Bakgrund: Hjärtoperationer förekommer över hela världen. Förutom den genetiska faktorn så ökar antalet insjuknanden delvis på grund av välfärdssamhället. Studier har visat att personer med hjärtsjukdom upplever ökad oro vid vardagliga aktiviteter. På grund av oron är informationen som ges till patienter mycket viktig. Syfte: Belysa patienters upplevelser av information inför planerad hjärtoperation. Metod: Allmän litteraturstudie, 10 artiklar användes. Resultat: Under analysen framkom fyra kategorier; emotionell påverkan, behov av information, mottaglighet och hanterbarhet samt delaktighet. Studier visade att information minskade oron och ökade tillfredsställelsen. Patienter som hade fått rutinmässig information efterfrågade ytterligare. Andra studier visade att informationsnivån inte hade någon effekt på oron inför operation och det fanns studier som visade att information ökade oron. När informationen gavs spelade stor roll för hur patienterna upplevde den preoperativa tiden. Patienter uttryckte även en önskan om att få ytterligare information för att kunna uppleva delaktighet i sin vård. Diskussion: Tre kategorier arbetades fram; positiv påverkan, informationskrav och negativ påverkan. Informationen var viktig och ledde till en bättre utgång. Patienternas krav på information har ändrats genom åren och är större nu. För lite information ledde till känslor som oro, rädsla och ovisshet. Slutsats: Information påverkar patienters upplevelser inför operation, både positivt och negativt. / Background: Cardiac surgery is carried out worldwide. The genetic factor and today’s welfare society has resulted in an increase in the number of episodes. Studies have shown that people with heart disease experience increased anxiety in everyday activities. The information given to patients therefore becomes highly important. Purpose: Highlight the patients' experiences of information prior to planned cardiac surgery. Method: Literature review. Results: Four categories was revealed: emotional impact, need of information, responsiveness and manageability and participation. Studies showed that information decreased anxiety and increased the level of satisfaction. Additional information was requested by patients who had received routine information. Other studies showed that the level of information had no effect on the patient’s anxiety and in other cases increased the anxiety. The timing of when the information was given had a large impact on how patients experienced the preoperative period. Discussion: Three categories were developed; positive impact, information requirements and negative impact. The information was important and led to a better outcome. Patients' information requirements are bigger today than in the past. A lack of information led to feelings of anxiety, fear and uncertainty. Conclusion: Information has both positive and negative impact on the patients’ experiences prior to surgery.

SAMMANFATTNING Bakgrund Postoperativt illamående och kräkningar (PONV) är de vanligaste komplikationerna efter kirurgi och anestesi. Många patienter kan uppleva illamående och kräkningar som ett större problem än postoperativ smärta i samband med kirurgiska ingrepp. Faktorer som kön, ålder och åksjuka kan öka risken att drabbas av PONV. Syfte Studiens syfte var att undersöka förekomsten av illamående efter hjärtkirurgi. Vi ville även kartlägga om det fanns skillnad mellan kvinnor och män, i ålder samt samband mellan åksjuka och tid med respiratorbehandling och illamående.    Metod Studiens design var kvantitativ. Data samlades in med hjälp av ett frågeformulär bland patienter som genomgått hjärtkirurgi. Resultatet bearbetades och analyserades i Excel och statistikprogrammet SPSS. Resultat Tjugoåtta patienter av totalt 36 tillfrågade tackade ja att medverka i studien. Resultatet visar att 75 % (21) av deltagande patienter upplevde illamående postoperativt. Merparten av patienterna drabbades av illamående under operationsdagen eller dagen efter. Inget samband mellan illamående och kön, ålder och åksjuka kunde ses. Slutsats Denna studie visar att många patienter drabbades av illamående och att illamåendet debuterade tidigt i det postoperativa förloppet, medan litteraturen visar att tre av tio patienter drabbas av illamående och att illamåendet kan ha sin kulmen upp till 2-3 dygn efter operationen. Undersökningsgruppen var för liten för att några säkra slutsatser kunde dras. / ABSTRACT Background Post-operative nausea and vomiting (PONV) are the most common complications after surgery and anaesthesia. Many patients experience nausea and vomiting as a bigger problem than post-operative pain following a surgical procedure. Factors such as gender, age and motion sickness could increase the risk of suffering from PONV. Purpose The aim of this study was to examine the presence of nausea after cardiac surgery. Another aim was to map out variation in experiences between male and female patients, age related susceptibility, connection to motion sickness and if respiratory treatment could increase the likelihood of nauseousness. Method This study was designed to be quantitative. Data was collected by using a questionnaire that was filled out by patients who had experienced cardiac surgery. All data were processed and analysed in Excel and with the statistical program SPSS. Result 28 patients out of 36 patients, gave their consent to taking part in this study. Seventifive procent (21) of the participated patients experienced post-operative nausea. The majority of patients experienced nausea during the day of operation or the following 24 hours. There was no difference between genders and nausea neither ageor, motion sickness seemed to have any direct influence in cases where nausea was experienced. Conclusion This study shows that many patients are affected by nausea and that nauseousness appears during the early stages of the procedure. Literature demonstrates that 30% patients are affected by nausea, and that it will peak 2 to 3 days post-operatively. The study group was too small to draw significant conclusions.

