Background:  Peri-operative myocardial infarction (PMI) may be under- and/or mis-diagnosed because WHO criteria are often not met and creatinine kinase (CK/CK-MB) ratios can be difficult to interpret.  Cardiac troponin (cTn) I is the most sensitive and specific marker of myocardial cell necrosis but is not yet widely available. Aims: 1.  To examine the use of pre-operative risk indices, including ASA score, POSSUM score and Goldman’s cardiac risk index and compare these with peri-operative cTnI rise. 2.  To compare cTnI levels with CK/CK-MB levels peri-operatively in the diagnosis of MI. 3.  To explore the role of the fibrinolytic system in patients undergoing emergency surgery for ruptured aneurysm and relate this to cTnI levels. 4.  To examine the use of the polymerase chain reaction (PCR) in the identification of bacteraemia and to relate this to systemic endotoxin levels and septic episodes. Methods:  Prospective observational study of 67 patients undergoing aortic surgery (29 elective AAA, 31 emergency AAA, 7 aorto-occlusive).  cTnI and endotoxin were measured pre-operatively and at 6, 24, 48, 72 and 96 hours post­operatively.  Blood for PCR was also collected at these time points.  CK and CK-­MB were measured where cTnI was detectable.  Fibrinolytic markers were measured up to 24 hours post operatively.  Clinical, septic, ECG and cardiac events were prospectively documented. Results:  ASA score was correlated with perioperative cTnI rise.  Over 50%<i> </i>of patients undergoing emergency, and more than a quarter undergoing elective, aortic surgery will suffer myocardial injury as determined by cTnI rise.  This is accompanied by CK/ CK-MB ratio in less than a fifth of cases.  eTnI rise is associated with inhibition of fibrinolysis with emergency AAA repair.  No relationships were observed with the presence of bacterial DNA, endotoxin response and sepsis.

Children are a group of patients that require special knowledge from the anesthesia staff, both general and specific. Theoretical knowledge and practical experience is necessary to adequately care for the child as it anatomically, physiologically and mentally may differ from adult patients. A growing problem in the pediatric population is overweight and obesity. From a stagnation in the early 2000s the prevalence of overweight and obesity among children in the world are again increasing.The purpose of this study was to examine peri-operative care of overweight and obese children. Systematic searches were done in PubMed, CINAHL and Scopus. After the quality audit according to SBU, twelve articles were included for analysis. Results suggest that overweight and obese children have a higher risk of respiratory peri-operative complications. The risk of hospital admission after outpatient surgery was also greater in this group as well as higher costs for health care. Overweight and obese children are complex subjects with more frequent peri-operative risk factors than normal-weight children. This group requires special knowledge of the anesthesia staff. More studies are required to secure evidence in anesthetic care for overweight and obese children.

Pancreas transplantation (PT) is considered a gold-standard cure for brittle insulin dependent diabetes mellitus. In over 90% of cases, this is conducted simultaneously with a kidney transplant, providing concurrent treatment for end-stage renal failure (Simultaneous pancreas and kidney transplantation, SPKT). However, since its inception in the 1960’s, SPKT has been associated with considerable morbidity and mortality. Despite significant recent improvements in graft and patient survival, the multi-factorial nature of the procedure has resulted in persistently high peri-operative morbidity. This thesis has identified four areas to study in the peri-operative assessment and management of these patients, potentially resulting in improved clinical outcomes. 1. Pre-operative risk-prediction scoring systems aide in the consent process and the peri-operative planning of care following major surgery. In PT, multi-system risk-prediction tools are deficient. We therefore assessed the utility of commonly used general surgical risk prediction models in PT recipients. Our finding suggested that The Waterlow Score, a multi-system tool originally developed for predicting the development of decubitus skin ulcers, identified high-risk individuals and has value in predicting outcome following SPKT.2. Peri-operative physiological optimisation (Goal-directed therapy, GDT) is well-recognised to improve outcomes following major general surgery in high-risk individuals. A randomised controlled trial was therefore performed to investigate the benefits of GDT in the peri-operative period following SPKT. The findings demonstrated improved short-term outcomes following GDT in our cohort.3. The temporal evolution of biomarkers following major physiological stresses allow for application in the diagnosis, management surveillance and treatment of diseases. In our cohort the acute evolution of inflammatory and diabetes biomarkers were delineated and correlated to clinical outcome. We identified that cold ischaemic time is significantly negatively related to early pancreatic function and CRP provides an easily measurable predictor of recipient morbidity.4. The final study aimed to evaluate the feasibility and assess the benefits of contrast enhanced ultrasound (CEUS) in the immediate post-operative period following PT. We found CEUS to be a clinically useful adjunct in the post-operative assessment of allograft morphology and perfusion, although further validation and correlation with outcomes is required.

