This study investigated the impact of open heart surgery (Coronary Artery Bypass Graft, Heart Valve Replacement, or Left Ventricular Assist Device placement) on cognition, functional performance, and mood in the three months following surgery. The Montreal Cognitive Assessment (MoCA), Kettle Test (KT), Physical Self Maintenance Scale (PSMS), and Hospital Anxiety and Depression Scale (HD) measured global cognition, functional cognition, functional performance, and mood states, respectively. Thirteen male participants (ages 38 – 75) completed assessments at four time points -- when they were scheduled for surgery, within one week prior to surgery, before hospital discharge after surgery, and three months after surgery. ANOVA analyses were conducted on overall raw mean scores taken at these time points. Correlational analysis compared changes in cognition and functional performance of daily activities for this group. Effect size estimations and power analyses were conducted to estimate sample sizes needed for adequately powered subsequent study. Two measures (KT and PSMS) were adequately powered at 95% for the study sample. Functional cognition as measured by the KT improved significantly after surgery and surpassed baseline within three months after surgery. Functional performance as measured by the PSMS declined significantly after surgery but returned to baseline within three months after surgery. Global cognition as measured by the MoCA did not change, was not correlated with other measures, and was below norms at all time points. Mood states as measured by the HADS did not change and were above norms at all time points. This study had a small sample, only male participants, and one pooled group that did not allow for group comparisons. Two measures were self-reported, which may have impacted results due to responses biases. Despite these limitations, this is one of the first studies to track and compare both cognitive and functional performance changes over time. As such, this study may help practitioners and researchers improve and prioritize assessment and treatment options for individuals with cognitive and functional performance deficits after open heart surgery.

Circulating neutrophil activation occurs during cardiac surgery with extracorporeal circulation (ECC) and is implicated in the pathophysiology of inflammatory tissue injury and peri-operative organ dysfunction. However, neutrophil directed antiinflammatory strategies have failed to demonstrate consistent therapeutic benefit indicating that the nature and significance of peri-operative circulating neutrophil activation remains incompletely defined. In particular, conformational activation of the b2 integrin Mac-1 (CD11b/CD18), which is required for neutrophil adhesion competence and facilitation of effector functions, has not previously been investigated during cardiac surgery, and the relative contribution of cellular activation and bone marrow neutrophil recruitment to peri-operative changes in circulating neutrophil phenotype and function is unknown. A novel whole blood flow cytometric technique was used to analyze circulating neutrophil phenotype (total Mac-1, conformationally-active CD11b, CD10, CD16, L-selectin and P-selectin glycoprotein ligand-1) and function in cardiac surgery patients to characterize the nature of changes in Mac-1 expression and activation status, and the effects of relative neutrophil immaturity on circulating neutrophil phenotype and function. The effect of heparin, a known CD11b ligand, on Mac-1 epitope expression was also investigated. Circulating neutrophil numbers observed during ECC were mathematically modeled to determine the acute response of the bone marrow neutrophil reserve to an inflammatory stimulus. Plasma cytokine, chemokine and acute phase mediators were measured in cardiac and lung surgery patients to determine potential regulators of systemic neutrophil recruitment. Neutrophils newlyemergent from the bone marrow were characterized as CD10-/CD16low and exhibited distinct changes in cell surface markers and enhanced functional responses, relative to their more mature CD10+ counterparts. Conformational activation of CD11b occurred peri-operatively and provided a more sensitive measure of circulating neutrophil activation status than changes in total Mac-1 or L-selectin expression, although detection of Mac-1 epitopes was reduced in the presence of heparin. Modeling of circulating neutrophil numbers predicted that post-mitotic maturation time was acutely abbreviated by 8.4 hours during 71 minutes of ECC. Systemic chemokine release occurred with cardiac but not non-cardiac thoracic surgery indicating some specificity of the acute inflammatory response. These findings expand the understanding of peri-operative circulating neutrophil activation and recruitment, and identify potential therapeutic targets to limit neutrophil injurious potential during cardiac surgery with ECC.

