Nausea intensity as a reflector of early physical recovery after surgery

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Citation for the original published paper (version of record):

Eriksson, K., Årestedt, K., Broström, A., Wikström, L. (2019)

Nausea intensity as a reflector of early physical recovery after surgery Journal of Advanced Nursing, 75(5): 989-999

https://doi.org/10.1111/jan.13893

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Nausea Intensity as a reflector of early physical recovery after

surgery.

Running head: Prediction of physical recovery after surgery

Kerstin ERIKSSON, RNICU, PhD,

_{Kristofer ÅRESTEDT, RN, PhD,}

Professor,

_{Anders BROSTRÖM, RN, PhD, Professor,}

_{Lotta WIKSTRÖM,}

RNICU, PhD

1_{School of Health and Welfare, Jönköping University, Jönköping, Sweden}

2_{Department of Anaesthesia and Intensive Care, Ryhov County Hospital, Jönköping, Sweden}

3_{Faculty of Health and Life Caring Sciences, Linnaeus University, Kalmar, Sweden}

4_{The Research Section, Kalmar County Council, Kalmar, Sweden}

5_{Department of Clinical Neurophysiology, University Hospital, Linköping, Sweden}

Address for correspondence, reprint requests and proofs: Kerstin Eriksson RN, PhD,

Department of Anaesthesia and Intensive Care, Ryhov County Hospital, SE-551 85

Jönköping, Sweden. Tel: +4636321000, Fax: +4636325055, E-mail: kerstin.eriksson@rjl.se

Acknowledgements

The authors are grateful to all patients who agreed to share their experiences and to all research nurses who assisted during the study.

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Funding

This research was funded by Futurum (no. 598311), Academy for Health and Care, County Council of Jönköping, Sweden and by FORSS (no. 376851), Medical Research Council of Southeast Sweden.

Conflict of interest

No conflict of interest.

Author contributions

All authors have agreed on the final version based on the following 4 criteria, as recommended by the ICMJE (http://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html):

• Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND

• Drafting the work or revising it critically for important intellectual content; AND

• Final approval of the version to be published; AND

• Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Abstract

Aim: To compare different levels of self-rated average nausea intensity with early physical

recovery, and determine if nausea can reflect recovery in patients undergoing general or orthopaedic surgery.

Background: Nausea has been found to influence postoperative physical recovery. Despite

the incidence of nausea within postoperative care, there is a knowledge gap about the possibility of using average nausea intensity to reflect recovery, motivating further investigation.

Design: An observational design with repeated measures.

Methods: General and orthopaedic patients answered a questionnaire (October 2012 -

January 2015) about nausea and impact on recovery on postoperative days 1 (n=479) and 2 (n=441). Questions about average nausea intensity at rest and during activity were answered based on the Numeric Rating Scale (0-10). Impact on recovery was evaluated using three dimensions from the Postoperative Recovery Profile tool.

Results: About one-fifth of the patients reported nausea intensity as moderate to severe on

days 1 and 2. Nausea intensity was associated with eight of nine aspects of recovery on postoperative day 1. Nausea intensity on day 1 also reflected four of nine aspects of recovery on day 2. With regard to reflecting physical recovery, the association was strongest between nausea intensity and appetite changes.

Conclusions: As postoperative nausea is common, regular assessments by healthcare

professionals are needed. Assessment of nausea is of importance since it reflects physical recovery. This also shows the importance of treating nausea without delay. Using the NRS to measure nausea intensity is a simple method that is easy to use in clinic.

4 KEYWORDS Nausea, nursing, Numeric Rating Scale, physical recovery, postoperative care.

Why is this research needed?

• In surgical care, enhanced recovery is known to reduce postoperative complications and length of hospital stay. Thus, monitoring of patients’ physical recovery is emphasized in clinical practice.

• Recovery tools may be extensive and require patients to complete a questionnaire. Furthermore, healthcare professionals need time to inform and instruct patients how to perform the task.

• Guidelines for pain management recommend regular screening for postoperative adverse events such as nausea, but if nausea could be used to reflect physical recovery is unknown.

What are the key findings?

• Average nausea intensity on postoperative day 1 reflected eight of nine recovery aspects for that day. Thus, nausea intensity can be used to indirectly summarize patients’ recovery status.

• Average nausea intensity on postoperative day 1 reflected four of nine recovery aspects for day 2. By following nausea intensity, healthcare professionals are alerted to the need to minimize the discomfort of nausea.

• On postoperative days 1 and 2, the association was strongest regarding appetite changes; on postoperative day 1, fatigue had a strong association.

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How should the findings be used to influence policy/practice/research/education?