Surgical services contribute to a large proportion of a hospital’s costs and revenues thus it is important to understand key performance drivers so that resources can be distributed in an informed way. Organizational policies can affect the performance of the peri-operative process, however, there is a lack of knowledge within the health services literature regarding how the organizational policies of a surgical service affect surgeons’ availability to perform operations. Additionally, simulation-based research has largely focused on operating room planning and scheduling, not on how surgeons’ operating time may be affected by organizational policies. The objective of this simulation study was to estimate the effects of organizational policies on surgeons’ availability to operate in the context of cardiac surgical care. The major finding was that surgeons’ availability to operate declines if surgeons are not permitted to be on-call and scheduled in the OR for non-emergency operations on the same day.

Surgical services contribute to a large proportion of a hospital’s costs and revenues thus it is important to understand key performance drivers so that resources can be distributed in an informed way. Organizational policies can affect the performance of the peri-operative process, however, there is a lack of knowledge within the health services literature regarding how the organizational policies of a surgical service affect surgeons’ availability to perform operations. Additionally, simulation-based research has largely focused on operating room planning and scheduling, not on how surgeons’ operating time may be affected by organizational policies. The objective of this simulation study was to estimate the effects of organizational policies on surgeons’ availability to operate in the context of cardiac surgical care. The major finding was that surgeons’ availability to operate declines if surgeons are not permitted to be on-call and scheduled in the OR for non-emergency operations on the same day.

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart defect and infants with TOF incur significant right ventricular(RV) dysfunction due to perioperative injury. Insulin has been shown to reduce perioperative myocardial injury and significantly improve postoperative cardiac function. However, studies are limited to the adult population and the effects in a pediatric heart with a CHD are unknown. To the best of our knowledge, this is the first randomized, double blind, placebo-controlled clinical study designed to investigate insulin’s potential cardioprotective effects postoperatively and mechanisms of action during pediatric cardiac surgery. Thirty infants with TOF were equally randomly allocated to receive either standard cardioplegia (SC) or 10UI insulin-enhanced (IC). Expression profiles of surgery were generated from biopsies extracted from the right ventricular outflow tract (end ischemia and five minutes of reperfusion) and hybridized to Affymetrix HG-U133A GeneChips. Gene expression profiles were generated using two softwares, ArrayAssist V2.6 (paired t-test) and affylmGUI (ANOVA). Survival rate was 100%. Compared to patients in the SC group, patients in the IC group demonstrated a trend toward a 1.8 fold decrease (p = .06) in reperfusion duration (61.93 ± 61.12 vs. 35.20 ± 23.16 hrs., respectively), a significant 2-fold decrease in the length of ICU stay (p = .04) (4.2 ± 3.9 vs. 2.3 ± 1.1 days, respectively) and a trend toward a 2.5 fold decrease in intubation duration (p= .06) (2.5± 12.2 vs. 55.0 ± 67 hrs., respectively). Patients in the IC group also demonstrated significantly lower inotropic scores, calculated at 12-hour intervals across a 48-hour ICU period, (ANOVA p = .01) and significantly greater urine volume, by 71%, (p = .02). IC evoked a cardioprotective gene expression profile aimed at mitigating perioperative myocardial injury, specifically; apoptosis, inflammation, cardiac hypertrophy, arrythmias and fibrosis. The improved postoperative outcome and cardioprotective gene expression signature with IC suggests that, administration of insulin during cardiac surgery in infants with TOF may prevent cardiac dysfunction as a result of mitigating perioperative myocardial injury. Overall, this exploratory study demonstrated insulin-enhanced cardioplegia to be a potential cardioprotective agent during pediatric heart surgery.

