecutiveJulian Hartley.

HEE spoke to staff whose wellbeing had beenaffected by their experiences in the NHS workplace,as well family members who had lost relativesthrough suicide. They also visited organisationsthat are already demonstrating good practice insupporting staff mental and physical wellbeing tounderstand how these initiatives could be rolled outacross the NHS.

The measures should help NHS organisations makepositive progress on sickness absence rates, staffperformance and retention.

The latest NHS staff survey showed that less than a thirdof staff felt their organisation took positive actiontowards improving their health and wellbeing.

For more information visit: https://www.gov.uk/government/news/mental-health-and-wellbeing-support-for-nhs-staff-government-pledges-overhaul

To download a copy of the report, go to: https://www.hee.nhs.uk/our-work/mental-wellbeing-report

Contains public sector information licensed under the OpenGovernment Licence v3.0.

Before and after surgery: Dedicated careoffers patients a 'teachable moment' toimprove long term health

Exercise and nutritional support before an operationcould reduce the time patients spend recovering inhospital after surgery, according to a new report fromthe Royal College of Anaesthetists (RCoA).


2019, Vol. 29(4) 70–72




DOI: 10.1177/1750458919840267


https://www.gov.uk/government/news/mental-health-and-wellbeing-support-for-nhs-staff-government-pledges-overhaul



https://www.hee.nhs.uk/our-work/mental-wellbeing-report

https://www.hee.nhs.uk/our-work/mental-wellbeing-report


http://dx.doi.org/10.1177/1750458919840267


The report, 'A teachable moment: deliveringperioperative medicine in integrated care systems',showcases numerous innovative and award-winningprogrammes in hospitals across England thatare improving patient care before, during andafter surgery.

The RCoA's report highlights how NHS England's newintegrated care systems (ICSs) can facilitate this wideradoption of perioperative pathways of care. The range ofinitiatives included in the report address a number ofthe priorities of the Long Term Plan for the NHS,including cancer recovery, cardiovascular care andpaediatric services.

The report focuses on the first-wave of ten ICSs acrossEngland, and is timely, given that the Long Term Plan forthe NHS includes an ambition for all of England to becovered by an ICS by April 2021.

The report looks at several initiatives at variousstages of the perioperative period, including inpreparation for surgery. One of these initiatives isthe WESFIT programme that is exploring thebenefits of exercise for patients undergoingcancer treatment.

To download the report, visit https://www.rcoa.ac.uk/system/files/IntegratedCareSystems2019.pdf

Hospital safety initiative wins national patientsafety award

A groundbreaking safety initiative adopted from theairline industry and now used to protect patients

undergoing surgery at the Royal Blackburn and BurnleyGeneral teaching hospitals has won a national award forpatient safety.

Known as 10,000 feet, the safety initiative came to UKhospitals thanks to Junior Charge Nurse Rob Tomlinson,who discovered how nurses in Australia were using thephrase to reduce the risk of hospital theatre errorscaused by noise, distractions and poor communication.

And when Rob explained 10,000 feet to leadinghealthcare safety experts, they decided the initiativedeveloped for hospitals in East Lancashire was theworthy winner of the 'Patient Safety Award' category.

Award winner, Rob Tomlinson, said: "Having a safeworking environment is essential in an operating theatreand the number one reason to introduce a uniquepatient safety initiative called 10,000 feet. In simpleterms, it's a straightforward way to stop all unnecessarynoise in a theatre all allow all staff, including thesurgeon, to concentrate completely on their work."

"In operating theatres, noise and distraction are twoleading causes of 'Never Events' - serious incidents orerrors that can be avoided if proper safety proceduresare followed."

Using 10,000 feet means anyone working in theoperating theatre can say the phrase '10,000 Feet' atany time before, during or after surgery, signalling toother staff the need for a quiet environment toconcentrate totally on the task at hand.

10,000 feet comes from the airline industry whereduring take-off and landing - before the aircraft passes10,000 feet on ascent and after it has passed 10,000feet on the approach - pilots must focus entirely on 'theiressential operational activities' and 'avoid non-essentialconversations'.

10,000 Feet innovator and Junior Charge Nurse Rob Tomlinson (right)and Consultant Anaesthetist Dr Mike Pollard with the PatientSafety Award

News Update 71

https://www.rcoa.ac.uk/system/files/IntegratedCareSystems2019.pdf

https://www.rcoa.ac.uk/system/files/IntegratedCareSystems2019.pdf

ELHT is the first Trust in the UK to introduce 10,000 feetwith the initiative now being used by operating theatrestaff at the Royal Blackburn and Burnley Generalteaching hospitals.

A spokesperson for East Lancashire Hospitals NHS Trust,said: "Many congratulations to Rob on winning this well-deserved award. 10,000 Feet is a simple, easy-to-remember phrase which can help to reduce errors andwe're encouraging all our theatres to adopt 10,000 feet."

In addition to a positive thumbs-up from theatre staff atBurnley and Blackburn hospitals, the national CareQuality Commission recently praised Rob's initiative bydeclaring '10,000 feet had strengthened safetyprocedure in (hospital) theatres'.

The Topol Review: Preparing the healthcareworkforce to deliver the digital future

Commissioned by the Secretary of State for Health andSocial care and produced by Health Education England(HEE); the Topol Review is an independent report whichlooks at the influence technology will have on healthcareand its workforce over the next two decades. Thereview focuses on the impact that areas such as digitalhealth, genomics, robotics and artificial intelligencewill have.

The report is written by the prominent cardiologist anddigital medicine expert, Dr Eric Topol.

To download a copy of the report, visit: https://topol.hee.nhs.uk/

For more information go to: https://topol.hee.nhs.uk/

Contains public sector information licensed under the OpenGovernment Licence v3.0.

72 Journal of Perioperative Practice 29(4)

https://topol.hee.nhs.uk/



Viewpoint

A personal view of the harmful effectsof diathermy smoke

Kathy Nabbie

Keywords

Surgical plume / Surgical diathermy smoke / Theatres / Smoke evacuation / Health hazard / Risk management

For a long time, perioperative practitioners have beenexposed to diathermy plume. The hazards associatedwith exposure emerged a number of years ago, however,despite national guidelines on the safe use of diathermy,few organisations seem to take the risks associated withinhaling diathermy smoke seriously. This has led me topetitioning the Government to take action to reduce therisk to perioperative staff across the UK and I hope youwill join me in raising awareness of this issue and signmy petition.

My story

My theatre career began in 1988 and after eight yearsI started to experience coughing and wheezing on aregular basis. Each time I had a common cold it wouldlead to a chest infection and chronic bronchitis. My GPuse to say, 'Are you sure you do not smoke?' I have neverbeen a smoker and therefore he could not understandwhy I was experiencing so many health problemsrelating to my chest. Meanwhile, I continued to inhalesmoke in the operating theatre each time the diathermywas used – oblivious to the risks.

Even though diathermy smoke was often suctioned awayto allow the consultant to have a clear field, a lot of thesmoke still managed to travel around the theatre,through the vents and into the corridors outside. It evenfound its way into the lifts. Other members of staffreported health problems and one of my surgicalcolleagues died of lung disease, he was also anon-smoker.

In 1998, I was introduced to a smoke evacuation systemand what a revelation it was. It was a joy to see it in useand what's more, I could breathe again. However, forvarious reasons some surgeons were reluctant to usesmoke evacuation, so once again I continued to beexposed to diathermy smoke on a regular basis.

In 2007, I changed specialty to breast oncoplastics.I introduced smoke evacuation to both the oncoplasticand plastic breast surgeons. They all found it beneficial,especially one of the Professors of surgery who never

liked the smell of smoke and found that the suctiondidn't really remove it from the working environment. Hebecame a great advocate of smoke evacuation and hewould not work in an operating theatre unless smokeevacuation was available. Needless to say; I stayed inthis specialty, and there were no more common coldsescalating to chronic bronchitis.

That was when I realised that the cause of my symptomsmight be attributed to diathermy smoke and I began tolook at the literature on this. Studies have shown thatjust one gram of ablated tissue is equivalent to smokingsix unfiltered cigarettes and the smoke emitted, just likecigarettes, is mutagenic (Hill et al 2012). Benzene andToluene are known carcinogens which can cause cells tomutate resulting in a harmful effect on the lungs, liverand kidneys as well as impairing the immune system.Both compounds are present in diathermy smoke.

In 2012, the British Association of Plastic Surgeons(BAAPS) conducted studies with six human and 78porcine tissue samples to find the total daily duration oftissue ablated during five minutes of using monopolardiathermy (Hill et al). This was measured and recordedfor a period of two months. On average, the resultsshowed that the total smoke collected daily wasequivalent to smoking 27 to 30 cigarettes.

The study also highlighted that only 66% of hospitals inthe UK had smoke evacuation units, many of which werenot utilized for each case. One likely contributing factoris that in the past some surgeons found them toocumbersome to use. Plus, despite the use of smokeevacuation being a recommendation by the Health andSafety Executive (HSE 2012), AfPP (2009) and theMedicines and Healthcare Products Regulatory Agency(MHRA 2015), it is not currently mandatory to use asmoke evacuation unit within the theatre environment.This is likely to be because there is no conclusive,

Theatre Practitioner

Corresponding author:

Kathy Nabbie, Theatre Practitioner.



2019, Vol. 29(4) 73–74




DOI: 10.1177/1750458919839290




http://dx.doi.org/10.1177/1750458919839290


validated evidence to support this. I spoke to the CareQuality Commission (CQC) and the National Institute forHealth and Care Excellence (NICE) last year andrepresentatives from these organisations reiterated thatit is only a recommendation. This might be becausethere is a lack of statistical data relating to surgicalsmoke but surely if the HSE (2012) recommend avoidingexposure to smoke of any kind we should be usingsmoke evacuation systems routinely?

Sign the petition

As I now work in a 'smoke free' environment, I want mycolleagues to enjoy the same benefit. In November2017, I approached the Minister for Health at aconference in London where he was speaking. He wasinterested in what I had to say and gave me his card sothat I could email him which I did. In December 2017, Ireceived a letter from him which stated that hospitalsshould have risk assessments to encourage the use of asmoke evacuation system. I was disheartened at thisresponse as I felt the way forward was to make itcompulsory just like the smoking ban in England. I havedecided to take this forward myself and AfPP aresupporting my petition to the British Government tomake smoke evacuation compulsory in theatres acrossEngland and Wales. Ten thousand signatures areneeded for the government to respond.

Please sign the petition to make smoke evacuationcompulsory, visit https://petition.parliament.uk/petitions/237619

Join in the conversation#BanSurgicalSmoke#BanSurgicalPlume

No competing interests declared

References

AfPP 2009 Surgical Smoke: What we know. Harrogate: AfPPBeswick A, Evans G, 2012 Evidence for exposure and harmful

effects of diathermy plumes (surgical smoke) Evidencebased literature review prepared by the Health and SafetyLaboratory for the Health and Safety Executive)

Hill DS, O'Neil JK, Powell RJ, Oliver DW 2012 Surgical smoke –a health hazard in the operating theatre; a study to quantifyexposure and a survey of the use of smoke extractorsystems in UK plastic surgery units Journal of Plastic,Reconstructive & Aesthetic Surgery 65 (7) 911–916

MHRA 2015 Electrosurgery – top tips. London: MHRA

Further reading:

AfPP 2016 Standards and Recommendations for practice.Harrogate: AfPP

Belcher J 2017 Let's Ban Surgical Smoke http://www.outpatientsurgery.net/surgical-facility-administration/personal-safety/lets-ban-surgical-smoke–staff-patient-safety-17 Outpatient Surgery (AORN)

Hedley A, 2018 Surgical Smoke Nearly Killed Me http://www.outpatientsurgery.net/issues/2018/02/surgical-smoke-nearly-killed-me Outpatient Surgery AORN

Morsch M 2019 Smoke Forced Her Out of the OR- She ThenForced Smoke Out of the ORhttp://www.outpatientsurgery.net/surgical-facility-administration/personal-safety/smoke-forced-her-out-of-the-or–she-then-forced-smoked-out-of-the-or–01-19 Outpatient Surgery AORN

Occupation health and wellbeing 2015 Case Study: protectionof healthcare staff from surgical smoke in operatingtheatres https://www.personneltoday.com/hr/case-study-protection-of-healthcare-staff-from-surgical-smoke-in-operating-theatres/ Personnel Today

Single Use Surgical The Hazards of Surgical Smoke https://susl.co.uk/the-hazards-of-surgical-smoke/




http://www.outpatientsurgery.net/surgical-facility-administration/personal-safety/lets-ban-surgical-smoke&hx2013;staff-patient-safety-17




http://www.outpatientsurgery.net/issues/2018/02/surgical-smoke-nearly-killed-me



http://www.outpatientsurgery.net/surgical-facility-administration/personal-safety/smoke-forced-her-out-of-the-or&hx2013;she-then-forced-smoked-out-of-the-or&hx2013;01-19




https://www.personneltoday.com/hr/case-study-protection-of-healthcare-staff-from-surgical-smoke-in-operating-theatres/



https://susl.co.uk/the-hazards-of-surgical-smoke/

https://susl.co.uk/the-hazards-of-surgical-smoke/

Review

Primary post-partum haemorrhage –Causation and management

Gareth Benson

Abstract

This paper looks to investigate the causes and management of haemorrhage in the post-partum patient, considering the

causes of obstetric bleeding and interventions that may be employed to arrest it.

Keywords

Bleeding / Haemorrhage / Obstetric / Placenta / Post-partum haemorrhage

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication 2 May 2018.