• The findings should alert healthcare professionals that a relatively large proportion of patients experience moderate to severe nausea postoperatively.

• Further studies are needed to determine whether regular assessments of nausea intensity and documentation of the ratings in the medical record can be used to reflect physical recovery.

1 INTRODUCTION

Nausea has been found to influence postoperative physical recovery (Allvin, 2009; Myles et al., 1999; White, O'Hara, Roberson, Wender, & Candiotti, 2008). Consequently, nausea is commonly included in existing tools for assessing recovery (Allvin, 2009; Myles et al., 1999; Royse et al., 2010). These, in many cases extensive self-assessment tools, monitor recovery during different postoperative phases (Bowyer and Royse, 2016a). The lengthy questionnaires used to fulfil this task can be a burden to patients weakened by surgery, as well as healthcare professionals who are required to inform the patient about the questionnaire and interpret the results. It would be easier if existing healthcare routines could capture recovery instead of using an extensive tool. Regular postoperative nausea assessments are a simple way to identify patients with nausea problems but can also be used to calculate an average score, preferable as a median core. Average pain assessments have earlier been found to reflect physical recovery (Eriksson, Wikström, Fridlund, Årestedt, & Broström, 2017), but to our

6 best knowledge no previous study has investigated if average nausea reflect different aspects of recovery. If possible, nausea intensity from monitoring records summarized to a median value might in the future be in use in everyday clinical practise to reflect recovery and alert which patients are in need of specific treatment to enhance their recovery.

1.1 Background

Programmes for enhanced recovery after surgery (ERAS) have been mentioned as a paradigm shift intended to support healthcare professionals in optimizing postoperative care (Fearon et al., 2005; Lombardi, Berend, & Adams, 2010). The aim is to accelerate physical recovery by minimizing complications such as infections, as well as reducing length of hospital stay (Fearon et al., 2005). The implementation of ERAS programmes has resulted in a multifaceted multidisciplinary approach with the use of evidence-based methods for pain relief, stress reduction, early mobilization and early enteral nutrition (Fearon et al., 2005). Of these, absence of nausea is considered as an important goal for physical recovery among healthcare professionals committed to the ERAS programmes (Aahlin et al., 2014). As nausea is regarded as a crucial aspect in these programmes, and in recovery tools, the symptom should be monitored and documented. Current postoperative healthcare routines include regular screening for pain and detection of common adverse events, such as nausea (Gordon et al., 2010). Yet, despite its high prevalence (Lee, Lee, Thinn, Poon, & Liu, 2015) and importance for recovery (Aahlin et al., 2014), only a few patients’ who experience nausea are detected by healthcare professionals (Franck et al., 2010). It is only when nausea is detected in real time that healthcare professionals can provide correct support to individual patients (Bowyer & Royse, 2016b). This emphasizes the importance of monitoring nausea intensity through regular assessment and documentation of patients’ responses in the medical record. In guidelines for postoperative care and pain management, it is recommended that nausea

7 Trinca, 2015; Apfelbaum et al. 2013). The Numeric Rating Scale (NRS) has been proposed for clinical practice when self-reporting nausea intensity because it is simple to use and is already used to assess pain intensity (Wood, Chapman, & Eilers, 2011).

In a recent study, average pain intensity was associated with early physical recovery (Eriksson, Wikström, Fridlund, Årestedt, & Broström, 2017). However, the possibility of using nausea intensity to reflect early physical recovery and whether this varies among surgical specialties has not been explored. Pain intensity has been found to differ for general and orthopaedic patients (Forsberg, Vikman, Walivaara, & Engström, 2015; Rothaug et al., 2013). This has resulted in different strategies for pain management with various risks for nausea. Furthermore, physical recovery of orthopaedic patients postoperatively is delayed compared with general surgery (Forsberg et al., 2015). These differences may interfere with the possibility of using nausea intensity to reflect physical recovery among general and orthopaedic patients. A simple method to monitor physical recovery to simplify healthcare professionals’ daily work is lacking. It is recommended that nausea is monitored regularly in postoperative care and is an essential part of ERAS, therefore nausea assessment might be an appropriate routine to indirectly capture real-time physical recovery. Despite the prevalence of nausea in the postoperative period, there is a knowledge gap about the possibility of using average nausea intensity to reflect recovery, which requires further investigation. Similarly, knowledge of how nausea intensity affects different aspects of physical recovery is

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2 THE STUDY

2.1 Aim

The aim of this study was to compare different levels of self-rated average nausea intensity with early physical recovery, and determine if nausea can reflect recovery in patients undergoing general or orthopaedic surgery.