Hypertension is not consistently associated with postoperative cardiovascular morbidity and therefore not considered a major peri-operative risk factor. However, hypertension may predispose to peri-operative haemodynamic changes known to be associated with perioperative morbidity and mortality, such as intra-operative hypotension and tachycardia. The objective of this study was to determine whether pre-operative hypertension was independently associated with haemodynamic changes known to be associated with adverse peri-operative outcomes. We performed a five-day multicentre, prospective, observational cohort study which included all adult inpatients undergoing elective, noncardiac, non-obstetric surgery. We recruited 343 patients of whom 164 (47.8%) were hypertensive. An intra-operative mean arterial pressure of 100 beats per minute) occurred in 126 (38.9%) patients, of which 61 (48.4%) were hypertensive. Multivariable logistic regression did not show an independent association between the stage of hypertension and either clinically significant hypotension or tachycardia, when controlled for ASA physical status, functional status, major surgery, the duration of surgery or blood transfusion. There was no association between pre-operative hypertension and peri-operative haemodynamic changes known to be associated with major morbidity and mortality. These data therefore support the recommendation of the Joint Guidelines of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the British Hypertension Society to proceed with elective surgery if a patient’s blood pressure is < 180/110 mmHg.

This study investigates the prevalence of peri-operative anxiety and the effective management of intra-operative anxiety during awake surgery. Plastic and vascular surgical patients were selected for the study as many procedures performed within these specialities are performed under local or regional anaesthesia. The study consists of two distinct stages. The first stage was a postal survey of patients (n=213) who had undergone awake plastic, renal access or carotid surgery up to two weeks previously, in order to determine retrospectively the prevalence of peri-operative anxiety. The second stage of the study was a randomised controlled trial of interventions for the effective management of intra-operative anxiety in patients (n=128) having undergone the same surgical procedures described in stage one. The interventions tested in stage two were handholding and an anxiety management package involving a relaxation technique and a procedural information leaflet, against a 'usual care' control. The findings from stage one of the study suggest that peri-operative anxiety prevalence is low, although unacceptable levels of anxiety are seen to elevate during the intra-operative phase. The RCT in stage two demonstrated that intra-operative anxiety was no more effectively managed by the interventions tested than by usual care alone. The validity and reliability of retrospective anxiety measurement was investigated by comparing anxiety scores from stage one with contemporaneous and post-hoc anxiety scores from stage two and found to be an accurate measure of anxiety experienced at the time of the event.

This study investigates the prevalence of peri-operative anxiety and the effective management of intra-operative anxiety during awake surgery. Plastic and vascular surgical patients were selected for the study as many procedures performed within these specialities are performed under local or regional anaesthesia. The study consists of two distinct stages. The first stage was a postal survey of patients (n=213) who had undergone awake plastic, renal access or carotid surgery up to two weeks previously, in order to determine retrospectively the prevalence of peri-operative anxiety. The second stage of the study was a randomised controlled trial of interventions for the effective management of intra-operative anxiety in patients (n=128) having undergone the same surgical procedures described in stage one. The interventions tested in stage two were handholding and an anxiety management package involving a relaxation technique and a procedural information leaflet, against a ¿usual care¿ control. The findings from stage one of the study suggest that peri-operative anxiety prevalence is low, although unacceptable levels of anxiety are seen to elevate during the intra-operative phase. The RCT in stage two demonstrated that intra-operative anxiety was no more effectively managed by the interventions tested than by usual care alone. The validity and reliability of retrospective anxiety measurement was investigated by comparing anxiety scores from stage one with contemporaneous and post-hoc anxiety scores from stage two and found to be an accurate measure of anxiety experienced at the time of the event.