Introduction

Obstetric haemorrhage is the global leading cause ofmortality during childbirth accounting for between 27.1%(Say et al 2014) and 28% (Chandraharan & Arulkumaran2008) of perinatal maternal deaths . The most commonform of obstetric haemorrhage is known as primary post-partum haemorrhage (PPH) and is defined by the WorldHealth Organisation (WHO) as 'a blood loss of 500ml ormore within 24hours after giving birth'. In somedeveloping countries the incidence of fatal PPH hasbeen reported to be as high as 1:1000 deliveries, indeveloped countries with comprehensive medicalfacilities such as the UK this risk is reduced to1:100,000 (Drife 1997).

Risk factors associated with PPH andrisk reduction

The recognised risk factors for developing PPH include ahistory of hypertensive disorder such as pre-eclampsia,delivery by forceps or vacuum extraction, failure toprogress in the third stage of labour, previous PPH andmacrosomia (Sheiner et al 2005); however, PPH canoccur in women with none of these factors andconsequently clinical teams should be acutely preparedto manage a PPH at even the most routine of deliveries.

Reducing the risk of both the occurrence and severity ofPPH can be achieved by considering its management'before the event' and acting proactively withpreventative steps; these can include addressinganaemia prior to delivery (Malhotra et al 2002), avoidingroutine episiotomy (Hartmann et al 2005) and mostimportantly actively managing the third stage of labour.

Active management encompasses the administration ofa uterotonic drug, usually oxytocin, in the first minutepost-delivery and applying controlled cord traction; somedefinitions of active management also include earlyclamping and cutting of the umbilical cord and externaluterine massage following the delivery of the placenta(Van Den Broek 2007). Prendiville et al (2000) foundthat by actively managing the third stage of labour, theincidence of PPH could be reduced by as much as 68%.

Causes

The cause of PPH is usually attributed to one, orindeed a combination of four origins. Known by thepneumonic '4Ts'.

Bleeding caused by poor tone manifests in thepresentation of an 'atonic uterus' a situation where thepost-delivery uterus fails to adequately contract. Tissue-related bleeding is caused by retained products,placental fragments or indeed a retained placenta leftbehind inside the uterus. Traumatic bleeding is caused

Glan Clwyd Hospital, Rhyl, UK


Gareth Benson, Glan Clwyd Hospital, Sarn Lane, Rhyl LL18 5UJ, UK.



2019, Vol. 29(4) 75–80




DOI: 10.1177/1750458918782902


http://orcid.org/0000-0002-6348-4546



http://dx.doi.org/10.1177/1750458918782902


by tearing of the vagina or vulva during delivery andthrombin relates to blood clotting disorders.

Tone

An atonic uterus after delivery is associated with highrates of blood loss and is the main cause of PPHaccounting for up to 70% of cases (Anderson & Etches2008). The natural physiological transit mechanismlinking the maternal and fetal circulation systemsinvolves spiral arteries passing from the uterus throughan interlacing mesh-like layer of myometrial fibroustissue into the placental bed. After delivery thecontraction of the uterus and connected myometrialfibres causes occlusion of the spiral arteries and 'selfseals' the circulatory connections between the maternalblood supply and the placental bed (Mukherjee &Arulkumaran 2009). An atonic uterus occurs when thisnatural contraction mechanism fails to initiate leavingthe connecting arteries to free flow into the uterinecavity. At term, up to 20% of maternal cardiac output isdirected to the uteroplacental circulation equating toapprox 600ml/min, hence unaddressed, an atonicuterus can cause rapid and fatal haemorrhage(EL-Refaey & Rodeck 2003).

Uterotonics, uterine massage and bimanualcompression

Management of an atonic uterus may incorporateseveral options to stem the bleeding. According to theWHO recommendations, the administration of oxytocinalong with external uterine massage is the initialtreatment as soon as the diagnosis is confirmed. Otheruterotonic drugs may then be considered. Ergometrine,oxytocin infusion, carboprost and misoprostol are allindicated by The Royal College of Gynaecologists for usein PPH (Mavrides et al 2016).

Should the uterus remain atonic and in a state ofhaemorrhage after pharmaceutical intervention andattempts to 'rub up' contraction then more invasive inputis required and the patient should be transferred to anarea of definitive care such as an operating theatre; toreduce bleeding during the transition to such a facilitytemporary measures to reduce blood loss can be usedand these include external pressure to causecompression of the abdominal aorta and bimanualuterine compression. Bimanual uterine compression isachieved by placing a hand into the vagina in the form ofa fist and compressing the main body of the uterus,another hand compresses the fundus of the uterusexternally through the abdominal wall, both hands arecompressed firmly and both apply a massaging motion(Figure 1).

Intrauterine tamponade

Once it has been established that the haemorrhageremains uncontrolled despite the administration ofoxytocin more invasive approaches are required, the firstchoice and least invasive of these is the intrauterinetamponade balloon.

The basic principle of the intrauterine tamponadeballoon is a capsule inserted inside the uterus andinflated to fill the uterine cavity; this exerts an outwardpressure onto the uterine wall causing a tamponadeeffect on the bleeding vessels. Many pre-existingmedical devices have been used to achieve this effectincluding the Rusch urological balloon (Johanson et al2001), and the Sengstaken–Blakemore double balloontube, primarily designed for the management ofbleeding oesophageal varices (Sengstaken & Blakemore1950). However, the most widely used device designedspecifically and primarily for intrauterine tamponade isthe Bakri balloon (Figure 2). The Bakri balloon isdesigned to take the shape of the uterus and can beeasily inserted either vaginally or abdominally through acaesarean section incision. Its effectiveness can beeasily gauged and if necessary it can be easily removed.The Bakri balloon can in many cases serve as adefinitive measure to stop the bleeding; however, inmore severe cases, it still serves to reduce haemorrhagetemporarily while surgical options are prepared.

Figure 1 Bimanual uterine compression. Source: Reproducedwith kind permission of Prof. B-Lynch


Surgical control

The options for controlling PPH after attemptingintrauterine balloon tamponade are surgical. The mostinvasive treatment for PPH is hysterectomy; this canhave negative physical and psychological effects on thepatient as well as the obvious effect on their long-termreproductive capability. There are several surgicaloptions that although still invasive fall short of theimpact caused by hysterectomy; these include uterineartery ligation and the use of compression sutures suchas the B-Lynch suture. The B-Lynch compression sutureutilises sustained external compression from a tautbrace suture to force uterine contraction, first describedin 1997 by Professor B-Lynch the method (illustrated inFigure 3) is widely taught due to its simplicity to performwith relatively little surgical expertise, its fertilitypreserving quality and repeated studies showing positive

Figure 3 B-Lynch Compression Suture. Source: Reproduced with kind permission of Prof. B-Lynch

Figure 2 Bakri balloon. Source: ! 2007 Lisa Clark courtesy ofCook Medical Inc, Reproduced with permission

Benson 77

results. Should bleeding remain uncontrolled despitefertility preserving surgical management such ascompression suturing the conclusive action to save thepatient from fatal haemorrhage is hysterectomy (Rossiet al 2010).

Trauma

Traumatic injury is the second most common cause ofPPH after uterine atony and accounts for up to 20% ofcases (Anderson & Etches 2008). Trauma to theperineum or lower vaginal structures following vaginal orinstrument assisted birth is not a rare event. The RoyalCollege of Obstetricians and Gynaecologists (2007)suggest that traumatic injury to the vagina to somedegree may be observed in as many as 85% of vaginaldeliveries; the traumatic injury may be caused by anunintended tear in the vaginal wall classified from first tofourth degree (see Table 1), an episiotomy formedsurgically to create an increase in the size of the vaginalopening or in some rarer cases by a tear to the cervix orthe upper internal aspect of the vagina.

Perineal tear

Management of all degrees of tear is usually surgical innature requiring suturing of the affected area, first andsecond degree tears require suturing under direct vision,of the skin, mucosa and if applicable underlying musclebed; generally using continuous sutures with anabsorbable suture material. A per rectal examinationshould be performed following first and second degreerepairs to confirm the exclusion of anorectal mucosa inthe suturing. Third and fourth degree tears involving theanal sphincters and anorectal mucosa, respectively, maybleed profusely; repair can be complex and should besutured under senior clinician supervision. The use ofurethral catheterisation and vaginal packing may benecessary to facilitate repair of third and fourth degreetears (Chandraharan & Arulkumaran 2008).

Episiotomy

An episiotomy is an intentional incision made at theopening of the vagina to help facilitate the passage of ababy through the vaginal opening. There is conflictingevidence on the benefit of routine episiotomy inavoidance of vaginal tearing; however, there is a

recommendation by the Royal college of Obstetriciansand Gynaecologists (2007) that in the case of vaginalinstrumental delivery an episiotomy at 45�–60� of themidline appears to have some merit. During birth anunintended extension of the precut episiotomy can occurcausing potential damage to surrounding perineal tissueand increased bleeding, episiotomy is not without riskand some studies suggest a five-fold increase in thelikelihood of PPH in patients with episiotomy (Coombs etal 1991).

Cervical/upper apex tear

Tears in the upper apex of the vagina, surrounding thecervix, although relatively rare, are notoriously difficult torepair due to restricted visualisation and access. Theproximity to other organs such as the bladder andurethra is also a consideration which makes it necessaryto be performed by a senior clinician; these tears canalso bleed profusely again hindering visualisation of thewound. Cervical tears above 2cm diameter or that bleedactively (regardless of size) should be addressed usingfigure of eight sutures along with speculum and roundforceps; the procedure will require an operating theatre(Chandraharan & Arulkumaran 2008).

Uterine damage

Both uterine rupture and uterine inversion are seriousand potentially life-threatening complications, which cancause PPH. Uterine rupture during late pregnancy andlabour is a rare but not insignificant risk; it is usuallyassociated with a scarred uterus and occurs in around0.7% of vaginal births in women with a history ofcaesarean section (Guise et al 2004). Uterine rupturemay present with symptoms of fetal bradycardia, heavyvaginal bleeding and maternal circulatory collapse; themanagement involves expedient maternal resuscitationand surgical repair of the rupture or hysterectomy.Uterine inversion occurs when the placenta fails toseparate from the internal uterine wall, as the placentais delivered it pulls on the inside surface of the uterusturning it inside out. Poor management of the third stageof labour, including excessive cord traction is thought toincrease the risk of uterine inversion although it is still arare complication of childbirth. The inverted uterus canoften be reinserted manually using the Johnson method,in which it is directed slowly with sustained pressure

Table 1 Degrees of perineal tear

First-degree tear Injury to perineal skin and/or vaginal mucosa

Second-degree tear Injury to perineum involving perineal muscles but not involving the anal sphincter

Third-degree tear Injury to perineum involving the anal sphincter complex

Grade 3a Less than 50% of external anal sphincter thickness torn

Grade 3b More than 50% of external anal sphincter thickness torn

Grade 3c Both external anal sphincter and internal anal sphincter torn

Fourth-degree tear Injury to perineum involving the anal sphincter complex (external anal sphincter,

internal anal sphincter) and anorectal mucosa


upwards towards the umbilicus. Other options includelaparotomy to retrieve the uterus internally; should alloptions fail, decisive management is hysterectomy.

Tissue

Haemorrhage relating to 'tissue' is associated withcomplications of the placenta; these include placentaaccreta, placenta praevia and retained placenta.

Placenta accreta

Placenta accreta occurs when there is an abnormalattachment of the placenta to the uterine wall leading tothe placenta indwelling into the uterus; the condition isgenerally picked up at prenatal scanning and mayrequire an elective caesarean section with a possiblehysterectomy. In the case of an unexpected placentaaccreta heavy bleeding may be noted during delivery ofthe placenta with a need for maternal fluid resuscitationand potentially hysterectomy. It is a relatively rareoccurrence with an incidence described in some studiesas low as 0.04% of births (Eshkoli et al 2013).

Placenta praevia

Placenta praevia is a complication associated with aplacenta that attaches low down in the uterus thusoccluding the cervical opening. The symptoms of brightvaginal bleeding are generally seen several weeksbefore delivery and so is rarely a post-partum problem,an elective caesarean section may be required. Withpartial occlusions a vaginal delivery may still bepossible, the increased chance of bleeding needs to beconsidered and adequate blood transfusions availableto explore this option. Placenta praevia is relatively rareand has a reported incidence of 0.4–0.5% ofpregnancies (Faiz & Ananth 2003).

Retained placenta

Under normal circumstances, aided by uterinecontraction the intact placenta generally separates fromthe uterine wall within the first 10min after birth; incases where this separation is delayed there is a greateramount of expected blood loss. Should this separationnot occur naturally, or indeed only separate partially,leaving fragments of placenta attached to the uteruswall, the effect is likely to be incomplete contraction ofthe uterus and consequently increased bleeding.Options for management include administration ofoxytocin and manual removal for a retained placenta;manual or surgical removal of any retained fragments ofplacenta may be indicated if uterine contraction isimpeded. A retained placenta has been shown to beprevalent in approximately 3% of vaginal births in the UKbut has a very low mortality rate with only a single deathattributed to PPH caused by a retained placenta in theUK between 1969 and 2005 (Weeks 2008).

Thrombin

Disorders of coagulation, although rare as a primarycause of PPH can contribute to an increase in severity ofexisting haemorrhage. These conditions includehaemophilia, HELLP Syndrome (haemolysis, elevatedliver enzyme levels and low platelets) and notably VonWillebrand disease. Expectant mothers with a knowncoagulation disorder should be closely monitored withclotting factor testing carried out during the thirdtrimester of pregnancy. Delivery should take place in amedical facility with access to multi-specialty careincluding haematology, anaesthetics, obstetrics andpaediatrics. PPH is significantly more prevalent inwomen with coagulation disorders and their birth planshould include planning for the possibility of activating amassive haemorrhage protocol.

Although a coagulation disorder is not a strict indicationfor elective caesarean section, a vaginal birth shouldideally be as non-traumatic as possible with vacuumextraction or the use of obstetric forceps avoided.Women with a known or suspected coagulation disorderare at higher risk of complication and should haveongoing contact with consultants from amultidisciplinary team at every stage of pregnancy andpost-delivery.