2.1 Design

An observational design with repeated measures was used.

2.2 Sample and setting

The study took place in six wards at three hospitals, covering a catchment area of about 415,000 inhabitants in southeast Sweden. The inclusion criteria were: patients

undergoing major general or orthopaedic surgery with a hospital stay of at least 2 days, age 18 years or older and having an understanding of the Swedish language. The definition of major surgery in this study is the same as used by Weiser et al. (2008) who define major surgery as surgery carried out under regional or anaesthetic treatment. Exclusion criteria were: cognitive impairment or in need of intensive care. The sample size in the study was based on previously conducted studies in the field of postoperative care, involving between 130-500 patients (Alvarez et al. 2015, Asakura et al. 2015, Guimaraes-Pereira et al. 2016, Siddiqui et al. 2013). Based on a convenience sample, eligible patients were invited to participate in the study. In total, 541 patients answered the first questionnaire, and 479 completed the second

questionnaire. As result of early discharge from the hospital, 441 completed the third questionnaire.

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2.3 Data collection

Data were collected over a period of 2 years (October 2012 to January 2015).

Research nurses in each ward enrolled patients to the study during the admission dialogue 1–2 weeks before surgery. At the enrolment, patients completed a questionnaire about their

background together with baseline values regarding nausea intensity last week, as well as current status of physical symptoms, physical function and activity. On postoperative days 2 and 3, questionnaires about the previous day’s nausea intensity and impact on recovery were completed by the patients. The research nurses collected supplementary clinical data such as drugs administered, ASA classification level and type of surgery.

2.4 Questionnaire

Data collection was performed with a questionnaire consisting of 11 questions

regarding nausea and physical recovery. Based on the recommendation by Wood et al. (2011), nausea intensity was measured by the NRS because it is already in clinical use to measure pain intensity. The NRS measured nausea intensity with a score between 0 and 10 (i.e. 0 = no nausea; 10 = worst nausea). In the questionnaire, 2 of the 11 questions were about nausea. Patients summarized the previous day’s average nausea intensity, the first question at rest and the second during activity. Rating of nausea with a visual analogue scale has been described previously to correspond with a verbal scale, where 1–3 is mild, 4–6 is moderate and 7–10 is severe nausea (Boogaerts, Lancker, Seidel, Albert, & Bardiau, 2000). Inspired by Boogaerts et al. (2000), nausea intensity was divided into three groups: 0–3 mild, 4–6 moderate and 7– 10 severe.

Postoperative physical recovery was measured with nine questions from the questionnaire postoperative recovery profile (PRP). The PRP has been developed in a Swedish setting and proven to be valid and reliable in previous research (Allvin, Ehnfors,

10 Rawal, Svensson, & Idvall, 2009). The PRP consist of 17 aspects when used for inpatients, divided into five dimensions. Of these, three dimensions corresponded to the aim of this study: physical symptoms, physical function and activity. Psychological and social dimensions were excluded because the aim focused on physical recovery. The physical symptoms dimension consists of pain, nausea, fatigue, appetite changes and sleeping difficulties. The physical function dimension includes gastrointestinal function, bladder function, mobilization and muscle weakness. The activity dimension includes personal hygiene. Because nausea intensity was measured with the NRS (i.e. 0–10), the nausea aspect of the PRP was excluded from the physical symptoms. Patients answered questions about the impact of disparate aspects of physical recovery. The response options in the PRP comprised four alternatives: 0 none, 1 mild, 2 moderate and 3 severe. These answers were dichotomized into two groups: none/mild and moderate/severe. This method has been used previously to compare average pain intensity and impact on recovery (Eriksson et al., 2017; Forsberg et al., 2015). At the analyses each aspect was analysed separately, and no sum score was used.

2.5 Ethical considerations

This study followed the ethical guidelines according to the principles of the Helsinki Declaration (World Medical Association, 2013). Patients received oral and written

information about their rights, the purpose of the study and what participation implied for them. Ethical approval was received from the Regional Ethical Review Board in Linköping, Sweden (no. M249-08).

2.6 Data analyses

Descriptive statistics were conducted to present background data as well as average nausea intensity. Differences in age between general and orthopaedic surgery patients were

11 analysed with an independent-samples t test. Comparisons of categorical background and clinical data were performed with Pearson chi-squared test.

Comparisons of average nausea intensity (NRS) between postoperative days 1 and 2 were conducted with a dependent-samples t test, and an independent t test was used to compare average nausea intensity between the two surgical groups. Cohen’s d within-group analyses (d = md/sd) and between-group analyses (d = m1 – m2/spooled) were calculated to

describe the effect size of average nausea intensity between postoperative days 1 and 2 as well as group differences between orthopaedic and general surgery. The effect size was considered as small (d = 0.2), medium (d = 0.5) and large (d = 0.8) (Cohen, 1988).

