The overall development of scientific and technical disciplines has enabled the introduction of minimally invasive surgical techniques in cardiac surgery practice. Implementation of minimally invasive cardiac surgery brings many positive effects for patients and healthcare. At the same time, however, it requires for the nurses to have appropriate knowledge, skills and experience to effectively provide comprehensive nursing care. The thesis is divided into theoretical and empirical parts. A total of four objectives were set. The first goal determines the specifics of nursing care of the patient before and after minimally invasive cardiac surgery. The second mapping the differences in nursing care in minimally invasive cardiac surgery from heart surgery classical approach. The third objective determines the role of nurses in patient awareness of minimally-invasive cardiac surgery. The fourth objective is focused on the needs and feelings of patients undergoing minimally invasive cardiac surgery. The results of qualitative research showed that preoperative and postoperative nursing care for minimally invasive cardiac surgery is similar to nursing care before and after cardiac surgery by standard median sternotomy approach. Nurses often wipe away differences associated with nursing care of standard and minimally invasive surgery, differences arose mainly after analysis of the data obtained. The differences include shorter hospital stay, shorter duration of mechanical ventilation, lower incidence of postoperative confusion, differences in invasive inputs, rehabilitation and awareness. For the majority of respondents from the ranks of the patients minimally invasive heart surgery technique had clearly positive impact on their mental condition.

Creating conditions for the effective healthcare provision in cooperation with the patient is one of the main missions of today's healthcare. A cardiac surgery is a difficult life situation for patients. Being informed, as the basic premise for the patient to become an active part of the entire healing process. The main aim of my thesis was to evaluate the awareness of patients who underwent a cardiac surgery, to map the problematic areas and to propose solutions. A combination of qualitative and quantitative method was used for the research. The qualitative part was carried out by means of semi-structured interviews with three interviewees. The quantitative part had the form of the questionnaire presented to 52 respondents. The results of both researches have been analyzed. The results show that the patients seem to have been provided with adequate information at the clinic. Impact of patients' awareness on their cooperation with healthcare professionals was proven, in particular in rehabilitation. A medical doctor remains the main source of information for patients, but they often seek to obtain additional information from other sources. The use of multiple sources and different forms of information seems to be advisable. I identified the groups of patients requiring a specific approach when...

Dehiscence or wound spacing is characterized by failure of wound healing and it is a very serious postoperative complication that occurs most frequently in patients who suffer from an associated disease. It usually develops between the fifth and ninth postoperative day. The cause of dehiscence is an infection in the wound, which is caused by proliferation of bacterial strains. The thesis on "Cardiac surgery patient with surgical wound dehiscence{\crqq} is focused on theoretical and practical parts. The theoretical part deals with the development of cardiac surgery and important personalities, medical indications for a cardiac surgery, cardiac surgery, surgical wound healing, surgical wound complications and nursing care of patients with dehiscence. The practical part was carried out by a quality - quantitative survey. The research sample for the qualitative research, which was conducted by the semi-structured interview technique with open questions, consisted of four cardiac surgery patients with wound dehiscence. The research sample for the quantitative research, which was carried out through anonymous questionnaires, consisted of 100 nurses working in cardiac surgery centers, Czech Republic, and 30 cardiac surgery patients with wound dehiscence. The results were processed into tables, graphs and diagrams. This work may serve as a resource for the interpretation of the subject matter or as a source of information for Cardiac Surgery Centers to improve the needs satisfaction in patients with wound dehiscence.