Conclusion

PPH remains a significant complication of childbirth,anticipation of the potential for it to occur in even themost routine of deliveries is paramount and having apredecided plan B and C is a pragmatic approach.Maternal fluid resuscitation is required for sustainedPPH regardless of the cause; this may involve activationof a major haemorrhage protocol and may require earlyspecialist assistance. Hysterectomy is often thedefinitive treatment; however, several fertility preservingmethods of haemorrhage control such as the Bakriballoon and the B-Lynch compression suture provide anoption for patients who desire further pregnancy. Pre-planned whole team-based simulation training canaddress the human factors elements involved in PPHmanagement and can be of great use to improving theefficiency of clinical teams when faced with anemergency situation (Drife 1997). Forethought andcareful preparation are key to delivering the highestpossible level of care to the patient experiencing PPH.


ORCID iD

Gareth Benson http://orcid.org/0000-0002-6348-4546

References

Anderson J, Etches DJ 2008 Postpartum haemorrhage thirdstage emergency. In: Damos JD, Eisinger SH, Baxley EG(Eds) Advanced Life Support in Obstetrics Course Syllabus.

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http://orcid.org/0000-0002-6348-4546

4th ed. American Academy of Family Physicians,London, RCOG

Chandraharan E, Arulkumaran S 2008 Surgical aspects ofpostpartum haemorrhage,best practice & research ClinicalObstetrics and Gynaecology 22 (6) 1089–1102

Coombs C, Murphy E, Laros R 1991 Factors associated withpostpartum haemorrhage with vaginal birth Obstetrics &Gynecology 77 (1) 69–76

Drife J 1997 Management of primary postpartumhaemorrhage British Journal of Obstetrics and Gynaecology104 (1) 275–277

EL-Refaey H, Rodeck C 2003 Post-partum haemorrhage:definitions, medical and surgical management. A time forchange British Medical Bulletin 67 (1) 205–217

Eshkoli T, Weintraub AY, Sergienko R, et al 2013 Placentaaccreta: risk factors, perinatal outcomes, andconsequences for subsequent births American Journal ofObstetrics & Gynecology 208 (219) 1–7

Faiz AS, Ananth CV 2003 Etiology and risk factors for placentaprevia: an overview and meta-analysis of observationalstudies The Journal of Maternal-Fetal & Neonatal Medicine13 (3) 175–190

Guise JM, McDonagh MS, Osterweil P, Nygren P, Chan BK,Helfand M 2004 Systematic review of the incidence andconsequences of uterine rupture in women with previouscaesarean section British Medical Journal 329 (1) 19–25

Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, ThorpJ, Lohr K 2005 Outcomes of routine episiotomy asystematic review Journal of the American MedicalAssociation 293 (17) 2141–2148

Johanson R, Kumar M, Obhrai M, Young P 2001 Managementof massive postpartum haemorrhage: use of a hydrostaticballoon catheter to avoid laparotomy British Journal ofObstetrics and Gynaecology 108 (1) 420–422

Malhotra M, Sharma JB, Batra S, Sharma S, Murthy NS, AroraR 2002 Maternal and perinatal outcome in varying degrees

of anemia International Journal of Gynecology & Obstetrics79 (1) 93–100

Royal College of Obstetricians and Gynaecologists 2007Management of Third- and Fourth-Degree Perineal TearsFollowing Vaginal Delivery Royal College of Obstetriciansand Gynaecologists guidelines, London

Mavrides E, Allard S, Chandraharan E, et al 2016 Preventionand management of postpartum haemorrhageBritish Journal of Obstetrics and Gynaecology 124(1) 106–149

Mukherjee S, Arulkumaran S 2009 Obstetrics post-partumhaemorrhage Obstetrics, Gynaecology & ReproductiveMedicine 19 (5) 121–126

Prendiville WJ, Elbourne D, McDonald S 2000 Active versusexpectant management in the third stage of labourCochrane Database of Systematic Reviews (3) CD000007

Rossi AC, Lee RH, Chmait RH 2010 Emergency postpartumhysterectomy for uncontrolled postpartum bleeding: asystematic review Obstetrics & Gynecology 115(1) 637–644

Say L, Chou D, Gemmill A, et al 2014 Global causes ofmaternal death: a WHO systematic analysis The Lancet 2(6) 323–333

Sengstaken RW, Blakemore AH 1950 Balloon tamponade forthe control of hemorrhage from esophageal varices Annalsof Surgery 131 (1) 781–789

Sheiner E, Sarid L, Levy A, Seidman D, Hallak M 2005Obstetric risk factors and outcome of pregnanciescomplicated with early postpartum hemorrhage: apopulation-based study The Journal of Maternal-Fetal &Neonatal Medicine 18 (3) 149–154

Van Den Broek 2007 Life Saving Skills Manual: EssentialObstetric and Newborn Care. 2nd ed. London, RCOG Press

Weeks A 2008 The retained placenta, best practice & researchClinical Obstetrics and Gynaecology 22 (6) 1103–1117


Clinical Feature

The presence of a Surgical CarePractitioner in the perioperative teamis of benefit both to the patient and theconsultant-led extended surgical team

Gabriel Rene M. Campaner

Abstract

Non-medically qualified professionals have progressively advanced and developed in line with the country’s constantly

evolving health care system. Recently, increasing hospital activity, underfunding in health care and a falling number of

doctors have left the NHS perpetually underdoctored, underfunded and overstretched. As the current health care

climate demands these 'non-doctors’ to demonstrate competent knowledge and skill in providing safe and effective care,

this paper discusses limitations, the scope of practice as well as the benefits the Surgical Care Practitioner provides to

the modern extended surgical team, and most importantly – the patients under their care.

Keywords

Surgical care practitioner / Non-medical practitioners / Extended surgical team

Provenance and Peer review: Invited contribution; Peer reviewed; Accepted for publication 18 February 2018

The National Health Service (NHS) is regarded as thebest health care service provider among developedcountries ranking first in overall health care quality,efficiency and accessibility (Davis et al 2014). Over theyears, however, there has been growing concernregarding its ability to maintain its class leading qualityagainst the current health care climate. Increase inhospital activity (Buchan et al 2016), underfunding inhealth care (Dunn et al 2016), a nationwide shortfall indoctors (Maybury 2014) and the economic uncertaintyresulting from the aftermath of the United KingdomEuropean Union membership referendum (McKee 2016)has left the NHS perpetually 'underdoctored,underfunded, and overstretched' (RCP 2016). For qualitycare to be continually accessible to all, the emphasis onthe development of extended roles such as Surgical CarePractitioners (SCPs) has become increasingly morerelevant in the modern surgical team (Abrahamet al 2016).

Non-medically qualified professionals have helpedenhance care amidst the country's constantly evolvinghealth system and challenging workforce for the past 25years. The SCP role has progressed largely since the firstcurriculum standard was published in 2006 (Abraham etal 2016). More recently, the NHS Five Year Forward View

supports the development of new roles and provides astrategic framework by extending the workforce as aneffort to improve care delivery (England NHS 2014). Asinnovations in practice must be grounded in well-founded underpinning, the Royal College of Surgeons(2014) strengthens the relevance of the role bydeveloping the curriculum framework as a structure fortraining SCPs to implement surgical interventions andperform significant roles in the patients' journey, whileunder the supervision of a consultant surgeon.Furthermore, by approving a revised prospectus andproviding clinically robust criteria, past concerns aboutthe non-medically qualified practitioner's lack ofregulation and approved quality standards areaddressed (RCS 2014).

The current health care climate demands thatpractitioners are aware of their legal and ethicalresponsibilities and are able to demonstrate the

Basildon and Thurrock University Hospital, NHS Foundation Trust,

Basildon, UK


Gabriel R Campaner, BSN, RGN, 171 Jack Clow Road, London E15 3AR,

UK.



2019, Vol. 29(4) 81–86




DOI: 10.1177/1750458918764520


http://orcid.org/0000-0002-6248-275X



http://dx.doi.org/10.1177/1750458918764520


necessary knowledge and skills to enable them toprovide safe and effective surgical assistance.

The relationship between law and ethics while someconsider to be closely related can be abstruse (Miola2007). One must understand how the minimallyacceptable standards set by law and the ideal way for aperson to behave (ethics) underpin the actions of healthcare professionals in an increasingly litigious society(Herring 2016). The NHS Litigation Authority reported10,965 new clinical negligence cases in 2015/16,spending £950.4 million for damages paid to patients;an increase of 23% from the previous year (NHLA 2016).As SCPs perform roles that are historically implementedby medically qualified members of the team, boundariescan become at times ambiguous, hence, exposing thepractitioner to a myriad of professional and legalliabilities (Nicholas 2010).

Unsurprisingly, the law does not provide any latitudewhen assessing liability as a trainee (Nettleship vWeston 1971). SCPs undergo a two-year intensiveMasters' level training programme, which underpins thetheoretical and practical applications of the role.However, a learner's incompetent best as demonstratedin the precedent of Wilsher v Essex Area Health Authority(1998) bears no justification in the crucible of law.Moreover, the insight to discern the need for referral as atrainee is of paramount importance (Gouldsmith v Mid-Staffordshire General Hospital 2007). While Newey et al(2006) suggest that SCPs demonstrate this pertinentskill, practitioners performing extended roles mustconscientiously work within the bounds of theircompetence and distinguish when to refuse or escalateas appropriate (HCPC 2016, NMC 2015).

The case of Donoghue v Stevenson (1932) establishedan essential legal precedent that was to be thefoundation of negligence law. Duty of care according toHerring (2016) is owed to anyone whom one mayreasonably foreseeably injure. In the performance oftheir role, health care professionals legally andprofessionally owe a duty of care to all patients chargedunder their care (Pirie 2012). Standard is yet anothercentral concept of tort law that is rigorously assessed.The landmark case of Bolam v Friern (1957) institutesthe Bolam test as a method of determining negligence.Although the law does not specify who can perform aparticular act, it however insists that there be anestablished standard. Hence, if a SCP performs this role,they must possess the knowledge, skills andcompetence to provide care equivalent to that of amedically qualified practitioner (Cox 2010,Dimond 2015).

Nevertheless, a criticism found in the Bolam test is itsdependence on the standards bequeathed bydistinguished 'peers' rather than standard set by law(Samanta & Samanta 2003). The case of Bolitho v City

and Hackney Health Authority (1997) transformed tortlaw by implying that not only should there be arecognised standard, but logic and analysis must beemployed in the scrutiny of the act in question. Theparadigm shift provided an impartial perspective to theotherwise subjective inclination of the Bolam test(Samanta & Samanta 2003). Likewise, the decisions ofChester v Afshar (2004) and Montgomery v LanarkshireHealth Board (2015) challenge the Bolam test byincluding material risk and reasonable alternativemodalities in the process of informed consent.

Ethical dilemmas are commonly encountered by healthcare providers in the work place (Kopala & Burkhart2005). Shortage in the workforce is believed to createdilemmas for staff where the provision of care isbalanced against scarcity of resources and maintainingsafety (Erlen 2004). Both the NMC and HCPC maintain aframework to guide ethical decision making in theclinical environment (HCPC 2016, NMC 2015). However,it is imperative for extended surgical roles to address thegeneral ethical principles of medical ethics to guidedecisions not inherent in their native regulatory body. Asethics being the application of ethical reasoning todecision making, the main theories of consequentialism(based on consequence) and deontology (based on theact itself) have significantly divided the approach tobioethical inquiry (Herring 2016). Virtue ethics placesemphasis on the virtues and moral character of theindividual as epitomised in the NMC guidance on goodhealth and good moral character (NMC 2015).

The introduction of the SCP into the extended surgicalteam has been extensively critiqued and debated sinceits inception. Job titles and qualifications have beenargued to cause confusion to both patients and medicalpractitioners (Cheang et al 2009), consequently raisingconcerns in areas pertaining to consent (Abood 2005).Bruce et al (2006) suggest offering patients the optionof being treated by a medically qualified practitioner, assome patients have been shown to prefer doctors toSCPs (Cheang et al 2009). A view debunked by a four-year study by Martin et al (2007) suggesting that 100%of the patients in their study were satisfied with the carethey received, 98% of which were happy to have a SCPinvolved in their care. It is incumbent upon SCPstherefore to identify their roles to provide full autonomyto the patient's preferred course of treatment. Abraham(2013) believes that less opposition exists when rolesare professionally identified and are clearly stated.

Abood (2005) argues that extended roles threaten theautonomous nature of doctors and may incuruncertainty regarding their place in health care. Theperceived lack of role clarity contributes to the negativeconnotations of SCPs in clinical practice (Gray et al2010). A multicentre study by Palan et al (2009)revealed that cemented hip arthroplasty mean operatingtime was reduced by up to 28min with a SCP as first


assistant compared to surgical trainees assisting in thesame procedure. Moreover, Tingle et al (2016) in a five-year multicentre study corroborates this and furtherestablished that following a sharp learning curve, a SCPfollowing rigorous in house training demonstratedsignificantly lower hip aspiration failure rates comparedmedical practitioners across three trusts. These studieshighlight the SCP's ability to provide safe and effectiveautonomous practice, as well as contributing to overalltheatre efficiency subsequently decreasingcomplications of prolonged surgery such as venousthromboembolism and surgical site infections (Kim et al2015, Zhang et al 2015). Furthermore, Quick (2013)believes that the holistic and continuous approach tohealth care provided by non-medical practitionerssignificantly improves patient experience andsatisfaction while providing the same quality of careprovided by medical practitioners (Abraham 2013,Kumar et al 2013).