No description available.

Depuis les dernières années, la prévalence de personnes souffrant de dégénérescence des cartilages articulaires, communément appelée ostéoarthrite (OA), ne cesse d’augmenter. Les douleurs articulaires et les raideurs musculaires associées à cette pathologie mènent à des limitations des capacités fonctionnelles, à une perte de mobilité et d’autonomie affectant grandement la qualité de vie de ces personnes. Afin de soulager les personnes souffrant de cette pathologie, l’arthroplastie de la hanche est une procédure chirurgicale fréquemment utilisée. À la suite de cette chirurgie, une amélioration de la qualité de vie et une reprise des capacités fonctionnelles sont souvent observées. Cependant, comparativement à des sujets sains, la vitesse de marche est diminuée, une faiblesse des muscles abducteurs de la hanche est constatée et des mouvements compensatoires au niveau du tronc sont persistants. L’objectif de cette thèse est d’évaluer le patron locomoteur chez des patients qui subiront une arthroplastie de la hanche. Plus spécifiquement, les adaptations locomotrices pré et post-opératoires seront quantifiées dans le but d’apporter des modifications aux programmes de réhabilitation pour ainsi favoriser un patron locomoteur sans déficit. Afin de répondre à cet objectif, trois études distinctes ont été effectuées. Dans le cadre de la première étude, l’impact de l’implantation d’une prothèse totale de la hanche avec une tête fémorale de large diamètre et une prothèse de resurfaçage a été évalué par rapport aux sujets sains lors de la locomotion. Au cours de cette étude, le contrôle du tronc a été analysé en utilisant la distance entre le centre de masse corporel et le centre articulaire de la hanche opérée. Suite aux résultats obtenus, aucune différence majeure n’existe entre les deux types de prothèses en ce qui a trait au contrôle du tronc et ce, à un an post-opératoire. Lors de la deuxième étude, la symétrie des paramètres biomécaniques des membres inférieurs lors de la locomotion chez des patients ayant bénéficié de l’implantation d’une prothèse de la hanche a été caractérisée suite à un programme d’exercices péri-opératoires (pré et post-opératoire). Lors de cette étude, le programme d’exercices péri-opératoires était complémentaire au protocole de réadaptation du centre hospitalier. D’après les résultats obtenus lors de cette étude exploratoire, ce programme d’exercices péri-opératoires semble permettre d’améliorer la symétrie de la puissance et du travail musculaire au niveau de la hanche, du genou et de la cheville favorisant ainsi un patron de marche avec de minimes compensations. Finalement, dans le cadre de la troisième étude, l’approche prédictive et l’approche fonctionnelle, utilisées pour localiser le centre articulaire de la hanche, ont été comparées aux mesures radiographiques, chez des patients à la suite d’un remplacement articulaire de la hanche. À la suite de cette étude, les résultats démontrent que l’utilisation de l’approche fonctionnelle est plus appropriée chez des patients ayant bénéficié d’une arthroplastie de la hanche. En effet, cette approche individualisée est plus précise ce qui, par conséquent, permettra d’obtenir des résultats de plus grande qualité lors d’analyses biomécaniques de la locomotion. / In recent years, the prevalence of people suffering from joint cartilage degeneration, called osteoarthritis (OA), still increases. The joint pain and muscle stiffness related to this pathology have an impact on patients’ quality of life by limiting their functional capacities, mobility and autonomy. In order to relieve these patients, hip arthroplasty is a frequently used surgical procedure. Even if there is an improvement in quality of life and a restoration of functional capacities in these patients, some impairment seem to persist during the post-operative period. The walking velocity is slower when compared to healthy subjects, a hip abductor muscle weakness is observed and trunk compensations lasted during the post-operative period. The aim of this thesis is to evaluate patients undergoing hip arthroplasty during locomotion. More specifically, gait pattern adaptations will be quantified pre and post-operatively to revise rehabilitation programs in order to promote a healthy gait pattern. Three separate studies were conducted to meet this objective. The first study compared the effect of a large femoral head hip prosthesis and a hip resurfacing prosthesis to healthy subjects. During this study, the trunk control was analyzed using the distance between the body center of mass and the hip prosthetic joint center. The results obtained show no major difference between the two types of prosthesis and the healthy control one year post-operatively. During the second study, biomechanics parameter symmetry of the lower limb of gait pattern in patients undergoing hip arthroplasty was characterized following a peri-operative (pre and post-operatively) exercise program. The exercise program was complementary to the medical center standard rehabilitation program. Based on the results of this exploratory study, the peri-operative exercise program seems to improve the symmetry of the muscular power and work of the hip, knee and ankle which promote a healthy gait pattern without compensations. Finally, for the third study, the predictive and the functional approaches, used to locate the hip joint center, were compared to radiographic measurements in patients undergoing hip arthroplasty. The results of this study demonstrated that the functional approach was more appropriate for these patients. This individualized approach is more accurate which leads to quality improvement during biomechanical analysis of gait pattern.