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

published_or_final_version / Paediatrics and Adolescent Medicine / Master / Master of Medical Sciences

Background Nosocomial infection is a crucial problem and cause of morbidity and mortality especially in cardiac surgery settings. The risk of acquiring such infection is even higher because cardiac surgery patients require intensive care postoperatively. The phenomenon is evidenced by longer length of hospital stay and increased cost of care. Pneumonia and surgical site infections were ranked among the top three most common hospital acquired infections. The usual practice for mouth care is diluted thymol gargle solution for intubated patients after cardiac surgery in Hong Kong. No local studies examine the effect of oronasopharyngeal care on minimizing such infections. An evidence based guideline in oral and nasopharyngeal nursing care is necessary to implement in hospitals for improving patient surgical outcome. Objective To develop an evidence based practice guideline for pre- and postoperative oronasopharyngeal care of in-patients undergoing cardiac surgery with implementation planning and discussion on evaluation. Methods The most recent publications were searched till August 2011. Randomized controlled trials with oropharyngeal and/ or nasopharyngeal care with outcome measures on surgical site infection and/ or nosocomial pneumonia were reviewed. Essential data were extracted with quality assessed methodologically. Results Six randomized controlled trials comparing oropharyngeal and/ or nasopharyngeal care intervention with usual care were reviewed. The studies mostly included middle-aged male patients undergoing cardiac surgery. The results showed positively of interventions on nosocomial pneumonia and surgical site infection when compared with usual care. In view of quality assessments and statistically significant findings, the proposed change that could improve surgical outcome of patients is to use chlorhexidine gluconate on oronasopharyngeal care in the guideline. It mainly carries out in in-hospital settings both by patients with education from nurses preoperatively, and by nurses postoperatively. Conclusion Reviewed evidence shown that the oronasopharyngeal care interventions help effectively on minimizing the occurrence of nosocomial pneumonia and surgical site infections for patients undergoing heart surgery. It could be potentially adopted for nurses working in cardiac surgical ward and cardiac intensive care unit. / published_or_final_version / Nursing Studies / Master / Master of Nursing

No description available.

Conclusions 1. In comparison to the Ringer‘s acetate solution the use of HyperHaes® solution after coronary artery bypass surgery had positive effect on haemodynamic parameters: cardiac index increased (p<0.05), systolic volume index increased (p<0.05), cardiac afterload decreased, that is pulmonary vascular resistance index decreased (p<0.05) and systemic vascular resistance index decreased (p<0.05); the difference between the central and peripheral temperatures in experimental group (p<0.05). 2. The oxygen transport was more effective (oxygen delivery index increased (p<0.05)) when HyperHaes® solution was used in comparison to Ringer‘s acetate solution. 3. No substantial effect of HyperHaes® solution on the duration of artificial lung ventilation and intrapulmonary shunt size was defined. 4. The use of HyperHaes® solution influenced substantially some parameters of homeostasis (serum sodium concentration increased (p<0.05), serum potassium concentration decreased (p<0.05)) in compa-rison to Ringer‘s acetate solution. 5. Higher diuresis (p<0.01), lower need for the infusion therapy for the first 24 hours (p<0.05), lower total fluid balance (p<0.01) were determined in HyperHaes® group versus Ringer‘s acetate group. 6. No adverse effects (disturbances of homeostasis, neurologic symptoms, increased bleeding through mediastinal tubes, anaphylactic reactions) were noted in patients who received HyperHaes® solution.