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart defect and infants with TOF incur significant right ventricular(RV) dysfunction due to perioperative injury. Insulin has been shown to reduce perioperative myocardial injury and significantly improve postoperative cardiac function. However, studies are limited to the adult population and the effects in a pediatric heart with a CHD are unknown. To the best of our knowledge, this is the first randomized, double blind, placebo-controlled clinical study designed to investigate insulin’s potential cardioprotective effects postoperatively and mechanisms of action during pediatric cardiac surgery. Thirty infants with TOF were equally randomly allocated to receive either standard cardioplegia (SC) or 10UI insulin-enhanced (IC). Expression profiles of surgery were generated from biopsies extracted from the right ventricular outflow tract (end ischemia and five minutes of reperfusion) and hybridized to Affymetrix HG-U133A GeneChips. Gene expression profiles were generated using two softwares, ArrayAssist V2.6 (paired t-test) and affylmGUI (ANOVA). Survival rate was 100%. Compared to patients in the SC group, patients in the IC group demonstrated a trend toward a 1.8 fold decrease (p = .06) in reperfusion duration (61.93 ± 61.12 vs. 35.20 ± 23.16 hrs., respectively), a significant 2-fold decrease in the length of ICU stay (p = .04) (4.2 ± 3.9 vs. 2.3 ± 1.1 days, respectively) and a trend toward a 2.5 fold decrease in intubation duration (p= .06) (2.5± 12.2 vs. 55.0 ± 67 hrs., respectively). Patients in the IC group also demonstrated significantly lower inotropic scores, calculated at 12-hour intervals across a 48-hour ICU period, (ANOVA p = .01) and significantly greater urine volume, by 71%, (p = .02). IC evoked a cardioprotective gene expression profile aimed at mitigating perioperative myocardial injury, specifically; apoptosis, inflammation, cardiac hypertrophy, arrythmias and fibrosis. The improved postoperative outcome and cardioprotective gene expression signature with IC suggests that, administration of insulin during cardiac surgery in infants with TOF may prevent cardiac dysfunction as a result of mitigating perioperative myocardial injury. Overall, this exploratory study demonstrated insulin-enhanced cardioplegia to be a potential cardioprotective agent during pediatric heart surgery.

This project set out to derive a prediction rule based on preoperative clinical variables to identify patients with high risk of developing atrial fibrillation following cardiac surgery. Methods: Prospectively collected data from a perioperative database was corroborated with chart review to identify eligible patients who had non-emergent surgery in 2010. Details on 28 preoperative variables were collected and significant predictors (p<0.2) were inserted into multivariable logistic regression and recursive partitioning. Results: 305 (30.5%) of 999 patients developed new onset postoperative atrial fibrillation. Eleven variables were significantly associated with atrial fibrillation, however, both final models included only three: left atrial dilatation, mitral valve disease and age. Bootstrapping with 5000 samples confirmed that both final models provide consistent predictions. Coefficients from the logistic regression model were converted into a simple seven point predictive score. Conclusions: This simple risk score can identify patients at higher risk of developing atrial fibrillation after cardiac surgery.

A blood transfusion is one of the most common hospital procedures, yet there is a lack of reliable information on the costs of administering blood. This thesis aims to fill this information gap, and considers the impact on total costs of alternative transfusion management strategies in the National Health Service (NHS) in the United Kingdom. A high user of blood transfusion, cardiac surgery, acts as a clinical exemplar. Comprehensive estimates of the costs of administering blood are first produced. The costs of administering blood add substantially to the costs of the blood products themselves, costs for red blood cells are 40% higher when the costs of administration are added to red blood cell costs. These cost estimates were used to more accurately cost blood products transfused (compared to the costs of blood products only) in two economic evaluations assessing firstly, the cost-effectiveness of a restrictive versus a liberal red blood cell transfusion threshold after cardiac surgery, and secondly, the cost-effectiveness of introducing bedside tests of haemostatic function in cardiac surgery. Both economic evaluations showed little difference in costs or outcomes between the groups and uncertainty around the cost-effectiveness results. While a restrictive threshold reduces costs associated with transfusion compared to a liberal threshold, there is no evidence based on detailed and comprehensive costings, to suggest that a restrictive threshold saves the NHS money overall. Reliable resource use data are vital for economic evaluations, and a subgroup of patients in both economic evaluations enabled resource use data collected from alternative sources to be compared. There was strong agreement between primary (clinical trial) data and routine datasets for data available from both sources, however, primary data captured post-operative complications more comprehensively than routine datasets. This thesis provides hospital managers and health economists with accurate information on the costs of administering blood for budget impact assessments and economic evaluations.