To determine the association between different levels of average nausea intensity and impact on the disparate recovery aspects, binary logistic regression analyses were performed. The association analysis was aimed at determining whether the level of nausea intensity reflected recovery for days 1 and 2. Physical recovery for day 1 and day 2 were included as outcome variables. The answer options were dichotomized as recovered (none/mild) or not recovered (moderate/severe). Average nausea intensity was included as an explanatory variable, dummy coded as NRS 0–3 mild problems (reference category), NRS 4–6 moderate problems and NRS 7–10 severe problems. Because few patients had average nausea intensity at NRS 7–10, general and orthopaedic patients were pooled into one group. The regression analyses were performed in two steps. In the first step, average nausea intensity on day 1 was included as an explanatory variable and recovery aspects from day 1 were included as

outcome variables. In the second step, the same explanatory variable was used to reflect physical recovery on day 2. The results are reported with odds ratio (OR) and confidence interval (CI).

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p values <.05 were considered statistically significant. All analyses were performed

using IBM SPSS statistics 21 (IBM Corporation, Armonk, NY, USA).

2.7 Reliability and validity

The PRP has been found to have satisfactory psychometric properties (Allvin et al., 2009). Content validity was achieved because each aspect in the dimensions has been regarded as a prerequisite for recovery by patients and healthcare professionals. Reliability was determined by Svensson analyses (Allvin et al., 2009). No global score was used in the current study; instead each aspect of recovery was analysed in relation to nausea intensity. The NRS has been proved to be reliable and valid when used for pain intensity (Ferreira-Valente, Pais-Ribeiro, & Jensen, 2011) but has not been studied in the context of

postoperative nausea intensity. However, the NRS has been recommended for assessment of nausea intensity (Wood et al., 2011). The analyses with the parametric t-test was preceded by analyses with the non-parametric Wilcoxon test, which gave no differences in results.

3 RESULTS

3.1 Background and clinical data

The sample consisted of patients undergoing general (n = 190) or orthopaedic surgery (n = 289). During postoperative days 1 and 2, 479 and 441 patients were included,

respectively. The mean age was 65.2 years (standard deviation, 11.0 years; range, 22–93 years). There were more men in the general surgery group and more women in the orthopaedic surgery (p < .001) (Table 1). Of the sample, 94.4% were born in Sweden. Postoperative pain was in the general surgery group mainly treated with epidural analgesia (57.4 %) while treatment in the orthopaedic group consisted of opioids for almost all patients

13 (95.8 %). The proportion of patients who received any antiemetic drug during postoperative days 1 and 2 was 25.2% and 20.6%, respectively.

3.2 Intensity of postoperative nausea

On postoperative day 1, 17.3% of the total sample reported average postoperative nausea as moderate or severe (NRS 4–10) at rest. The prevalence was higher during activity (22.9%). The corresponding values for postoperative day 2 were 13.3% at rest and 18.6% during activity (Table 2).

The orthopaedic surgery group reported more problems with moderate or severe postoperative nausea than the general surgery group for day 1 at rest (18.3% vs 14.5%) and during activity (24.0% vs 17.1%). In contrast, the orthopaedic surgery group reported less problems with moderate or severe postoperative nausea than the general surgery group at rest (10.8% vs 16.4%) and during activity (16.0% vs 18.4%) on day 2 (Table 2).

3.3 Comparison of average postoperative nausea between day 1 and day 2

3.4 Comparison of average postoperative nausea between the orthopaedic

and general surgery groups

Average postoperative nausea intensity was lower after general surgery compared with orthopaedic surgery, both at rest (p = .016) and during activity (p = .001) on

14 postoperative day 1. However, the effect size was small (d < 0.3). In contrast, no significant difference was found for day 2 between the surgical groups (rest, p = .575; activity, p = .155) (Table 3).

3.5 Ability of average nausea intensity day 1 to reflect early physical

recovery, day 1

The results showed that a higher level of average nausea intensity on day 1 reflected most aspects of physical recovery on the same day. At rest, all aspects of physical recovery, except gastrointestinal function and bladder function, were reflected by average nausea intensity (OR, 1.83–13.12). During activity, all aspects of physical recovery, except bladder function, were reflected by average nausea intensity (OR, 1.82–6.96). The association

between nausea intensity and recovery was strongest for fatigue and appetite changes, both at rest and during activity (Table 4).