The Royal College of Surgeons (2014) specifies thatjunior doctor training will not be compromised by theintroduction of SCPs. Non-medical practitioners in theextended surgical team have been organised to supportsurgical training; nonetheless, many claim they dilutethe already diminished surgical training opportunitiesavailable to junior doctors (Scholfield 2016). Similarly,Bruce et al (2006) also claim that consultant-ledlearning will be greatly reduced if they are to beresponsible for the training and supervision of SCPs intheir team. However, Williams (2016) argues thatqualified SCPs support junior surgical training anddevelopment by acting as first assistants, SCPs providetrainees with a transition to independent proximallysupervised operating, thus enhancing trainingexperience while maintaining patient safety (JonesArshad & Nolan 2012). A view shared by Quick (2013)who adds that SCPs facilitate training by coaching juniortrainees basic skills in the intraoperative setting.Furthermore, Peckham-Cooper et al (2016) concludethat SCPs are a valuable addition to the workforce with asignificant potential to enhance surgical training.

Non-medically qualified practitioners regularly traverseboundaries that separate them from medically qualifiedmembers of the team, as such; their culpabilitytranscends their qualification (Dimond 2015).Accountability is being answerable to one's owndecisions (RCN 2008). It can be considered a frameworkof encompassing professional, legal, ethical andemployment accountability (Caulfield 2005).Practitioners performing extended roles must act withinthe limits of their competence and boundaries of theirpractice (NMC 2015). As SCPs have yet to come underthe umbrella of a role relevant governing body, theyremain under their native regulatory authorities. Theprofessional bodies (NMC and HCPC) stand to protectthe public from potentially harmful outcomes by

establishing regulations and providing guidance forpractice (Griffith & Tengnah 2017).

Earlier permutations of the SCP role were predominantlyunstandardised and locally based. Hence, transferabilityand sustainability of practice was not feasible to othertrusts (Armitage 2006). The Royal College of Surgeonsco-authored the early curriculum framework as an effortto establish an effective educational pathway for trainingand maintain a high standard of care (DH 2006). ThePerioperative Care Collaborative (2012) subsequentlyreleased a position statement to specify qualifiedassistance by registered health care professionals andsought to demarcate the roles and responsibilities ofeach level of assistance. This established the clinicalinterventional roles that are expected of the SCP andserved to clarifying confusions pertaining the scope anddelimitations of non-medically qualified practitioners(Quick & Hall 2014). Furthermore, the recent ratificationof the new SCP curriculum framework by the RoyalCollege of Surgeons (2014) identified specific roles andresponsibilities expected of the SCP to serve as thefoundation for further training in the Master's levelof education.

Practitioners owe a duty of care to themselves in thesame way they do for the patients under their care.Accountability to one's self is a hallmark of professionalcompetence and is fundamental to safe and effectivepractice (Dimond 2015). The regulatory bodiesgoverning nurses and ODPs share a common standardwhich demands practitioners to possess competentknowledge and relevant skills in order to deliver a highstandard of care at all times (HCPC 2016, NMC 2015).Moreover, as an addition to the standards imposed foradvanced non-medical roles, the AfPP (2013) initiated avoluntary code of professional conduct for perioperativepractitioners encompassing aspects of practice that maynot be covered by their native regulatory body.

SCPs are expected to maintain active membership withtheir professional governing authorities (RCS 2014).Failing to do so exposes the practitioner to a significantrisk of liability (Dimond 2015). In the same way, allregistered professionals are expected to take part inappropriate learning and clinical activities to maintainknowledge and skills throughout their working life (HCPC2016, NMC 2015). As a member of the extendedsurgical team, SCPs work under the supervision of theoperating surgeon (RCS 2014). To provide safe andeffective care, it is the responsibility of the delegatingmedical practitioner to ensure requisite competenceand skill is evident before designation of activities (GMC2013). However, the accountability remains on theindividual practitioner's level of skill, knowledge andcompetence for safe practice (Dimond 2015).

In keeping with acquiring the competence and skillexpected of a medically qualified practitioner, the SCP

Campaner 83

must embody an approach to patient care much liketheir medical counterparts. Among others, knowledgeand understanding of anatomy and physiologyunderpins the Royal College of Surgeons (2014)curriculum framework for SCPs.

The study of human anatomy and physiology isconsidered to be one of the fundamental pillars ofmedical training (McLachlan & Patten 2006). It hasbeen argued that by learning the body's form andfunction, practitioners are immersed in a fundamentalknowledge that permeates most of clinical practice andinforms decision making (White & Sykes 2012).Mompeo and Perez (2003) believe that a practitioner'sawareness of normal and altered physiology supportssymptom evaluation, physical examination, as well asinterpretation of diagnostic scans and radiographs.Similarly, a firm grounding in anatomy and physiologyallows for a more fluid language exchange betweenmedically qualified colleagues and can further beutilised by the SCP to be an advocate on the patient'sbehalf (McColl et al 2012).

In the operating theatre, by considering anatomicallandmarks and knowledge of physiology, appropriatepositioning can be implemented to aid optimum surgicalsite exposure, preventing falls, nerve damage andhypothermia (Servant et al 2009). Similarly, thisknowledge combined with the application ofpreoperative skills such as correct shaving anddecontamination is vital to the SCP practice and is animportant component in preventing surgical siteinfections (Rothrock & Seifert 2009). Moreover, duringthe draping process, the SCP's understanding ofairway, breathing and circulatory management will aidsuitable access for the anaesthetic team (Servant et al2009). Flin et al (2015) believe assisting is not justproviding extra hands, but is as well both a science andan art. Rothrock and Seifert (2009) assert that the SCP'sskilled anticipation of the surgeon's next movesdevelops a collaboration of manoeuvres that lead to agraceful and synchronised procedure. Furthermore,since assisting not only entails retracting tissues for anenhanced field of vision, the SCP's skill in managingbleeding with suction, the use of swabs, and diathermyis vital in the perioperative stage (Rothrock &Seifert 2009).

The application of a knot deprived of the appreciation foranatomy and physiology can potentially lead todisastrous outcomes (Johnson & Stulting 2007). Kirk(2010) suggests that skilled retraction and handling ofthe operative site demands an intimate understandingof the structures and functions in underlying tissues andis essential for safe and effective practice (Rothrock &Seifert 2009). William Halstead's principles areconsidered the gold standard for tissue handling insurgery. As cited by Zeltzman (2012), his emphasis onaseptic technique, meticulous tissue handling, careful

haemostasis and accurate skin apposition is ofparamount importance. Practitioners are expected toobserve and encourage aseptic technique in thefoundation of infection control. Thus, familiarity withdisease aetiology and principles of antibiotic prophylaxisto prevent occurrence of iatrogenic and surgical siteinfections is an important function of the SCP. Similarly,appropriate evidence-based practices such as surgicalhandwashing and aseptic technique can reduce risks ofsurgical site infections. Moreover, during the applicationof wound closure and dressing, the knowledge andunderstanding of the skin and wound healing isessential to achieving a robust wound closure free ofinfection and dehiscence while healing with anacceptable scar (Rothrock 1999). Furthermore, asoperations can be a traumatic and stressful experience,a SCP's holistic and continuous approach to care allowsthem to become their advocates not only while they areconscious and coherent, but more importantly whenthey are most vulnerable while under anaesthetic(Cornwell et al 2012). The SCP's informed knowledge ofanatomy and physiology constitutes the foundation ofeach phase of surgical practice from preoperativeexamination to postoperative follow-up.

Over the years, the survival of the NHS has largelydepended on its ability to adapt with socio-economicand political pressures. Significant efforts to modernisethe NHS have led to the growth of roles for the non-medical members of the health care team. Although theSCP role is yet to be unreservedly accepted, theirpositive impact to the country's allegedly underdoctored,underfunded and overstretched health care system isirrefutable. By understanding the legal and ethicalissues surrounding the role, accepting professionalaccountability and acquiring a firm grounding inanatomy and physiology, the SCP will progressively be ofbenefit to the modern extended surgical team andultimately find its place in the world class health caresystem that is the NHS.


ORCID iD

Gabriel Rene M. Campaner http://orcid.org/0000-0002-6248-275X

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Clinical Feature

Nurses’ knowledge aboutperioperative care of patientswith neurological diseases

Evagelia Laopoulou1, Petros Papagiorgis2,Chrysa Chrysovitsanou3, Chrysoula Tsiou4,Sotirios Plakas5 and Georgia Fouka6

Abstract

This study investigated the level of nurses’ knowledge regarding the perioperative care of neurological patients. An

author-developed questionnaire of 20 items was used in a sample of 94 hospital nurses serving in the neurology, surgery

and anesthesiology departments and the intensive care unit. The average percentage of participants with correct

answers was 49.2%. The mean value of participants’ score was 9.8 �3.4. Preexisting experience in the care of cases with

multiple sclerosis and Parkinson’s disease was positively related to the level of knowledge (p¼ 0.001 and 0.014

respectively). The ascertained level of nurses’ knowledge regarding the perioperative care of neurological patients was

moderate, questioning their adequacy to handle such cases. Previous experience in the care of particular diseases had

significantly positive impact on knowledge, suggesting potential improvement strategies through targeted education and

specialization of nurses. In conclusion, nurse’s knowledge regarding perioperative care of neurological patients was

insufficient, requiring appropriate improvement interventions.

Keywords

Perioperative care / Neurological patient / Neurological diseases / Nursing care / Postoperative complications

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication 2 March 2018.

Introduction

Neurological diseases are generally common, with alifetime prevalence of 6% in the general population, andhigher among the elderly for some particular disorders(Alzheimer's, Parkinson's, stroke, epilepsy). Surgery inneurological patients, either related to the disease or(more frequently) to non-neurological causes(orthopedic, urologic, cardiovascular etc) represents a

clinical challenge. It requires the management of severalmedical issues:

• Selection of the optimal surgical and anestheticmethod

• Stabilization of neurological disease

1Staff nurse in Cardiology ICU, N.I.M.T.S. (Medical Institution Military

Shareholder Fund) Graduate of the post-graduate program "Neurological

Diseases: Evidence based practice", Technological Educational Institute ofAthens, Faculty of Health and Caring Professions, Nursing Department,

AgiouSpyridonos St., Egaleo, 122 10 Athens, Greece2General Surgeon, Scientific Collaborator in Technological Educational

Institute of Athens, Faculty of Health and Caring Professions,

Department of Medical Laboratories, AgiouSpyridonos St., Egaleo, 122 10

Athens, Greece3Supervisor of Multiple Sclerosis Clinic, Eginitio Hospital, University of

Athens, School of Medicine, Vas.sofias 72, Athens, Greece

4Professor of Adult Nursing & Perioperative Care Nursing, Director of

the post-graduate program "Neurological Diseases: Evidence based

practice", Faculty of Health and Caring Professions, Department of

Nursing, Technological Educational Institute of Athens, AgiouSpyridonos

St., Egaleo, 122 10 Athens, Greece5Assistant Professor, Faculty of Health and Caring Professions,

Department of Nursing, Technological Educational Institute of Athens,

AgiouSpyridonos St., Egaleo, 122 10 Athens, Greece6Associate Professor, Faculty of Health and Caring Professions,

Department of Nursing, Technological Educational Institute of Athens,

AgiouSpyridonos St., Egaleo, 122 10 Athens, Greece


Petros Papagiorgis, MD PhD, Scientific Collaborator in Technological

Educational Institute of Athens, Greece.



2019, Vol. 29(4) 87–93




DOI: 10.1177/1750458918788984




http://dx.doi.org/10.1177/1750458918788984


• Consideration and handling of the existing sensory,motor and mental deficits

• Identification of modifiable risk factors• Appropriate regulation of neurological treatment (with

prevention of potential adverse effects and interac-tions) and

• Diminution, recognition and care of complications(Lieb & Selim 2008, Probasco et al 2013, Fagerlundet al 2013, Hudson & Greene 2015).

The level of nurses' knowledge on this issue may haveconsiderable effect on their clinical adequacy andtherefore warrants thorough investigation.

Background

A variety of factors may hamper the perioperativemanagement of neurological patients, increasingperioperative risk and complications, delaying therecovery and extending hospitalization. Thesefactors are:

• multisystem disease pathology (not rarely withserious cardiopulmonary manifestations) (Lieb &Selim 2008, Turakhia et al 2013)

• treatment side-effects and interactions with anes-thetic and other perioperative medications (Lieb &Selim 2008, Blichfeldt-Lauridsen & Hansen 2012,Probasco et al 2013, Makris et al 2014, Katus &Shtilbans 2014)

• susceptibility to particular anesthetic techniques anddrugs (Lieb & Selim 2008, Blichfeldt-Lauridsen &Hansen 2012, Probasco et al 2013) or to surgicalstress (Lieb & Selim 2008, Probasco et al 2013) and

• presence of motor, sensory and cognitive deficits(Schneider 2005, Williams 2009, Probasco et al2013, Makris et al 2014, Katus & Shtilbans 2014).

The nurse, as an integral member of themultidisciplinary team managing the patient andstanding on the front line of this process, should be fullyaware of the above factors to fulfill his/her tasks (pre,intra and postoperatively).

Literature review

Nonetheless, clear, detailed and comprehensiveguidelines about perioperative nursing care ofneurological patients are scarce, while the existingrelevant articles are largely focused on perianestheticmanagement of particular disorders (Schneider 2005,Williams 2009) or to specific treatment issues(Fagerlund et al 2013). In parallel, data in the literatureabout the knowledge of nurses on the issue are rare andlimited to particular aspects of the topic eganti-Parkinson's medications (Swarztrauber & Graf2007) or delirium (Christensen 2014, Korkmaz et al2015), or to indirect approaches (through theperspective of patients and their relatives) (Anderson &

Fagerlund 2013). This study was an attempt to obtainfurther and broader information about this specific andclinically important theme.

Methods

A quantitative survey was conducted, using a specificallydeveloped (by the authors) questionnaire.

Sample

The study population was a purposive (non probability)sample, including 135 nurses from three tertiaryinstitutions (one state and two teaching hospitals) inAttiki (see Table 1). Certified registered nurses employedat the surgery neurology, anesthesiology wards andintensive care units (ICU), were considered eligible forthis study. The instrument was delivered to all nursesmeeting the above criteria and the overall response ratewas 70% (94/135).