A síndrome da fragilidade, definida como a redução da reserva energética e da resistência aos estressores, associada à indicação tardia de alguns procedimentos cirúrgicos, resulta em maior ocorrência de situações de risco para os pacientes cardiopatas, com maior predisposição para o desenvolvimento de complicações pós-operatórias, que estão relacionadas a um aumento nos casos de readmissão hospitalar e tempo prolongado de internação. Com o objetivo de melhorar o manejo pós-operatório e aperfeiçoar nossa avaliação da gravidade, prevenção e estratificação de risco, a fisioterapia pré-operatória utiliza testes funcionais que traduzem a real condição física e pulmonar do paciente, permitindo a identificação de fatores potencialmente de risco. Como forma de avaliar a prevalência de fragilidade na população candidata a cirurgia cardíaca, a associação dos testes funcionais com fragilidade e a morbidade e mortalidade peri e pósoperatória, avaliamos os candidatos à cirurgia cardíaca de acordo com os cinco critérios de propostos por Fried: perda de peso não intencional, sinais de depressão, redução da força de preensão palmar, baixo nível de atividade física e redução da velocidade da marcha, além da capacidade pulmonar (manovacuometria, ventilometria e peak flow), da tolerância ao esforço (TC6) e função cognitiva (MEEM). Após a cirurgia foram coletadas informações com relação ao procedimento cirúrgico e recuperação pós-operatória e então os indivíduos foram divididos em dois grupos: frágeis e não frágeis e subdivididos de acordo com a faixa etária em idosos e não idosos. Foram avaliados 100 indivíduos, sendo 59 valvopatas e 41 coronariopatas; 13% foram considerados não-frágeis, 70% pré-frágeis e 17% frágeis; a pressão inspiratória máxima foi significativamente menor nos indivíduos frágeis (52±21 contra 75±33 nos não-frágeis; p=0,044), assim como a força de preensão palmar (31±11 contra 22±8; p=0,007); 11 pacientes evoluíram com óbito após o procedimento, sendo 7,2% dos não frágeis contra 29,4% dos indivíduos frágeis (p=0,019). A partir dos resultados encontrados podemos concluir que a prevalência de fragilidade nos pacientes candidatos a cirurgia cardíaca foi alta, mesmo entre os indivíduos não considerados idosos e que além disso, os indivíduos frágeis apresentaram menor força de preensão palmar, menor capacidade vital e menores pressões inspiratórias e expiratórias que as observadas em pacientes não-frágeis, bem como maior mortalidade hospitalar. / Frailty syndrome, defined as the reduction of energy reserve and resistance to stressors, associated with late indication of some surgical procedures, results in a higher occurrence of risk situations for the patients with heart disease, with a greater predisposition to the development of postoperative complications, which are related to an increase in cases of hospital readmission and high length of stay. In order to improve postoperative management and our assessment of severity, prevention and risk stratification, preoperative physiotherapy uses functional tests that translate the patient\'s actual physical and pulmonary condition, allowing the identification of potentially risk factors. As a way of evaluating the prevalence of frailty in population for cardiac surgery, the association of functional tests with frailty, and peri and postoperative morbidity and mortality, we evaluated the candidates for cardiac surgery according to five criteria proposed by Fried: loss of weight, depression, low handgrip strength, low level of physical activity and reduction of walking speed, as well as lung capacity (manovacuometry, ventilometry and peak flow), effort tolerance (6MWT) and cognitive function (MMSE). After surgery, information was collected regarding the surgical procedure and postoperative recovery and then, subjects were divided into two groups: fragile and nonfragile and subdivided according to the age group in the elderly and not elderly. We evaluated 100 individuals, being 59 valvopaths and 41 coronary disease; 13% were considered nonfragile, 70% pre-fragile and 17% fragile; the maximum inspiratory pressure was significantly lower in the fragile individuals (52 ± 21 vs 75 ± 33 in non-fragile, p = 0.044), as well as the handgrip strength (31 ± 11 vs. 22 ± 8, p = 0.007); 11 patients died after the procedure (7.2% non-fragile versus 29.4% fragile individuals; p = 0.019). From the results found, we can conclude that the prevalence of frailty in cardiac surgery patients was high, even among individuals not considered elderly, and, in addition, fragile individuals had lower handgrip strength, lower vital capacity and lower inspiratory pressures and expiratory rates than those observed in non-fragile patients, as well as higher in-hospital mortality.

This project set out to derive a prediction rule based on preoperative clinical variables to identify patients with high risk of developing atrial fibrillation following cardiac surgery. Methods: Prospectively collected data from a perioperative database was corroborated with chart review to identify eligible patients who had non-emergent surgery in 2010. Details on 28 preoperative variables were collected and significant predictors (p<0.2) were inserted into multivariable logistic regression and recursive partitioning. Results: 305 (30.5%) of 999 patients developed new onset postoperative atrial fibrillation. Eleven variables were significantly associated with atrial fibrillation, however, both final models included only three: left atrial dilatation, mitral valve disease and age. Bootstrapping with 5000 samples confirmed that both final models provide consistent predictions. Coefficients from the logistic regression model were converted into a simple seven point predictive score. Conclusions: This simple risk score can identify patients at higher risk of developing atrial fibrillation after cardiac surgery.