3.6 Ability of average nausea intensity day 1 to reflect early physical

recovery, day 2

A higher level of average nausea intensity of day 1 reflected physical recovery for day 2, but to a lesser extent compared with day 1. At rest, four of nine aspects of recovery could be reflected by average nausea intensity: fatigue, appetite changes, sleeping difficulties and gastrointestinal function (OR, 1.87–6.28). During activity, three of nine aspects of physical recovery could be reflected by average nausea intensity: appetite changes, sleeping difficulties and personal hygiene (OR, 2.48–4.12).The association between nausea intensity on day 1 and physical recovery on day 2 was strongest regarding appetite changes (Table 5).

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4 DISCUSSION

The aim of this study was to compare different levels of self-rated average nausea intensity with recovery and determine if they could reflect early physical recovery in patients undergoing general or orthopaedic surgery. About one-fifth of the patients stated nausea intensity as moderate or severe. The results show that nausea intensity (i.e. at rest and during activity) was associated with almost all disparate recovery aspects on postoperative day 1. Nausea intensity on day 1 also reflected recovery for day 2, but with fewer aspects of recovery compared with the number that reflected recovery. In reflecting physical recovery day 1, the association was strongest between nausea intensity and fatigue, and with appetite changes. The corresponding association regarding reflecting recovery day 2 was strongest for appetite changes.

Postoperative days 1 and 2 were average nausea intensity’s association strongest about the PRP dimension physical symptoms which include appetite changes, fatigue, sleeping difficulties and pain. Average nausea intensity was associated with more aspects of physical recovery day 1 than day 2. This is in line with an earlier study using symptom evaluation with average pain intensity to reflect recovery (Eriksson et al., 2017). Feldman, Lee, and Fiore (2015) claim that recovery tools should include aspects of importance for the patient. Nausea is a symptom that patients find unpleasant and also has an impact on the early physical recovery process (Allvin, Ehnfors, Rawal, & Idvall, 2008; Mallick-Searle & Fillman, 2017; Myles & Wengritzky, 2012). Regular monitoring for nausea is recommended to enable early treatment (Franck et al., 2010). This justifies the use of nausea to indirectly monitor the recovery progress. However, in comparison with a recent study regarding pain intensity (Eriksson et al., 2017), nausea intensity had a lower ability to reflect recovery. In contrast to pain intensity, average nausea intensity on day 1 had the ability to reflect the impact on

16 recovery for day 2 regarding appetite changes, which pain intensity did not (Eriksson et al., 2017). By monitoring nausea intensity frequently, in the same way as pain intensity, nausea could complement pain intensity in reflecting the next day’s recovery, especially changes in appetite. Moreover, postoperative complications can be identified using an early warning score, which is common today for quick detection of changes in vital signs, such as pulse, blood pressure and respiratory rate (Hollis et al., 2016). In the same way, the presence of nausea, as well as pain, might be an early warning for affected recovery. Healthcare professionals can be alerted to take action in real time to reduce discomfort and promote physical recovery.

Average postoperative nausea intensity in the present study reflected sleeping difficulties; sleeping quality in turn has been found to have an impact on postoperative physical recovery (Gong, Wang & Fan, 2015; Miller, Roth, Roehrs, & Yaremchuk, 2015). Furthermore, sleep restriction is believed to increase perceived pain intensity (Tiede et al., 2010) and experience of fatigue (Oliveira, Oliveira, Souza-Talarico, & Mota, 2016). The recovery aspect of fatigue was associated with nausea intensity. As stated in a previous study, patients consider fatigue as one of the most common constraints for recovery (Munter,

Clemmesen, Foss, Palm, & Kristensen, 2017). Equally important, the treatment of one recovery aspect may affect another aspect. For example, the choice of treatment for pain may influence nausea intensity (Nicholson, 2017). For this reason, dialogue with patients is required to find out the meaning of the nausea rating for each individual to enable a shared decision on minimizing symptoms. Nausea intensities ability to reflect gastrointestinal function was weak. This is in line with the clinical experience in the research team, that nausea rarely is related to impaired GI function postoperative day 1. In the medical record, documentation of nausea with the NRS (nausea is present or not) is required to monitor its course and transfer the information to the next working shifts. However, lack of

17 documentation of symptoms is common (Larsson, Sahlsten, Segesten, & Plos, 2011; Meissner et al., 2015). For this reason, care routines, as well as electronic medical records that support and simplify documentation routines, need to be developed to facilitate healthcare

professionals’ clinical work. Yet, these issues go beyond healthcare professionals’ ability to make structural changes. Rather, a managerial approach is necessary because it requires adjustments to documentation tools and procedures. Furthermore, future studies are needed to determine whether a compiled value from each patient’s self-rated nausea ratings,

documented in the medical record, can be used to summarize nausea intensity.