Bakgrund: Hjärtkirurgi är idag ett av de vanligaste större kirurgiska ingreppen i Sverige. Smärta efter hjärtkirurgi kan hindra patienter från att ta djupa andetag eller att röra sig. Om smärtan blir underbehandlad kan det resultera i postoperativa komplikationer. Intensivvårdssjuksköterskor ska ha kunskap om postoperativ smärta, smärtbehandling samt regelbundet dokumentera patienternas smärta. Syfte: Att undersöka postoperativ smärta hos patienter som genomgått hjärtkirurgi med median sternotomi. Metod: Kvantitativ deskriptiv tvärsnittsundersökning med konsekutivt urval. Totalt 22 patienter inkluderades i studien. Materialet samlades in med hjälp av enkäter som ansvariga sjuksköterskor hade som underlag vid skattning av patienternas postoperativa smärta två timmar efter avslutad respiratorbehandling. Smärtskattningsinstrumenten som användes var visuell analog skala (VAS) eller numerisk skala (NRS). Övrig information inhämtades via journalgranskning av övervakningsjournalerna. Resultat: Det var fler patienter som skattade sin smärta till VAS &gt; 3 vid djupandning eller hosta än i vila. 17 av 22 patienter skattade sin smärta till VAS &gt; 3 vid djupandning eller hosta två timmar efter avslutad respiratorbehandling. Intensivvårdssjuksköterskornas behandling av den postoperativa smärtan varierade och dokumentationen av patienternas skattade smärta var bristfällig. Slutsats: Majoriteten av patienterna hade ont två timmar efter avslutad respiratorbehandling och det talar för att patienternas smärtbehandling inte var tillräcklig. Patienternas smärtintensitet var svår att följa under det första postoperativa dygnet på grund av bristfällig dokumentation. Förklaringen till detta kan vara att intensivvårdssjuksköterskorna inte prioriterar dokumentation av smärta. Klinisk betydelse: Eftersom otillräcklig behandling av smärta kan leda till komplikationer är det av klinisk betydelse att fokusera på smärta efter hjärtkirurgi och optimera behandlingen av postoperativ smärta. / Background: Today, heart surgery is one of the most common larger surgical interventions in Sweden. Pain after heart surgery can prevent patients from taking deep breaths or keep them from participating in activities. If the pain remains undertreated, post-operative complications can occur. Intensive care nurses must have knowledge about post-operative pain and its treatment and regularly document patients’ pain. Aim: To examine post-operative pain in patients that has undergone heart surgery with median sternotomy. Method: Quantitative descriptive cross-sectional survey with consecutive selections. In total 22 patients were included in the study. The material was gathered with questionnaires that intensive care nurses used to estimate the patients’ post-operative pain two hours after extubation. The pain assessment tool that was used was VAS or NRS. Other information was acquired from medical record review of the monitoring records. Results: More patients rated their pain VAS &gt; 3 during deep breathing or coughing than during rest. 17 patients rated their pain during deep breathing or coughing to VAS &gt; 3 two hours after the completion of respiratory therapy. The intensive care nurses’ treatment of the postoperative pain varied and the documentation of the pain estimate was inadequate. Conclusion: The majority of the patients experienced pain two hours after the completion of respiratory therapy, and this may indicate that the treatment of patients’ pain was not sufficient. The intensity of the patients’ pain was difficult to follow during the first post-operative day and night due to inadequate documentation. Possibly, the documentation of patients’ estimated pain was not prioritized. Clinical importance: Since insufficient treatment of pain can lead to complications, it is of clinical importance to focus on pain after heart surgery and to optimize the treatment of post-operative pain.

Circulating neutrophil activation occurs during cardiac surgery with extracorporeal circulation (ECC) and is implicated in the pathophysiology of inflammatory tissue injury and peri-operative organ dysfunction. However, neutrophil directed antiinflammatory strategies have failed to demonstrate consistent therapeutic benefit indicating that the nature and significance of peri-operative circulating neutrophil activation remains incompletely defined. In particular, conformational activation of the b2 integrin Mac-1 (CD11b/CD18), which is required for neutrophil adhesion competence and facilitation of effector functions, has not previously been investigated during cardiac surgery, and the relative contribution of cellular activation and bone marrow neutrophil recruitment to peri-operative changes in circulating neutrophil phenotype and function is unknown. A novel whole blood flow cytometric technique was used to analyze circulating neutrophil phenotype (total Mac-1, conformationally-active CD11b, CD10, CD16, L-selectin and P-selectin glycoprotein ligand-1) and function in cardiac surgery patients to characterize the nature of changes in Mac-1 expression and activation status, and the effects of relative neutrophil immaturity on circulating neutrophil phenotype and function. The effect of heparin, a known CD11b ligand, on Mac-1 epitope expression was also investigated. Circulating neutrophil numbers observed during ECC were mathematically modeled to determine the acute response of the bone marrow neutrophil reserve to an inflammatory stimulus. Plasma cytokine, chemokine and acute phase mediators were measured in cardiac and lung surgery patients to determine potential regulators of systemic neutrophil recruitment. Neutrophils newlyemergent from the bone marrow were characterized as CD10-/CD16low and exhibited distinct changes in cell surface markers and enhanced functional responses, relative to their more mature CD10+ counterparts. Conformational activation of CD11b occurred peri-operatively and provided a more sensitive measure of circulating neutrophil activation status than changes in total Mac-1 or L-selectin expression, although detection of Mac-1 epitopes was reduced in the presence of heparin. Modeling of circulating neutrophil numbers predicted that post-mitotic maturation time was acutely abbreviated by 8.4 hours during 71 minutes of ECC. Systemic chemokine release occurred with cardiac but not non-cardiac thoracic surgery indicating some specificity of the acute inflammatory response. These findings expand the understanding of peri-operative circulating neutrophil activation and recruitment, and identify potential therapeutic targets to limit neutrophil injurious potential during cardiac surgery with ECC.

Thesis (M.S.)--University of Michigan, 1982.