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Gegenstand der vorliegenden Dissertation bilden persistierende und akute postoperative Schmerzen in der Herzchirurgie nach anterolateraler Thorakotomie und Sternotomie. Kardiochirurgische Eingriffe sind mit einer erwarteten hohen Schmerzintensität verbunden. Eine unzureichende Schmerzkontrolle hat sowohl psychologische als auch physiologische Konsequenzen für alle Körpersysteme, welche die Genesung der Patienten nach einer Operation beeinträchtigen. Dabei stehen mittelstarke und starke postoperative Schmerzen mit dem Auftreten von chronischen postoperativen Schmerzen in Zusammenhang. Als sicher und vorteilhaft haben sich in den meisten chirurgischen Disziplinen Operationstechniken mit einer Reduktion der Größe des Operationsgebietes erwiesen, wo die Minimierung des Gewebetraumas postoperativ zu einer weniger hoch ausgeprägten Schmerzsymptomatik führt. Zu minimalinvasiven Techniken in der Kardiochirurgie gehört unter anderem die anterolaterale Thorakotomie. Die vorliegende Studie wurde in Anbetracht mangelnder Daten zum Vergleich akuter und chronischer postoperativer Schmerzen nach Herzoperationen durch Sternotomie und anterolaterale Thorakotomie durchgeführt. Im Rahmen dieser prospektiven Studie wurden Daten von 202 Patienten analysiert, bei denen ein elektiver, kardiochirurgischer Eingriff minimalinvasiv oder konventionell mit perioperativer Betreuung gemäß dem Fast-TrackKonzept durchgeführt worden ist. Die aufgetretene Schmerzintensität sowie der Schmerzmittelbedarf wurden bis hin zu der Krankenhausentlassung sowie drei, sechs und zwölf Monate nach dem operativen Eingriff verfolgt. Die Studie kommt zu folgenden Ergebnissen: Es konnten keine signifikanten Vorteile des anterolateralen Thorakotomiezugangs im Vergleich zur Sternotomie zur kurz- oder langfristigen Schmerzlinderung unter Anwendung eines standardisierten opioidbasierten perioperativen Schmerzmanagementprotokolls nach dem Fast-Track-Konzept bei elektiven kardiochirurgischen Eingriffen festgestellt werden.:Inhaltsverzeichnis: Abkürzungsverzeichnis: 2 Bibliografische Beschreibung: 3 Einführung: 4 Akuter postoperativer Schmerz 4 1.1. Pathophysiologie 5 1.2. Konsequenzen unzureichender postoperativer Schmerzkontrolle 8 1.3. Schmerzerfassung 9 1.4. Risikofaktoren für das Auftreten starker APP 11 1.4.1. Patientenbezogene Risikofaktoren 11 1.4.2. Prozedurale Risikofaktoren 12 1.5. Therapie 14 2. Persistierender postoperativer Schmerz 17 2.1. Definition 17 2.2. Pathophysiologie 18 2.3. Konsequenzen 18 2.4. Risikofaktoren 19 2.4.1. Nichtmodifizierbare Risikofaktoren: 19 2.4.2. Modifizierbare Risikofaktoren 20 2.5. Therapie 21 3. Fast-track und ERACS Konzepte 23 3.1. Definition und Ziele 23 3.2. Rolle der Schmerzkontrolle 27 3.3. Operativer Zugangsweg als Teil der schmerzminimierenden Strategien 27 4. Die Zielsetzung der Arbeit 29 Publikationsmanuskript 30 Zusammenfassung der Arbeit 40 Literaturverzeichnis 44 Anlagen 54 Spezifizierung des eigenen Beitrags zur Publikation: 54 Erklärung zu den Beiträgen der Mitautorin bei diesem Publikationsmanuskript 55 Erklärung über die eigenständige Abfassung der Arbeit 56 Lebenslauf 57 Publikationen: 58 Mündliche und Poster Präsentationen in internationalen Kongressen: 58 Danksagung 59 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​