Approximately every fifth patient reported average nausea intensity levels corresponding to moderate or severe problems (NRS 4–10). This is in line with previous research where the share of moderate to severe nausea was 18% among patients who had undergone surgical procedures, including general and orthopaedic surgery (Lee et al., 2015). There was no major difference in incidence of nausea between general surgery and

orthopaedic surgery, even though slightly more orthopaedic patients stated moderate to severe nausea day 1. This may be due to that almost all patients in the orthopaedic group were

treated with opioids postoperatively, which is associated with higher risk of nausea (Gan et al., 2014). To identify the presence of nausea, patients should be specifically asked about nausea, otherwise there is a risk that it will not be detected (Jokinen, Smith, Roewer, Eberhart, & Kranke, 2012; Kranke, 2015). When evaluating another important clinical postoperative symptom, that is pain, healthcare professionals are advised to always ask for a rating on the NRS (0–10) even if patients neglect pain (Wikström et al., 2017). This procedure can also be used when assessing nausea to capture low ratings of nausea intensity. Patients may deny they have any problem and the nuances of symptoms are lost. In the same way as described when assessing postoperative pain (van Dijk et al., 2012; Eriksson, Wikström, Fridlund, Årestedt, & Broström, 2016), patients’ ratings for nausea assessment are probably affected by the manner

18 of healthcare professionals. Interpretation of symptom assessments is a complex task

requiring knowledge how to interpret assessments and knowledge about communication to achieve good quality of documented ratings.

Although there are programmes that include prevention of nausea, there are patients who still suffer from it. Consequently, it is recommended that ongoing nausea should be treated vigorously using a multimodal approach (Azhar et al., 2016; Gan et al., 2014). However, besides prophylaxis of nausea, research on the treatment of established nausea is insufficient (Jokinen et al., 2012). Absence of nausea is a vital part of postoperative care because intake of nutrition promotes wound healing and decreases the prevalence of

infections, leading to enhanced physical recovery (Weimann et al., 2017; Yeung, Hilkewich, Gillis, Heine, & Fenton, 2017). Because of the impact of early oral nutrition on recovery, the lack of specific guidelines for monitoring and documenting nausea intensity is astonishing. In postoperative care, guidelines for nausea ought to be as obvious as those for pain.

Furthermore, discomfort from nausea interferes with the other disparate recovery aspects and thereby overall recovery.

4.1 Limitations

The purpose of the study was to determine the impact of nausea intensity on disparate aspects of physical recovery. For this reason, three of five dimensions from the PRP (Allvin et al., 2009) which were within the aim of the study were used. No total score for the PRP recovery tool was used, justifying why the whole tool was not used. The purpose was to explore if the ability to reflect recovery differed between general and orthopaedic surgery. However, because the number of patients with average nausea intensity at NRS 7–10 was low, the two surgical groups were pooled. Further studies are required to determine whether there are any differences between the groups in their ability to reflect recovery. The low

19 proportion of patients in the level of NRS 7-10 made it impossible to validate the result by dividing the sample and compare if the outcome was equivalent. In the present study, the NRS was used to measure nausea intensity as recommended by Wood et al. (2011) but no study has been shown to prove whether the NRS has validity and reliability for measuring nausea

intensity during postoperative care. However, the NRS has been found to have a high association with the four-point verbal scale, which strengthens its appropriateness in the present study (Wikström, Nilsson, Broström, & Eriksson, 2018). As this was an observation study, no study specific intervention was performed to decrease nausea intensity, but patients were during the study treated according to established routines on respectively clinic. Further studies are needed to explore how treatment of nausea impact on the disparate recovery aspects as well as whether lower incidence decrease the length of stay in hospital.

5 CONCLUSIONS

Average nausea intensity was demonstrated to have ability to reflect early physical recovery, particularly on postoperative day 1. The association between nausea and recovery aspects was strongest concerning physical symptoms which include appetite changes, fatigue, sleeping difficulties and pain. Of these were appetite changes and fatigue most strongly associated with nausea intensity, both at rest and during activity days 1 and 2. Monitoring of recovery is crucial for all patients, including those who are not participating in any enhanced recovery programme. Using average nausea intensity, it is possible to monitor all patients who are able to rate nausea intensity with the NRS. The findings from this study also show that moderate to severe nausea intensity occurred in about one-fifth of patients. For this reason, assessments of nausea are needed to enable healthcare professionals to identify those in need of treatment in real time. This highlights the need to regularly ask patients about nausea

20 intensity in the same way as pain intensity to promote further enhanced recovery. By regular assessment of nausea intensity in combination with pain intensity, early physical recovery may be monitored indirectly.