Structure and content of the questionnaire. Theinstrument consisted of two distinct parts:

• The 'informative' part included nine questionsregarding the demographic characteristics of theparticipants

• The 'knowledge' part included 20 questions assess-ing the level of knowledge on the issue.

The knowledge part was subdivided into two sectionsand included seven questions focusing on thepreoperative care and main clinical manifestations ofneurological diseases and 13 questions aboutpostoperative complications, problemsand management.

In more detail, there were seven questions aboutParkinson's disease, four about multiple sclerosis (MS),two about myasthenia gravis, two about stroke, twoabout Alzheimer's, one about epilepsy and two questionsabout perioperative risks and management ofneurological patients. This distribution was preferentiallyoriented to particular diseases (eg Parkinson's, MS)frequently exhibiting various complex and seriousperioperative problems, requiring nurses' specificknowledge for their prevention, recognitionand management.

The selected items pertained to neurological symptoms,pharmacological treatment (modification, side-effects,interactions), postoperative complications and handlingof specific issues. Questions were constructed in theform of a statement and participants were requested torespond by choosing between the following answers: 'Iagree', 'I disagree', 'I don't know'. Each correct answerreceived one point and consequently the potential scorefor each participant varied between 0 and 20.


The knowledge part of the instrument was based onrelevant literature, including systematic and otherreviews (Lieb & Selim 2008, Blichfeldt-Lauridsen &Hansen 2012, Macellari et al 2012, Probasco et al2013, Makris et al 2014, Katus & Shtilbans 2014)specific educational courses (Schneider 2005), andoriginal articles (Williams 2009, Hu et al 2012, Chang etal 2012, Anderson & Fagerlund 2013). Although thestructure of questionnaires of other relevant studiesinvestigating certain parts of the topic was generallytaken into account (Swarztrauber & Graf 2007, Korkmazet al 2015), the current instrument was substantiallydifferent in terms of number, form and content of theincluded items.

Content validity

The questionnaire was reviewed by a panel of experts(professors of neurology, academic nurses and nursesspecialized in neurology) and revised according to theirremarks and suggestions. The final form of theinstrument was developed following a pilot study, whichwas conducted in a selected sample of 50 nurses andphysicians to test the fitness and functional efficiency ofthe items as knowledge indicators.

Statistical analysis

The collected data were analyzed using the IBM SPSS20.0 program. Cronbach's alpha coefficient was used toexamine the internal reliability of the items giving arelatively satisfactory result (0.719) which was alsosupported by the values of the Gutman split-half andSpearman-Brown coefficients, testing the internal split-half reliability of the items (0.676 for both).

Data were presented as numbers and percentages(n, %). The overall level of knowledge was expressedin the following forms:

• The average score (mean value� standard deviationof the scores of the 94 participants) and

• The average percentage (mean value of thepercentages of correct answers).

The data are summarized in Table 2.

Correlations of participants' characteristics with theaverage score or with the answers to particularquestions were examined using t-test (to compare meanvalues), Kruscal-Wallis and Mann-Whitney U test(to compare mean-ranks) and x2 (for comparison offrequencies). P values �0.05 were considered asstatistically significant.

Ethical considerations

The study was approved by the ethical committees andthe scientific boards of the hospitals where the researchwas conducted. It was also approved by the committeeof the postgraduate course Neurological Diseases of theNursing Department of Technological EducationalInstitute of Athens. All participants were fully informedabout the objective and the details of the questionnaire.Participation was totally voluntary and anonymous.Collected data remained strictly confidential.

Results

The majority of the participants were females (83%),between 20 and 40 years old (62.6%) and with more

Table 1 Demographic and other descriptive characteristics of the participants

Characteristic n¼94 %

Gender Male 16 17.0

Female 78 83.0

Age 21–40 years 59 62,8

>40 years 35 37,3

Hospital Aiginiteio 22 23.4

Attiko 45 47.9

NIMITS 27 28.7

Present department Neurology 29 30.9

Surgery 23 24.5

Anesthesiology 42 44.7

Years of work 0–20 71 75,6

>20 23 24.5

Years of work in the present post 0–5 38 40.4

6–20 45 47.9

>20 11 11.7

Previous experience in handling neurological diseases Multiple sclerosis 42 44.7

Parkinson 69 73.4

Alzheimer 64 68.1

Myasthenia gravis 56 59.6

Epilepsy 71 75.5

Stroke 87 92.6

Laopoulou et al. 89

than 5 years in the present post (� 60%). The mostfrequently reported department of employment wasanesthesiology or ICU (44.7%). Finally, the reportedpreexisting experience in handling particularneurological diseases was varying between 44.7% forMS and 92.6% for stroke (see Table 1).

The average score of knowledge (obtained by theindividual scores of the 94 participants) was 9.8 �3.4(mean value �SD), ranging between 2 and 16, withmedian value¼10. Alternatively, the average percentageof knowledge (ie the mean value of the percentages ofparticipants with correct answers) was 49.2%. Asindicated in Table 2, percentages varied widely (1-99%)depending on the particular question. For example, only1% of the nurses were aware of the appropriatepostoperative handling of neurological patients withepidural analgesia, whereas almost all (99%)participants knew certain categories of Parkinson'ssymptoms. In general, results for the questions relatedto preoperative management and clinical manifestationswere better than those for questions pertaining to

postoperative complications and management (averagepercentages: 60.5% and 43.1%, respectively).

Investigation of associations between knowledge leveland nurses' characteristics (hospital, department etc)revealed that only the previous experience in the care ofMS and Parkinson cases was positively related toknowledge. Nurses with such experience attainedsignificantly better results (p¼0.009 and 0.014respectively, Table 3).

Analysis by individual item highlighted eight questionswith significant variations of the percentages of correctanswers according to particular characteristics, mostcommonly the department (Table 4). Thematically, theseitems were about Parkinson's (questions 4, 13, 16), MS(questions 8, 9 11) and myasthenia gravis (questions 3,6). A relative pertinence was observed (althoughinconsistently) between item content and theparticularly prevailing (in knowledge) department. Forexample, nurses from surgery were more aware of theincreased postoperative risk of deep vein thrombosis in

Table 2 Knowledge regarding perioperative care of neurological patients

Questions

Correct answers

n/% *

1 Patients with Parkinson’s may have motor, psychiatric and urinary dysfunction symptoms (True) 93=98.92 Patients with Alzheimer’s may experience serious respiratory failure and inability to communicate

(False)

18/19.1

3 Patients with myasthenia gravis may develop muscular weakness and respiratory failure (True) 85/90.4

4 Patients with Parkinson’s require higher doses of anti-Parkinson’s regimens before surgery (False) 27/28.7

5 In patients with a history of stroke, warfarin therapy should be discontinued before surgery and

replaced by low molecular weight heparin (bridging therapy) (True)

71/75.5

6 In some cases, there is need for plasmapheresis or administration of immunoglobulin in patients with

myasthenia gravis before surgery (True)

36/38.3

7 In epileptic patients, medications should be interrupted the day before surgery (False) 68/72.3

8 Patients with multiple sclerosis are at increased risk of postoperative vein thrombosis due to motor

defects (True)

28/29.8

9 The risk of postoperative wound disruption is increased in patients with multiple sclerosis treated with

corticosteroids (True)

43/45.7

10 Administration of immunosuppressants in patients with multiple sclerosis increases the risk of post-

operative confusion(True)

25/26.6

11 Patients with multiple sclerosis are prone to postoperative urinary dysfunction (True) 50/53.2

12 Postoperative worsening of Parkinson’s symptoms could be caused by the administration of some anti-

emetic or neuroleptic agents (True)

58/61.7

13 Parkinson’s patients are at increased risk of postoperative heart failure (False) 30/31.9

14 The risk of postoperative confusion and hallucinations is elevated in Parkinson’s patients (True) 69/73.4

15 The risk of postoperative dysphagia is increased in Parkinson’s patients (True) 46/48.9

16 Serious or lethal postoperative complications could be caused in Parkinson’s patients due to the

interaction of the MAO inhibitor selegiline with the opioid meperidine (True)

21/22.3

17 Dyskinesiain Parkinson’s and Alzheimer’s patients may seemingly improve after surgery (False) 13/13.8

18 Patients with recent history of stroke may have greater difficulty to perform deep breathing exercises

after surgery (True)

66/70.2

19 Interactions of neurological medications with antibiotics, analgesics, anti-inflammatory drugs and anti-

coagulants may worsen neurological symptoms and/or cause serious or lethal complications (True)

77/81.9

20 Neurological patients with pre-existing motor defects and receiving postoperative self-regulated epi-

dural analgesia, should be checked (for motor status) every 3-4 hours to prevent high administration

rate (False)

1/1.1

*n/% number/percentage of participants with correct answers per question (overall n¼ 94).


MS (question 8), anesthesia/ICU nurses answeredquestion 3 better (pertaining to respiratory failure inmyasthenia gravis) and neurology nurses were betterinformed about complications and interactions relatedto particular medications, ie corticosteroids (question 9)and selegiline (question 16).

Discussion

Study limitations

The main limitations of the current study were therelatively small sample size (limiting the validity of thefindings) and the rather minor figure of items included inthe questionnaire (not allowing a thorough investigationof nurses' knowledge on the issue). However, the samplesize was comparable (equal or larger) to other relevantstudies (Christensen 2014, Korkmaz et al 2015),whereas its multicenter and multidepartment originprovided a wider and more representative illustration ofthe knowledge level of clinical nurses.

On the other hand, the number of items, although small,was focused on clinically important (according to

literature) issues, while the brevity of the questionnaireprobably encouraged participation. This is supported bythe rather satisfactory response rate (70%). Moreover,the items, although pertaining to different neurologicaldiseases, were fairly interrelated, as suggested by therecorded Cronbach's Alpha value (>0.7) (Rattray &Jones 2007). Nevertheless, targeted improvementinterventions (focused modifications and selectedadditions of items, sample size increase) could beconsidered for future studies.

Study results

In the current study, the ascertained level of nurses'knowledge on the examining issue was moderate, asindicated by both the average knowledge score and theaverage percentage of participants with correct answers.Interestingly, among the various characteristics of theparticipants, only the preexisting experience in caring forMS and Parkinson patients was found to be significantlyrelated to the level of knowledge.

These results were comparable with those of relevantstudies which also reported moderate level of

Table 4 Summary of significant correlations between nurses’ characteristics and knowledge about individual items

Characteristic Knowledge prevailing subgroup Individual item* P value**

Age 21–40 years 8 0.039

Hospital NIMTS 4 0.042

Aiginitio 6, 16 0.018. 0.002

Department Anesthesiology / ICU 3 0.001

Surgery 4, 8 0.013 0.004

Neurology 9, 11, 16 0.009 0.012 0.010

Experience in present post >20 years 13 0.013

*Only items with ascertained significant correlations between knowledge and particular nurse’s characteristics were included in this table. The figures

depicted in this column represent the numbers of the particular questions (indicated in Table 2).

**x2 test was used to compare the percentages of correct answers (for each question) between nurses’ subgroups (classified according to particular

characteristics eg 21–40 years vs >40 years of age). The prevailing subgroup for each comparison is depicted in the second column (eg 21–40 years of

age, prevailing in the comparison of correct answers for question 8, p¼ 0.039).

Table 3 Correlation between knowledge and previous experience in handling neurological diseases

Characteristic Comparing subgroup N (Total¼ 94)

Comparing score

values (Mean Rank) P value*

Previous experience in handling

neurological diseases

Multiple sclerosis Yes 42 55.63 0.009

No 52 40.93

Parkinson’s Yes 69 51.64 0.014

No 25 36.08

Alzheimer’s Yes 64 50.42 0.128

No 30 41.27

Myasthenia gravis Yes 58 49.32 0.423

No 38 44.82

Epilepsy Yes 71 49.71 0.165

No 23 40.67

Stroke Yes 87 48.41 0.253

No 7 36.21

* Mann-Whitney U test (comparing mean-rank values).

Laopoulou et al. 91

knowledge of nurses and/or other health professionalsregarding specific neurological issues. In particular,nurses with special training regarding postoperativedelirium and those serving in cardiosurgery ICU had ahigher level of knowledge on the issue, compared to theuntrained nurses and those serving in the correspondingward (Korkmaz et al 2015). Another study reported ahigher level of knowledge regarding Parkinson treatmentfor specialized health professionals (nurses andphysicians) compared to their nonspecialized colleagues(Swarztrauber & Graf 2007). Consistent with our results,these findings indicated that only the specific experienceand/or education may lead to a higher level of relevantknowledge. This is supported by particular studies whichdemonstrate improvements in knowledge level andcompetence in caring for neurological patients, followingthe implementation of appropriate educationalstrategies, preferentially multifaceted and includingexperiential learning and a disease specific approach(Ballard et al 2012, Reynolds et al 2016).

In our opinion, the association of knowledge level withthe preexisting experience in MS and Parkinson'sdetected in the current study, could be explained (inpart) by the particularly demanding nursing carerequired for these patients (Segatore 1998, Schneider2005, Katus & Shtilbans 2014). Nurses with suchexperience have possibly obtained a broader and morecomplete knowledge in handling neurological patients(potentially extending beyond the specific field ofthese diseases).

The significant variations of knowledge about individualitems depending on nurses' characteristics (principallythe department) were rather expected, as participantstended to attain better results in particular questionswith content relevant to their clinical area. However, itwas noteworthy that all significant findings werethematically related to Parkinson's, MS and gravis. Thecomplex and multifaceted nature of the particularmedical issues (Segatore 1998, Schneider 2005,Blichfeldt-Lauridsen & Hansen 2012, Katus & Shtilbans2014) were likely to have acted as a discriminatingfactor, resulting in the highlighting of the existingknowledge differences among nurses.