Systemische Inflammation (SIRS) und Sepsis sind bekannte postoperative Komplikationen nach kardiochirurgischen Eingriffen. Bei 77,1 % der untersuchten 3653 kardiochirurgischen Patienten bestanden am ersten postoperativen Tag definierte Symptome eines SIRS. Nur 20 % dieser Patienten entwickelten ein prolongiertes SIRS über mindestens die ersten 72 Stunden postoperativ und 4,4 % eine Sepsis im weiteren primären intensivmedizinischen Verlauf. Aus der Patientengruppe mit prolongiertem SIRS entwickelten immerhin 21,8 % eine Sepsis. Die 564 Patienten mit prolongiertem SIRS waren durch eine signifikant (p< 0,001) verlängerte Beatmungs- und Behandlungsdauer auf der Intensivstation (ICU), eine erhöhte Krankenhausliegedauer sowie eine um den Faktor 10 signifikant erhöhte ICU- und Krankenhausmortalität im Vergleich zu Patienten ohne prolongiertes SIRS gekennzeichnet. Die 135 Patienten mit einer Sepsis während ihrer primären postoperativen intensivstationären Behandlung hatten eine deutlich erhöhte intensivstationäre Mortalität von 40,7 % gegenüber 1,6 % bei Patienten ohne Sepsis. Die Patienten mit prolongiertem SIRS (15,4 % der Gesamtpopulation) benötigten insgesamt 52,9 % der Bettentage und 57,7 % der Gesamtkosten der intensiv-medizinischen Behandlung. Die septischen Patienten (3,7 %) verursachten alleine 24,6 % der intensivstationären Behandlungstage sowie 28,7 % der Gesamtkosten. Die fünf Variablen weibliches Geschlecht, das Auftreten definierter intraoperativer Komplikationen, ein APACHE II- Score > 17 bei Aufnahme auf der Intensivstation, der postoperative Bedarf von mehr als einem Inotropikum sowie das Vorhandensein von definierten, therapiebedürftigen metabolischen Störungen innerhalb der ersten 24 Stunden postoperativ diskriminierten in Bezug auf das Vorhandensein oder Nicht-Vorhandensein der Zielvariablen prolongiertes SIRS (> 3 Tage ) mehr als 88 % der Patienten richtig. Jeweils über 96 % der Patienten konnten durch die aus diesen Variablen entwickelten Regressionsgleichungen richtig zugeordnet werden bezüglich des Auftretens oder Nicht-Auftretens einer Sepsis bzw. eines letalen Ausgangs. Das intern validierten Modell für die Zielvariable prolongiertes SIRS (> 3 Tage) erreichte eine hohe Spezifität von über 97 % bei einer Sensitivität von 39 %. Die vorliegenden Regressionsgleichungen ermöglichen es somit, am Patientengut dieser Institution prospektiv Patienten mit erhöhtem Risiko auf ein prolongiertes SIRS bzw. eine Sepsis mit hoher Spezifität zu selektionieren. / The development of a systemic inflammatory response syndrome (SIRS) and sepsis are well known complications after cardiac surgery. In the present study, 77.1 % of the 3653 cardiac surgical patients developed SIRS or SIRS-like symptoms on the first postoperative day. Only 20 % of these patients, however, showed a prolonged SIRS during the first 3 postoperative days. 4.4 % of all patients had septic complications during their stay on the intensive care unit (ICU). However, 21.8 % of the patients with prolonged SIRS developed sepsis. The identified 564 patients with prolonged SIRS showed a significantly (p < 0.001) increased duration of mechanical ventilation, ICU- and hospital treatment, respectively. Their ICU- and hospital mortality was tenfold higher than in patients without prolonged SIRS. The ICU-mortality of 135 septic patients was 40.7 % in contrast to 1.6 % in patients without sepsis. Patients with prolonged SIRS (15.4 % of the study population) accounted for 52.9 % of the bed days on ICU and for 57.7 % of the total costs. Septic patients (3.7 % of the study population) required 24.6 % of the bed days and 28.7 % of the total costs during their ICU-stay. The use of 5 variables including female gender, defined intraoperative complications, an APACHE II- Score of > 17 on ICU-admission, the use of more than one inotrope postoperatively, and the treatment of defined metabolical disorders identified 88 % of the patients with prolonged SIRS (> 3 days) correctly during the first 24 hours postoperativly. The resulting predictive models identified more than 96 % of the patients with sepsis or lethal outcome correctly. The internal validation of the predictive model for prolonged SIRS (> 3 days) demonstrated a specifity of 97 % and a sensitivity of 39 %. Therefore, the early identification of patients at risk for the development of prolonged SIRS or sepsis in our institution seems to be possible using multiple logistic regression of these predictive models.

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In the past years, the cardiac surgery performance was very demanding. The limited range of medical performances, imperfect procedures and techniques resulted in frequent postoperative complications and high postoperative mortality. Over time, surgical techniques, heart replacements, extracorporeal circulation and postoperative care have improved. This makes it possible today to operate on much older patients, where surgeries previously were nor feasible. The diploma thesis on the topic Cardiac surgical patient in the RES room and the approach of a nurse to nursing care is dedicated to the patient after heart surgery. It deals with meeting the patient's needs in the RES room and what the patient perceives while staying in the resuscitation unit and what he /she needs from a nurse. In the empirical part of this thesis two objectives were stated. To determine what a cardiac surgical patient perceives and what he /she needs in the RES room, and to find out whether it is possible to improve the quality of patient-oriented care. Based on these objectives, hypotheses and research questions were established. The objectives were successfully achieved, the hypothesis was confirmed and the questions answered. The research was conducted using qualitative quantitative research methods in the RES units of the cardiac surgery department, where the patients with heart disease are operated on. For the quantitative research the questionnaire interview method was selected. The qualitative research method was used to carry out semi-conducted interviews with the patients.

This thesis focuses on the psychological factors that play a role in the development and maintenance of chronic postsurgical pain in patients after cardiac surgery. The literature review deals with the mechanisms of chronic postsurgical pain, its risk factors, the process of the transformartion of acute pain into chronic pain, and the psychological management of chronic pain after surgery, specifically in the field of cardiosurgery. The thesis focuses in particular on patient-related factors in terms of anxiety or depression before or after the surgery, coping strategies, fear of pain, attachment styles, and how are these factors involved in the development nad maintenance of chronic pain. The empirical part consists of a research of quantitative design conducted at the Department of Cardiac Surgery of the 3rd Faculty of Medicine and FN KV in Prague, which monitors the development of pain in patients after cardiac surgery at the time of discharge, 3 months after the surgery and after 1 year after the surgery, and focuses on the assessment of preoperative and postoperative patient-related factors that contribute to the development and maintenance of chronic pain. The main aim of the research is to identify these psychological factors.