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27

TABLE 1 Background and clinical data for general and orthopaedic surgery (n = 479)

Variables, n (%) Total (n = 479) General surgery (n = 190)

Orthopaedic surgery (n = 289)

p value

n (%) n (%) n (%)

Age, mean (SD) [range] 65.2 ( 11.0) [22–93] 65.6 (10.6) [23–92] 65.0 (11.3) [22–93] . 626a

Women 211 (44.1) 54 (28.4) 157 (54.3) <.001b

Education .873b

Up to elementary school 197 (41.1) 79 (41.6) 118 (40.8)

Upper secondary school 166 (34.6) 69 (36.3) 97 (33.6)

University 112 (23.4) 41 (21.6) 71 (24.6)

Preoperative conditions

Smoker 28 (5.8) 22 (11.6) 6 (2.1) <.001b

Motion sickness 34 (7.1) 19 (10.0) 15 (5.2) .032b

Daily intake of analgesia 6 months before surgery

Only non-opioids 136 (28.6) 14 (2.5) 122 (24.8) .507b

Opioidsc _{with or without non-opioids 66 (13.9) 9 (1.9) 57 (13.2) .566}b

Type of surgery n/a

Cystectomy and nephrectomy 22 (4.6) 22 (11.6) – –

Prostatectomy 67 (14.0) 67 (35.3) – –

Other urology 4 (0.8) 4 (2.1) – –

Lower abdominal 89 (18.6) 90 (47.4) – –

Vascular 6 (1.3) 6 (3.2) – –

Other general surgery 2 (0.4) 1 (0.5) – –

Knee replacement 76 (15.9) – – 76 (26.3)

Hip replacement 149 (31.1) – – 149 (51.6)

Neck and back 49 (10.2) – – 49 (17.0)

Other orthopaedic surgery 15 (3.1) – – 15 (5.2)

Postoperative antiemeticsd

One or several doses, day 1 117 (25.2) 31 (16.3) 86 (29.8) .001b

One or several doses, day 2 90 (20.6) 36 (19.9) 54 (21.1) .759b

28

a_{Independent samples t test.} b_{Pearson chi-squared test.}

c_{Codeine, tramadol, morphine, oxycodone, fentanyl, buprenorfin.} d_{Metoclopramid, ondansetron, granisetron, meklozin.}

29

TABLE 2 Prevalence of average nausea intensity (NRS) postoperative days 1 and 2

Average nausea intensity

Postoperative day 1 Postoperative day 2

NRS 0–3 NRS 4–6 NRS 7–10 NRS 0–3 NRS 4–6 NRS 7–10 n (%) n (%) n (%) n (%) n (%) n (%) All patients Rest 383 (82.7) 58 (12.5) 22 (4.8) 326 (86.7) 34 (9.0) 16 (4.3) Activity 358 (77.2) 57 (12.3) 49 (10.6) 307 (81.4) 47 (12.5) 23 (6.1) General surgery Rest 159 (85.9) 23 (12.4) 3 (1.6) 140 (87.0) 18 (11.2) 3 (1.9) Activity 155 (81.6) 21 (11.3) 10 (5.3) 138 (84.7) 18 (11.0) 7 (4.3) Orthopaedic surgery Rest 224 (80.6) 35 (12.6) 19 (6.8) 186 (86.5) 16 (7.4) 13 (6.0) Activity 203 (76.0) 36 (13.5) 39 (13.5) 169 (79.0) 29 (13.6) 16 (7.5)

30

TABLE 3 Comparisons of average nausea intensity (NRS) postoperative days 1 and 2

Average nausea intensity

Postoperative day 1 Postoperative day 2 p valuea _{Effect size}b

Mean SD Mean SD All patients Rest 1.58 2.26 1.31 2.04 .014 .214 Activity 2.15 2.82 1.62 2.39 <.001 .129 General surgery Rest 1.15 1.69 1.25 1.84 .587 .046 Activity 1.50 2.04 1.40 2.09 .482 .043 Orthopaedic surgery Rest 1.90 2.56 1.35 2.18 <.001 .253 Activity 2.65 3.21 1.78 2.59 <.001 .334

General vs orthopaedic surgery

Postoperative day 1 Postoperative day 2

Rest p valuec _{.016 .575} Effect sized _{.236 .060} Activity p valuec _{<.001 .155} Effect sized _{.315 .152}

NRS, Numeric Rating Scale; SD, standard deviation. a_{Dependent sample t test.}

b_{Cohen’s d effect size for within-group analyses; 0.2, small; 0.5, medium; 0.8, large.} c_{Independent sample t test.}

31

TABLE 4 Associations between patients' retrospectively stated average nausea intensity on

day 1 and impact on recovery for day 1, based on binary logistic regression analyses.