Regardless of the underlying causes responsible for thedetected (or undetected) correlations, the fact that therecorded knowledge level even for nurses withexperience in MS and Parkinson's, although relativelyhigher, remained moderate, indicates the necessity forimprovement in virtually all nurses' categories.Insufficient knowledge may affect nurses' competence tohandle neurological cases with a potential negativeimpact on patient outcome (Anderson & Fagerlund2013, Christensen 2014, Korkmaz et al 2015).

The implementation of effective educational programspreferentially for nurses serving in the departments of

neurology, surgery, anesthesiology and ICU, may lead tothe desirable level of knowledge and subsequentimprovement of neurological perioperative nursing carein Greece, through the adoption of and adherence toappropriately developed clear, specific and clinicallyapplicable guidelines. Certain proposals, such as aprimer for nursing care of Parkinson's cases (Anderson& Fagerlund 2013), a detailed practical guidance for theperioperative management of orthopaedic patients withParkinson's (Segatore 1998) and a correspondingguidance for perianesthesia care of the Alzheimer'spatient (Williams 2009) represent remarkable attemptstowards this direction. In addition, the potentialestablishment of highly specialized nurses for particulardisorders (eg MS) should be examined (While etal 2009).

To our knowledge, this is the first study that investigatesthe level of nurses' knowledge regarding perioperativecare of neurological patients. With the exception of thearticle reporting the perioperative experience ofParkinson's patients along with their comments aboutnursing care (Anderson & Fagerlund 2013), the otherrelevant publications investigated health providers'knowledge about particular aspects of care ofneurological patients, albeit not specifically about theperioperative handling of such cases (Swarztrauber &Graf 2007, Christensen 2014, Korkmaz et al 2015).However, the exploratory character of our study and theexisting limitations warrant additional investigation toconfirm, elucidate and extend the findings, examining indetail the knowledge regarding perioperative care ofeach particular disease. Thus, a more completedepiction of nurses' knowledge (with detection ofspecific gaps) could be obtained, facilitating thedetermination and planning of the appropriateimprovement interventions.

Conclusion

The level of nurses' knowledge regarding theperioperative care of neurological patients was generallymoderate (although participants with experience inparticular disorders attained significantly better results),raising questions about their clinical adequacy. Thepotential negative impact of these findings (if validated)on nurses' clinical competence necessitates theimplementation of appropriate educational interventionsto improve nurses' knowledge and, hopefully, the carerequired for neurological patients undergoing surgery.

No competing interests declared.

References

Anderson LC, Fagerlund K 2013 The Perioperative experienceof patients with Parkinson's disease: A qualitative studyAmerican Journal of Nursing 113 (2) 11326–11332

Ballard J, Mead C, Richardson D, Lotz A 2012 Impact ofdisease-specific orientation on new graduate nurse


satisfaction and knowledge retention Journal ofNeuroscience Nursing 44 (3) 168–174

Blichfeldt-Lauridsen L, Hansen BD 2012 Anesthesia andmyasthenia gravis Acta Anaesthesiologica Scandavia56 (1) 17–22

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Fagerlund K, Anderson LC, Curvich O 2013 Perioperativemedication withholding in patients with Parkinson'sdisease: A retrospective electronic health records reviewAmerican Journal of Nursing 113 (1) 26–35

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Laopoulou et al. 93

Original Article

Psychometric evaluation of the PostHospitalization Behavior Questionnairefor Ambulatory Surgery andpostoperative behavior and recovery inchildren undergoing tonsil surgery

Ulrica Nilsson1 , Elisabeth Ericsson1, Mats Eriksson1,Ewa Idvall2 and Ann-Cathrine Bramhagen2

Abstract

The study comprised a prospective, comparative cross-sectional survey in 143 (of 390) children undergoing tonsil

surgery. Parents answered the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery (PHBQ-AS), and

children answered the questionnaire Postoperative Recovery in Children (PRiC). The PHBQ-AS had positive correlation

with the PRiC and with general health. On day 10 after surgery, up to one-third of the children still reported physical

symptoms (PRiC). No gender or age differences concerning the items of behavior (PHBQ-AS) were found. The quality

of postoperative recovery (PRiC) in girls was lower, with higher levels of nausea, dizziness, coldness, and headache

compared to the boys. Children <6 years of age reported higher levels of dizziness and lower sleep quality and lower

general health.

Keywords

Behavior / Children / Pain / Postoperative recovery / Tonsil surgery

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication 24 May 2018.

Introduction

Postoperative recovery in children is an individualprocess with subjective experiences, affecting daily lifeactivities, physical and emotional comfort (Eriksson et al2017), and behavioral changes (Karling et al 2007,Wilson et al 2016). Tonsil surgery is a frequentlyperformed surgical procedure among children, andbehavioral disturbance has been reported as a commoncomplication (Karling et al 2007, Sathe et al 2017,Stanko et al 2013, Wilson et al 2016). The mostfrequent behavioral changes were apathy andseparation anxiety (Fortier et al 2010, Kotiniemi et al1996, 1997), eating disturbances (Eriksson et al 2017,Karling et al 2007, Kotiniemi et al, 1996, 1997, Satheet al 2017), and sleep disturbance (Eriksson et al 2017,Karling et al 2007, Kotiniemi et al 1996, 1997), "makinga fuss about eating," and "temper tantrums" (Beringer etal 2014). Preoperative anxiety has been found to be a riskfactor for, for example, postoperative pain, sleepingproblems, and eating problems after surgery (Kain et al2006). Young age (Fortier et al 2010, Karling et al 2007,Stargatt et al 2006) and being a boy (Beringer et al 2014)

have also been reported as risk factors for behavioralchanges postoperatively. Even long-lasting problematicbehavior persisting for up to four weeks after surgery hasbeen found in 16%–32% of children (Pearson & Hall2017, Stargatt et al 2006). Day-case tonsil surgery playsa prominent role in pediatric practice in many countries(Hallenstål et al 2017).

Vernon et al (1966) developed a parent-ratedinstrument, the Post Hospital Behavior Questionnaire(PHBQ), to quantify behavioral changes in children whoundergo hospitalization due to surgery or illness in theUnited States. The PHBQ comprises 27 items in sixsubscales: general anxiety and regression, separation

1School of Health Sciences, Faculty of Medicine and Health, €Orebro

University, €Orebro, Sweden2Department of Care Sciences, Faculty of Heath and Society, Malm€oUniversity, Malm€o, Sweden


Ulrica Nilsson, School of Health Sciences, €Orebro University, 70182€Orebro, Sweden.



2019, Vol. 29(4) 94–101




DOI: 10.1177/1750458918782878


http://orcid.org/0000-0001-5403-4183



http://dx.doi.org/10.1177/1750458918782878


anxiety, eating disturbance, aggression toward authority,apathy/withdrawal, and anxiety about sleep. For eachitem, parents are asked to compare their child'sbehavior before hospitalization to the child's currentbehavior (post-hospitalization) on a Likert-type scale(Vernon et al 1966). The PHBQ has been translated intoSwedish, and its psychometric properties were found tobe acceptable (Karling et al 2006). The Swedish PHBQincludes 25 items. Two items, Does your child need a lotof help doing things? and Is it difficult to get your child totalk to you?, loaded poorly on any factor (<0.4), andwhen this was evaluated by an expert panel thesequestions were omitted (Karling et al 2006).

Jenkins et al (2015) reduce the number of items from27 to 11, creating the Post Hospitalization BehaviorQuestionnaire for Ambulatory Surgery (PHBQ-AS). ThePHBQ-AS demonstrated good internal consistency,reliability, and concurrent validity (Jenkins et al 2015).Since most of the tonsil surgeries among children areperformed on a day surgery basis (Alm et al 2017),we created a modified version of the PHBQ-AS to testconstruct validity and internal consistency and tomeasure behavioral changes in children undergoingtonsil surgery.

The instrument Postoperative Recovery in Children(PRiC) was recently developed and tested in Sweden asa questionnaire aiming to measure self-reportedpostoperative recovery after tonsillectomy in childrenaged 4–12 years. The results of the study providedevidence of the reliability and validity of the PRiC as ameasure of postoperative recovery among children aftertonsil surgery. Cronbach's alpha for the totalquestionnaire was 0.83. The parents reported in 59%of the cases that the children participated very muchin answering the questions (Bramhagen et al 2016).However, continued psychometric testing ofquestionnaires measuring postoperative recovery andpost hospital behavior are needed, as well as anassessment of these outcomes.

Purpose

The study objectives were to (1) examine thepsychometric properties of the modified Swedish versionof the PHBQ-AS, (2) describe post-hospitalizationbehavior and postoperative recovery in childrenundergoing tonsil surgery, and (3) explore any gender orage differences in connection with these aspects.

Methods

Study design and population

The study employed a prospective, comparative cross-sectional survey. A sample of 390 children undergoingtonsil surgery (tonsillectomy or tonsillotomy/partialtonsillectomy) and their parents were invited to

participate in answering one questionnaire each on day10 after surgery. The children were consecutivelyrecruited from five different settings, four hospitals, andone private day surgery clinic, in Sweden in 2012–2014.The inclusion criteria were as follows: healthy childrenwithout any chronic disease between the ages of 4 and12 years, who were selected for day surgery and whoseparents could read, understand, and speak Swedish.

QuestionnairesPHBQ-AS. The modified version of the PHBQ-ASconsisted of nine items, that is, the two items excludedin the Swedish version of PHBQ was also excluded in thePHBQ-AS version. The two excluded items were: Is itdifficult to get your child to talk to you? and Does yourchild need a lot of help doing things? The nine itemswere answered by the parents on a five-point scale:1¼much less than before, 2¼ less than before,3¼ same as before, 4¼more than before, and5¼much more than before.

Postoperative recovery in children. Postoperativerecovery was measured with the PRiC, by the childrenthemselves or with help from the parents. The PRiCincludes 23 items, 21 items about different aspects ofrecovery in general and 2 items that are specific to tonsilsurgery (earache and blood in the mouth). The itemsconcern the previous 24 h and are assessed on a four-grade scale: 1¼ not at all, 2¼ a little, 3¼much, and4¼ very much, where "very much" indicates the lowestlevel of recovery. The PRiC also includes one item of amore general nature that addresses the children'spresent general health, to be answered with: 4¼ verygood, 3¼ pretty good, 2¼ pretty bad, or 1¼ very bad.

Background data were collected from the child's medicaljournal using a protocol developed a priori, concerninggender, age, surgical procedure, and type of anesthesia.

Procedure

The invited children and their parents received verbaland written information about the study. At dischargefrom the hospital, the children received the PRiCquestionnaire for assessing postoperative recovery onthe 10th day postoperatively. Their parents received theSwedish version of the PHBQ-AS, also to be answered onthe 10th day postoperatively, along with prepaidenvelopes. No reminder was sent out.

Ethical approval

The study was approved by the Research EthicsCommittee in Uppsala (No. 2012/106). Parentsprovided written informed consent for the study, and thechildren provided assent. The children could either writetheir name or draw a picture on the consent form. Theresearcher stated that children could withdraw fromthe study at any time. Data sheets were stored in a

Nilsson et al. 95

locked cabinet and no identifying informationwas collected.

StatisticsPower calculation. Based on the suggestions byFerketich (1991) of a five-to-one ratio (five individualsper scale item) for examining psychometric properties ina nine-item instrument, a minimum of 45 participantswould be needed to conduct principal componentsanalysis (Ferketich 1991). Therefore, our sample sizeprovided sufficient power to conduct psychometrictesting of the Swedish modified version of PHBQ-AS.

Validity to evaluate the accuracy was assessedas follows:

1. Principal components analysis: Although the PHBQ-AS (Jenkins et al 2015) was developed during thetime of data collection of the present study, a deci-sion was made to determine construct validity of theSwedish version of the PHBQ-AS, using a principalcomponents analysis with varimax rotation ratherthan presenting all 25 items, that is, the Swedishversion of the PHBQ.

2. Construct validity is the degree to which the scores ofa questionnaire are consistent with hypothesesbased on the assumption that the questionnairevalidity measures the construct to be measured. Fora correlation coefficient 0.3< r<0.7, moderate cor-relation was assumed.

3. Hypothesis testing: To analyze construct validity, apriori hypotheses were set up, hypothesizing thatthe PHBQ-AS would correlate moderately positivelywith the PRiC and with general health measured withSpearman rank (rho) correlation coefficients.

Internal consistency (reliability) describes consistencyand was assessed based on the following: Cronbach'salpha coefficient was calculated to determine thehomogeneity of each factor among the items in thePHBQ-AS.

Analysis of the PHBQ-AS and PRiC. Parent-reportedbehavioral changes, PHBQ-AS, are presented asfrequencies and proportions.

The self-reported items of the PRiC are presented withmean and standard deviation (SD) and with thefrequencies for all answers in each item.

Age was categorized dichotomously as younger children(<6 years) or older children (�6 years), guided by themean age 6.5 years of the included population. Ageswere compared using the Mann Whitney U-test.

4. Differences between genders were analyzed withMann Whitney U-test.

All statistical analyses were conducted with SPSS 23.0(SPSS Inc., Chicago, IL, USA). Descriptive statistics arepresented as numbers and percentages, arithmeticmeans, and medians. A P-value less than 0.05, two-tailed, was considered statistically significant.

Results

On the 10th day after the surgical procedure, a total of37% (n¼143) of the included children answered thePRiC, while their parents answered the PHBQ-AS. Themean age of the responding children was 6.5 years (SD2.3); 58% were girls (n¼82) and 42% boys (n ¼ 61).

Half of the children underwent adenotonsillotomy(n¼60) or tonsillotomy (n ¼ 7), and the other halfunderwent adenotonsillectomy (n ¼ 41) or tonsillectomy(n ¼ 35). The main indications for the procedures wereairway obstruction/hypertrophic tonsils (n ¼ 112),infection/inflammation such as recurrent tonsillitis (n ¼16), and "chronic" tonsillitis (n ¼ 15). The types ofanesthesia were inhalation (78%, n ¼ 112) and totalintravenous anesthesia (22%, n ¼ 31).