Recovery aspects, day 1

Average nausea day 1

At rest During activity

OR 95% CI for OR p value OR 95% CI for OR p value NRS 0–3 (reference) Pain NRS 4–6 2.43 1.32–4.48 .005 1.72 0.96–3.09 .070 NRS 7–10 5.05 1.45–17.63 .011 2.58 1.21–5.49 .014 Fatigue NRS 4–6 3.26 1.79–5.92 <.001 3.64 2.00–6.63 <.001 NRS 7–10 13.12 2.99–57.62 .001 4.37 2.04–9.35 <.001 Appetite changes NRS 4–6 7.48 4.01–13.93 <.001 3.77 2.12–6.70 <.001 NRS 7–10 10.94 3.55–33.76 <.001 6.96 3.31–14.65 <.001 Sleeping difficulties NRS 4–6 1.83 1.05–3.20 .034 1.32 0.75–2.33 .344 NRS 7–10 3.83 1.42–10.30 .008 4.28 2.05–8.94 <.001 Gastrointestinal function NRS 4–6 1.56 0.87–2.81 .136 1.15 0.64–2.07 .639 NRS 7–10 1.16 0.44–3.06 .766 2.21 1.10–4.47 .026 Bladder function NRS 4–6 2.59 0.75–8.94 .133 1.99 0.50–7.86 .326 NRS 7–10 5.50 0.46–65.16 .177 2.51 0.48–13.07 .279 Mobilization NRS 4–6 2.04 1.24–3.91 .007 2.01 1.13–3.54 .017 NRS 7–10 3.85 1.17–9.55 .025 1.90 0.95–3.80 .072 Muscle weakness NRS 4–6 1.47 0.84–2.59 .179 1.82 1.03–3.20 .039 NRS 7–10 2.59 1.02–6.60 .046 1.72 0.87–3.40 .122 Personal hygiene NRS 4–6 2.39 1.35–4.22 .003 2.28 1.28–4.09 .005 NRS 7–10 3.16 1.25–8.01 .015 2.98 1.49–5.93 .002

32

TABLE 5 Associations between patients' retrospectively reported average nausea intensity on

day 1 and impact on recovery on day 2, based on binary logistic regression analyses.

Recovery aspects, day 2

Average nausea on day 1

At rest During activity

OR 95% CI for OR p value OR 95% CI for OR p value NRS 0–3 (reference) Pain NRS 4–6 1.58 0.86–2.91 .145 1.16 0.61–2.21 .653 NRS 7–10 1.52 0.54–4.31 .427 2.06 0.98–4.29 .056 Fatigue NRS 4–6 1.59 0.86–2.95 .143 1.70 0.86–3.26 .111 NRS 7–10 3.06 1.06–8.84 .039 2.02 0.98–4.18 .058 Appetite changes NRS 4–6 6.28 3.26–11.94 <.001 4.12 2.12–7.98 <.001 NRS 7–10 3.91 1.37–11.16 .011 3.38 1.82–7.96 <.001 Sleeping difficulties NRS 4–6 1.98 1.06–3.69 .031 1.06 0.53–2.14 .861 NRS 7–10 2.91 1.02–8.27 .045 2.70 1.30–5.60 .008 Gastrointestinal function NRS 4–6 1.87 1.01–3.47 .047 1.62 0.83–3.07 .141 NRS 7–10 1.34 0.46–3.90 .597 1.44 0.68–3.02 .339 Bladder function NRS 4–6 2.12 0.86–5.23 .103 1.38 0.27–6.91 .669 NRS 7–10 3.09 0.97–9.87 .056 2.67 0.65–11.05 .176 Mobilization NRS 4–6 1.34 0.61–2.14 .689 1.25 0.65–2.42 .551 NRS 7–10 0.95 0.32–2.85 .924 1.00 0.47–2.17 .991 Muscle weakness NRS 4–6 1.49 0.77–2.86 .234 1.26 0.62–2.54 .521 NRS 7–10 2.60 0.91–7.41 .073 1.80 0.84–3.87 .132 Personal hygiene NRS 4–6 1.79 0.90–3.56 .096 1.12 0.51–2.46 .786 NRS 7–10 2.18 0.72–6.61 .171 2.48 1.15–5.35 .021