Psychometric properties

A principal components factor analysis with varimaxrotation was conducted, using the nine remaining itemsof the PHBQ-AS to determine whether the Swedishversion was unidimensional. The principal componentsanalysis resulted in a one-factor solution explaining50.8% of the total variance (Table 1). The Cronbach'salpha was 0.86. Construct validity showed a low positivecorrelation between the PHBQ-AS and PRiC,rho¼�0.25, P¼0.003 and a moderate correlationbetween PHBQ-AS and general health, rho¼�0.30,P¼0.000. On item level, low positive correlations werefound between seven PHBQ-AS items and 13 PRiC

Table 1 Factor loading and items in the modified version of theSwedish version of the Post Hospitalization BehaviorQuestionnaire for Ambulatory Surgery, PHBQ-AS

Item

Factor

loading

Does your child make a fuss about eating? 0.626

Does your child spend time just sitting or lying and

doing nothing?

0.708

Is your child uninterested in what goes on around

him (or her)?

0.805

Is it difficult to get your child interested in doing

things (like playing games with toys)?

0.688

Does your child have temper tantrums? 0.761

Does your child have bad dreams at night or wake

up and cry?

0.747

Does your child get upset when you leave him (or

her) alone for a few minutes?

0.853

Does your child have trouble getting to sleep

at night?

0.595

Does your child have poor appetite? 0.675


items. The strongest correlation was found between theitems PHBQ-AS Does your child make a fuss abouteating? and the PRiC items difficulty eating (rho¼0.31,P¼0.000) and sore throat (rho¼0.30, P¼0.000). Thehighest frequencies of correlations were found in the twoPHBQ-AS items measuring fuss about eating and pooreating. No correlations were found between two of thePHBQ-AS items, Does your child have bad dreams atnight or wake up and cry? and Does your child get upsetwhen you leave him (or her) alone for a few minutes?,and any of the PRiC items (Table 2).

Behavioral changes, PHBQ-AS

The most frequently reported negative behavioralchanges were fuss about eating (17%, n¼28) andhaving a poor appetite (17%, n¼28) (Figure 1). Therewere no significant differences in younger childrencompared to children from six years and older in thePHBQ-AS or on item levels. No differences were seenbetween genders.

Postoperative recovery (PRiC)

The item general health was scored to be rather good,3.7 (SD 0.5), and the majority of the children had arelatively high quality of recovery on postoperative day10, with 61%–98% reporting no symptoms or difficulties.The most frequently reported symptoms were sorethroat (39%), difficulties with eating (28%), feeling sad(20%), and feeling cold (18%). Twenty percent of thechildren reported difficulties with attending daycare orschool (Table 3). Younger children reported moredifficulties with dizziness, 1.3 vs. 1.1 (P¼0.009), andsleep 1.3 vs. 1.1 (P¼0.042), compared to the olderchildren. There were no differences in the other 21items. Girls suffered more from nausea, 1.1. vs. 1.0(P¼0.048); dizziness, 1.2 vs. 1.0 (P¼0.009); coldness,1.4 vs. 1.1 (P¼0.001); and headache, 1.2 vs. 1.0(P¼0.002), compared to the boys. There were nodifferences in the other 19 items. A difference in agewas also seen in the item general health, in whichyounger children assessed lower levels of healthcompared to the older ones, 3.6 vs. 3.8 (P¼0.021). Nodifferences were observed between genders.

Discussion

The study examined a parent-reported questionnaireabout post-hospitalization behavior, PHBQ-AS (Jenkins etal 2015), together with a child-reported questionnaireabout postoperative recovery, PRiC (Bramhagen et al2016), in a group of tonsil-operated children. Ourfindings from the psychometric testing suggest that themodified Swedish version of the PHBQ-AS has goodconstruct validity and internal consistency. The Swedishversion of PHBQ-AS consists of 9 items, instead of 11items as in the original PHBQ-AS (Jenkins et al 2015),due to two items being excluded in the Swedish versionof PHBQ (Karling et al 2006). The Swedish 9-item

version of PHBQ-AS cannot be compared with theoriginal American 11-item version of PHBQ-AS. We alsoassume that there could be cultural differences betweenSweden and the United States that also might influenceitems on the scale and the psychometric properties.Assessment of construct validity should include testinghypotheses that can demonstrate the proposedconstruct. We expected and found a positive correlationbetween the PHBQ-AS and the PRiC and general health,because they measure related concepts (behavior vs.recovery/health), and children with behavioral changesare expected, to some extent, to have lower quality ofrecovery and general health. Jenkins et al (2015) founda moderate positive correlation, r 0.49, between thePHBQ-AS and the Functional Disability Inventory (FDI).The FDI is a 15-item instrument that assesseslimitations in psychosocial and physical functioning as afunction of children's physical health (Walker & Greene1991). In the present study, we also found some positivecorrelations on item level between PHBQ-AS items andPRiC items. The strongest correlation was noticedbetween the PHBQ-AS item Does your child make a fussabout eating? and PRiC items difficulty eating(rho¼0.31, P¼0.000) and sore throat (rho¼0.30,P¼0.000). Highest frequencies of correlations werefound in the two PHBQ-AS items measuring fuss abouteating and poor eating. However, we strongly suggestthat the results from both PHBQ-AS and PRiC should beanalyzed on item level, not as total scores. The reasonbehind this is that we believe it is important to studyeach item separately when evaluating the child'spostoperative behavior and recovery. To merge all items(symptoms and signs) into a sum score can dilute or blurthe results and thus diminish the external validity.

The present study also aimed to describe both post-hospitalization behavior and postoperative recovery 10days after tonsil surgery. The results showed that 61%–98% of the children reported no symptoms in thedifferent PRiC items and also scored general health ashigh. However, 39% reported a sore throat and 28% haddifficulties eating on day 10 after surgery. This is in linewith other studies showing that children experiencedpain up to 14 days after tonsil surgery (Stanko et al2013, Stewart et al 2012). Regarding the eating factorin the behavioral changes instrument (PHBQ-AS), theparents reported that only 15% had poor appetite. Oneexplanation for this discrepancy could be that theappetite was considered to be normal, but the pain fromthe sore throat made it difficult for the children to eat.

Previous research has shown that pain medications areunderused in pediatric populations (Baugh et al 2011).This underutilization can be attributed to several factors,including parental concerns. A behavioral measurementcan provide information to parents about the distressand behavioral changes that children exhibit followingsurgery, indicative of pain. An advantage of creating ashort form of PHBQ is that it would increase the utility of

Nilsson et al. 97

Table

2Correlationsbetw

eenPHBQ-ASitemsandPRIC

items,measuredwithSpearman

rank(rho)correlationcoefficients

HospitalizationBehaviorQuestionnaire

forAmbulatory

Surgery,PHBQ-AS

Postoperative

Recovery

inChildren,PRiC

Doesyour

child

make

afuss

about

eating?

Doesyour

child

have

poorappetite?

Doesyour

child

have

trouble

getting

tosleepat

night?

Isitdifficult

togetyour

child

interested

indoingthings

(likeplaying

gameswithtoys)?

Doesyour

child

spend

timejust

sitting

orlyingand

doingnothing?

Isyourchild

uninterested

inwhat

goes

onaroundhim

(orher)?

Doesyour

child

have

temper

tantrums?

Doesyour

child

havebad

dream

sat

nightor

wakeup

andcry?

Doesyour

child

get

upsetwhen

youleave

him

(orher)

alonefora

few

minutes?

Feelingcold

rho¼0.16

P¼0.044

Dizzy

rho¼0.17

P¼0.027

Sore

throat

rho¼0.300

P¼0.000

rho¼0.22

P¼0.006

rho¼0.16

P¼0.042

Stomachache

rho¼0.19

P¼0.017

rho¼0.17

P¼0.032

Earache

rho¼0.19

P¼0.014

Frighteningdream

srho¼0.16

P¼0.048

rho¼0.18

P¼0.021

Difficultypooping

rho¼0.18

P¼0.025

Difficultypeeing

rho¼� 0

.18

P¼0.021

Bloodin

mymouth

rho¼0.17

P¼0.029

rho¼�0

.16

P¼0.025

Difficultysleeping

rho¼0.19

P¼0.017

rho¼0.18

P¼0.021

Difficultyeating

rho¼0.31

P¼0.000

rho¼0.19

P¼0.017

Difficultyplaying/

beingactive

rho¼0.21

P¼0.007

rho¼0.16

P¼0.044

Difficultyattending

daycare/school

rho¼0.17

P¼0.032

rho¼0.19

P¼0.022

rho¼0.29

P¼0.000

rho¼0.18

P¼0.031

PHBQ-AS:

Post

HospitalizationBehaviorQuestionnaire

forAmbulatory

Surgery;PRiC:Postoperative

Recovery

inChildren.


the tool, making it faster to complete and possiblyincrease compliance, with repeated use during thechild's postoperative recovery. Pain and postoperativerecovery are individual and subjective experiences andshould be measured with self-assessment in children,as is standard practice in adults. The PHBQ-AS couldassist parents and serve as a supplement to the

children's recovery self-reports. Parents play a crucialrole in pain management after hospital discharge,particularly given the increases in day surgery and briefhospitalization.

We did not find any gender differences in behavioralchanges or general health, but the PRiC results revealed

28 28

20

16

12

10 10

9

7

F U S S A B O U T E A T I N G

P O O R A P E T I T E T R O U B L E G E T T I N G T O

S L E E P

B A D D R E A M S U P S E T L E A V I N G D I F F I C U L T I N T E R E S T E D

T E M P E R A N T R U M S

D O I N G N O T H I N G U N I N T E R E S E D

Figure 1 Graph representing the frequency of negative behavioral changes (n¼ 140) on postoperative day 10

Table 3 The results of the individual items in the postoperative recovery in children, frequencies, mean, and median (n¼ 143)

Item

Not at all

n (%)

A little

n (%)

Much

n (%)

Very much

n (%) Media, n Mean

During the last day/night (within the last 24 h)

Have I. . .felt like vomiting 134 (94) 8 (6) 1 (1) Not at all 1.1

thrown up 138 (97) 2 (1.5) 2 (1.5) Not at all 1.1

been feeling cold 118 (82) 18 (12) 5 (3) 2 (1) Not at all 1.2

been dizzy 126 (89) 14 (10) 22 (2) Not at all 1.0

had a sore throat 86 (61) 46 (32) 7 (5) 3 (2) Not at all 1.5

had a stomach ache 119 (83) 22 (16) 2 (1) Not at all 1.2

had an earache 116 (81) 16 (11) 8 (6) 3 (2) Not at all 1.3

had a headache 127 (89) 14 (10) 2 (1) Not at all 1.1

felt sad 114 (80) 23 (16) 4 (3) 1 (1) Not at all 1.2

had frightening dreams 116 (82) 20 (14) 4 (3) 1 (1) Not at all 1.0

had difficulty peeing 139 (98) 2 (1) 1 (1) Not at all 1.0

had difficulty pooping 132 (93) 6 (4) 4 (3) Not at all 1.0

had blood in my mouth 137 (96) 5 (4) Not at all 1.0

Have I had difficulty. . .breathing 138 (98) 2 (1) 1 (1) Not at all 1.0

sleeping 116 (83) 20 (14) 3 (2) 1 (1) Not at all 1.2

eating 101 (72) 32 (23) 6 (4) 1 (1) Not at all 1.3

playing/being active 122 (87) 17 (12) 2 (1) Not at all 1.2

resting 121 (86) 18 (13) 2 (1) Not at all 1.2

talking 123 (87) 14 (10) 4 (3) Not at all 1.2

brushing my teeth 122 (86) 18 (13) 1 (1) Not at all 1.1

washing myself/showering 202 (85) 22 (9) 6 (3) 2 (1) Not at all 1.0

attending daycare/school 118 (80) 11 (8) 6 (4) 10 (7) Not at all 1.4

Nilsson et al. 99

that girls reported more nausea, dizziness, coldness,and headache compared to the boys. No differenceswere found in the other 19 items of the PRiC. Genderdifferences reported in other studies include a higherincidence of postoperative nausea and vomiting in girls,following outpatient tonsillectomy (Sadhasivam et al2015), and less postoperative pain in boys (Chieng et al2013). A Swedish registry of 32,225 tonsil surgeries onchildren reported no clinically relevant differencebetween genders in patient-reported pain-relatedoutcome measurements, except for days to regular foodintake, which was somewhat higher in the girls aftertonsillectomy. One factor was that the girls tended to beolder at the time of surgery, which could influencepatient-reported outcome measures for pain (Alm et al2017). One possible explanation in our study is that thegirls' symptoms were related to dehydration from theinfluence of diet in the postoperative recovery.

Our study showed that younger children scored lower inthe item general health compared to older children.Younger children reported more dizziness and moreproblems going to sleep on day 10 after surgery. This isin line with other studies that have reported that youngerchildren are at higher risk of behavioral changes aftersurgery (Fortier et al 2010, Karling et al 2007, Stargattet al 2006). Karling et al (2007) considered that theitems in the original subscale of the PHBQ better reflectbehaviors in younger children. There was no differencein age in the item "sore throat" to explain untreated painin our study. Alm et al (2017) found that older childrengenerally reported higher pain in patient-reportedoutcome measures. It might be speculated that olderchildren need more support for coping with the pain andthat they also are more aware that the parents areresponsible for the pain treatment.

One limitation in the present study is the chosen follow-up time. The pain after tonsil surgery increases a fewdays after surgery before gradually decreasing, and isoften most pronounced on days 3 to 5 aftertonsillectomy (Ericsson et al 2015). We might have seena stronger correlation between behavior (PHBQ-AS) andrecovery (PRiC) if data collection had been performedduring that period.

Implications for clinical practice andfurther research

It has previously been shown that the family structuresone-parent families (Karling et al 2007), two or moreolder siblings (Stargatt et al 2006), area of residence,and parental education (Karling et al 2007) are riskfactors for developing negative behavioral changespostoperatively. This was not the focus of our study,but is perhaps something worth studying in the future,together with other sociodemographic factors that

possibly could influence postoperative recovery andpost-hospitalization behavioral changes.

This study is limited in terms of generalizability andwhether the sample size is enough for a subgroupanalysis of gender and age. Furthermore, this study wasconducted in Swedish-speaking children and theirparents. Further studies including all types of anesthesiaand surgeries should be conducted, as well as studiesincluding non-Swedish-speaking participants answeringin their own languages. Another limitation to beacknowledged which may influence the results is that wehad no information about if the children had any earlierexperiences of undergoing surgery or any siblings withexperience of it.

The modified Swedish PHBQ-AS seems to be relevant formeasuring parent-reported behavioral changes inchildren undergoing tonsil surgery. However, there is adifference between the child's perspective and, forexample, the healthcare system that defines what isgood for them (Nilsson et al 2015). Children's own viewsshould be considered when measuring children'spostoperative recovery and care (Bramhagen et al2016). Furthermore, to ensure that important andrelevant outcomes are measured in clinical practice andfuture studies, a core outcome set developed specificallyfor this purpose would be highly desirable. Such a coreoutcome set would also help limit heterogeneity inoutcome reporting. There is a lack of core outcome setswithin pediatric anesthesia and surgery, both parent-reported and self-reported among children (Pearson &Hall 2017). We therefore suggest that parent proxyPHBQ-AS reporting should be supplemented withchildren's self-reported symptoms during thepostoperative phase, as assessed with the PRiC(Bramhagen et al 2016). This would identify bothchildren with behavioral changes due to anesthesia andsurgery and those children who currently experience low-quality postoperative recovery, such as girls and youngerchildren, as well as measure differences in behavior andpostoperative recovery in clinical trials. The availability ofthe PHBQ-AS and the PRiC will be valuable in researchand clinical practice with children experiencing pain athome following medical care.

Conclusion

Our findings from the psychometric testing suggest thatthe modified Swedish version of the PHBQ-AS has goodconstruct validity and internal consistency, and it reflectsaspects of the postoperative period measured by PRiC.Both instruments have their value and should beimplemented in the postoperative follow-up.Postoperative recovery seems to differ between gendersand ages, presented as lower quality of recovery in girlsand younger children.


Acknowledgments

The authors thank the contributions of the staff in the ENTclinics. They also thank children and parents for their partici-pation in this research.


ORCID iD

Ulrica Nilsson http://orcid.org/0000-0001-5403-4183

References

Alm F, Stalfors J, Nerfeldt P, Ericsson E 2017 Patient reportedoutcome of pain after tonsil surgery: an analysis of 32,225children from the National Tonsil Surgery Register inSweden 2009–2016. In: Nordic pediatric pain symposium2017, Stockholm, Sweden, 30–31 March 2017.

Baugh RF, Archer SM, Mitchell RB, Rosenfeld RM, Amin R,Burns JJ, Li KK 2011 Clinical practice guideline:tonsillectomy in children Otolaryngology – Head and NeckSurgery 144 (1_suppl) S1–30

Beringer RM, Segar P, Pearson A, Greamspet M, Kilpatrick N2014 Observational study of perioperative behaviorchanges in children having teeth extracted under generalanesthesia Pediatric Anesthesia 24 (5) 499–504

Bramhagen AC, Eriksson M, Ericsson E, Nilsson U, Harden S,Idvall E 2016 Self-reported post-operative recovery inchildren: development of an instrument Journal ofEvaluation in Clinical Practice 22 (2) 180–8

Chieng YJS, Chan WCS, Liam JLW, Klainin-Yobas P, Wang W, HeHG 2013 Exploring influencing factors of postoperative painin school-age children undergoing elective surgery Journalfor Specialists in Pediatric Nursing 18 (3) 243–52

Ericsson E, Brattwall M, Lundeberg S 2015 Swedish guidelinesfor the treatment of pain in tonsil surgery in pediatricpatients up to 18 years International Journal of PediatricOtorhinolaryngology 79 (4) 443–50

Eriksson M, Nilsson U, Bramhagen A-C, Idvall E, Ericsson E2017 Self-reported postoperative recovery in children aftertonsillectomy compared to tonsillotomy InternationalJournal of Pediatric Otorhinolaryngology 96 47–54

Ferketich S 1991 Focus on psychometrics. Aspects of itemanalysis Research in Nursing & Health 14 (2) 165–68

Fortier MA, Del Rosario AM, Rosenbaum A, Kain ZN 2010Beyond pain: predictors of postoperative maladaptivebehavior change in children Pediatric Anesthesia 20(5) 445–53

Hallenstål N, Sunnergren O, Ericsson E, Hemlin C, HessénS€oderman A-C, Nerfeldt P, Stalfors J 2017 Tonsil surgery inSweden 2013–2015. Indications, surgical methods andpatient-reported outcomes from the National Tonsil SurgeryRegister Acta Oto-Laryngologica 137 (10) 1096–1103

Jenkins BN, Kain ZN, Kaplan SH, Stevenson RS, Mayes LC,Guadarrama J, Fortier MA 2015 Revisiting a measure ofchild postoperative recovery: development of the PostHospitalization Behavior Questionnaire for AmbulatorySurgery Pediatric Anesthesia 25 (7) 738–45

Kain ZN, Mayes LC, Caldwell-Andrews AA, Karas DE, McClainBC 2006 Preoperative anxiety, postoperative pain, andbehavioral recovery in young children undergoing surgeryPediatrics 118 (2) 651–8

Karling M, Stenlund H, H€aggl€of B 2006 Behavioural changesafter anaesthesia: validity and liability of the PostHospitalization Behavior Questionnaire in a Swedishpaediatric population Acta Paediatrica 95 (3) 340–46

Karling M, Stenlund H, H€aggl€of B 2007 Child behaviour afteranaesthesia: associated risk factors Acta Paediatrica 96(5) 740–47

Kotiniemi LH, Ryh€anen P, Moilanen I 1997 Behaviouralchanges in children following day-case surgery: a 4-weekfollow-up of 551 children Anaesthesia 52 (10) 970–76

Kotiniemi LH, Ryh€anen PT, Moilanen IK 1996 Behaviouralchanges following routine ENT operations in two-to-ten-year-old children Pediatric Anesthesia 6 (1) 45–9

Nilsson S, Bj€orkman B, Almqvist A-L, Almqvist L, Bj€ork-Willén P,Donohue D, Hvit S 2015 Children's voices – differentiatinga child perspective from a child's perspectiveDevelopmental Neurorehabilitation 18 (3) 162–68

Pearson KL, Hall NJ 2017 What is the role of enhancedrecovery after surgery in children? A scoping reviewPediatric Surgery International 33 (1) 43–51

Sadhasivam S, Chidambaran V, Olbrecht VA, Costandi A, ClayS, Prows CA, Martin LJ 2015 Opioid-related adverse effectsin children undergoing surgery: unequal burden on youngergirls with higher doses of opioids Pain Medicine 16(5) 985–97

Sathe N, Chinnadurai S, McPheeters M, Francis DO 2017Comparative effectiveness of partial versus totaltonsillectomy in children: a systematic reviewOtolaryngology – Head and Neck Surgery 156 (3) 456–63

Stanko D, Bergesio R, Davies K, Hegarty M, Ungern-SternbergBS 2013 Postoperative pain, nausea and vomiting followingadeno-tonsillectomy – a long-term follow-up PediatricAnesthesia 23 (8) 690–96

Stargatt R, Davidson AJ, Huang GH, Czarnecki C, Gibson MA,Stewart SA, Jamsen K 2006 A cohort study of the incidenceand risk factors for negative behavior changes in childrenafter general anesthesia Pediatric Anesthesia 16(8) 846–59

Stewart DW, Ragg PG, Sheppard S, Chalkiadis GA 2012 Theseverity and duration of postoperative pain and analgesiarequirements in children after tonsillectomy, orchidopexy, oringuinal hernia repair Pediatric Anesthesia 22 (2) 136–43

Vernon DT, Schulman JL, Foley JM 1966 Changes in children'sbehavior after hospitalization: some dimensions ofresponse and their correlates American Journal ofDiseases of Children 111 (6) 581–93

Walker LS, Greene JW 1991 The functional disability inventory:measuring a neglected dimension of child health statusJournal of Pediatric Psychology 16 (1) 39–58

Wilson CA, Sommerfield D, Drake-Brockman TF, Bieberstein L,Ramgolam A, Ungern-Sternberg BS 2016 Pain afterdischarge following head and neck surgery in childrenPediatric Anesthesia 26 (10) 992–1001

Nilsson et al. 101

http://orcid.org/0000-0001-5403-4183

Surgery of the Past

Neurectomy for trigeminal neuralgia

Professor Harold Ellis

Keywords

Trigeminal neuralgia / Neurectomy / Trigeminal nerve

Provenance and Peer review: Commissioned; Accepted for publication 31 March 2017.

Attacks of sudden agonising pain on one or other side ofthe face were well recognised in ancient times andappear in the writings of Galen (AD 131-201) and thePersian physicians Rhazes, in the 9th century AD andAvicenna in the 10th century. Sir Charles Bell, surgeonat the Middlesex Hospital, London in his textbook, TheNervous System of the Human Body (1833), showedthat the distribution of the pain corresponded preciselyto that of the 5th cranial nerve – the trigeminal nerve.

Most patients present at or after middle age and womenare more often affected than men. The symptoms are ofsudden attacks of excruciating pain in the cutaneousdistribution of one or more branches of the 5th, thetrigeminal, cranial nerve. During these attacks, theremay be twitching of the facial muscles on the affectedside, hence the alternative name of 'tic doloreux',(painful tic), for this condition.

The attacks may eventually become bilateral and may beprecipitated by only slight sensory stimulation – combingthe hair, shaving or brushing the teeth – and thesubject's personal hygiene may suffer because ofavoiding these activities. The pain is resistant to themost powerful analgesic drugs and may drive theunfortunate patient to suicide.

Excision of the sensory ganglion of the trigeminal nerve,buried deeply on the base of the middle cranial fossa ofthe skull, was suggested by the Philadelphianneurologist W.G. Spiller and was carried out by VictorHorsley (Figure 1), surgeon at the Hospital for NervousDiseases, Queen Square London in 1891, using atemporal approach, and he continued to perform thisdifficult procedure even though his first patient diedpostoperatively.

The operation was taken up with great enthusiasm byHarvey Cushing, who is regarded as the father of modernneurosurgery and who published several articles on thiscondition and its surgical treatment. Cushing started hissurgical career in Baltimore, and then moved to Boston,to the newly opened Peter Bent Brigham Hospital in1912, as chief of surgery. Among his many contributions

he helped overcome the problem of haemorrhage inbrain surgery, by introducing the silver clips, which bearhis name, adrenaline infiltration of the scalp along theline of the skin incision and, most important of them all,the surgical diathermy.

In 1900, Cushing published an important article in theJournal of the American Medical Association entitled Amethod of total extirpation of the Gasserian ganglion fortrigeminal neuralgia by a route through the temporalfossa. This was beautifully illustrated by the author, who

Figure 1 Sir Victor Horsley

Emeritus Professor of Surgery, University of London, Department of

Anatomy, Guy’s Hospital, London


Professor Harold Ellis, Department of Anatomy, University of London,

Guy’s Campus, London, SE1 1UL.


2019, Vol. 29(4) 102–103




DOI: 10.1177/1750458918790185



http://dx.doi.org/10.1177/1750458918790185


was also an accomplished artist. By the following year, itwas found that simple division of the sensory root of thetrigeminal nerve sufficed, making removal of theganglion unnecessary and the operation somewhatless hazardous.

Many theories were put forward to account for thisrather mysterious condition. These included infection bythe herpes virus. It was also known that rarely thesymptoms could be produced by a tumour in this region.However, it was one of Harvey Cushing's trainees, WalterDandy, now chief of neurosurgery at the Johns HopkinsHospital, Baltimore, who, in 1934 published a paper inthe American Journal of Surgery in which he reported ahigh incidence of vascular channels which impingedupon the root entry zone of the trigeminal nerve found atoperation for trigeminal neuralgia. He proposed thattheir pressure could be the cause of trigeminalneuralgia. Walter Dandy, we might notice in passing, wasa complete contrast to his old chief, Harvey Cushing.Dandy was a brilliant and very rapid operator, in contrastto the slow, meticulous surgery of his teacher. He madenumerous important advances, including fundamentalstudies on the formation and absorption ofcerebrospinal fluid, which of course was fundamental tothe understanding and treatment of hydrocephalus, anddevised the radiological technique of ventriculography

(filling the ventricular system with air) which was onlycomparatively recently replaced by the CT scanner.

It was more than 40 years after Dandy's publication thatPeter Jannetta published his important study in theJournal of Neurosurgery in 1977. By now, the operatingmicroscope was having a dramatic effect onneurosurgical technique. This enabled him to make adetailed study which confirmed an over 97% incidenceof trigeminal root compression by adjacent circle ofWillis blood vessels. The remaining 3% are due to suchcauses as pressure from an acoustic neuroma,meningioma or cholesteatoma.

The operation is now performed via a limited sub-occipital, retromastoid approach, usually with the patientin the sitting position and under general anaesthesia.The dura is opened to expose the cerebello-pontine angle.

The impinging arterial channel is dissected free andsecured away from the trigeminal nerve by means of aplastic sponge. An extraordinary advance in technologysince Victor Horsley's pioneering craniectomy in 1900with a hammer and chisel!


Ellis 103

PerioperativePractice

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