Depuis les dernières années, la prévalence de personnes souffrant de dégénérescence des cartilages articulaires, communément appelée ostéoarthrite (OA), ne cesse d’augmenter. Les douleurs articulaires et les raideurs musculaires associées à cette pathologie mènent à des limitations des capacités fonctionnelles, à une perte de mobilité et d’autonomie affectant grandement la qualité de vie de ces personnes. Afin de soulager les personnes souffrant de cette pathologie, l’arthroplastie de la hanche est une procédure chirurgicale fréquemment utilisée. À la suite de cette chirurgie, une amélioration de la qualité de vie et une reprise des capacités fonctionnelles sont souvent observées. Cependant, comparativement à des sujets sains, la vitesse de marche est diminuée, une faiblesse des muscles abducteurs de la hanche est constatée et des mouvements compensatoires au niveau du tronc sont persistants. L’objectif de cette thèse est d’évaluer le patron locomoteur chez des patients qui subiront une arthroplastie de la hanche. Plus spécifiquement, les adaptations locomotrices pré et post-opératoires seront quantifiées dans le but d’apporter des modifications aux programmes de réhabilitation pour ainsi favoriser un patron locomoteur sans déficit. Afin de répondre à cet objectif, trois études distinctes ont été effectuées. Dans le cadre de la première étude, l’impact de l’implantation d’une prothèse totale de la hanche avec une tête fémorale de large diamètre et une prothèse de resurfaçage a été évalué par rapport aux sujets sains lors de la locomotion. Au cours de cette étude, le contrôle du tronc a été analysé en utilisant la distance entre le centre de masse corporel et le centre articulaire de la hanche opérée. Suite aux résultats obtenus, aucune différence majeure n’existe entre les deux types de prothèses en ce qui a trait au contrôle du tronc et ce, à un an post-opératoire. Lors de la deuxième étude, la symétrie des paramètres biomécaniques des membres inférieurs lors de la locomotion chez des patients ayant bénéficié de l’implantation d’une prothèse de la hanche a été caractérisée suite à un programme d’exercices péri-opératoires (pré et post-opératoire). Lors de cette étude, le programme d’exercices péri-opératoires était complémentaire au protocole de réadaptation du centre hospitalier. D’après les résultats obtenus lors de cette étude exploratoire, ce programme d’exercices péri-opératoires semble permettre d’améliorer la symétrie de la puissance et du travail musculaire au niveau de la hanche, du genou et de la cheville favorisant ainsi un patron de marche avec de minimes compensations. Finalement, dans le cadre de la troisième étude, l’approche prédictive et l’approche fonctionnelle, utilisées pour localiser le centre articulaire de la hanche, ont été comparées aux mesures radiographiques, chez des patients à la suite d’un remplacement articulaire de la hanche. À la suite de cette étude, les résultats démontrent que l’utilisation de l’approche fonctionnelle est plus appropriée chez des patients ayant bénéficié d’une arthroplastie de la hanche. En effet, cette approche individualisée est plus précise ce qui, par conséquent, permettra d’obtenir des résultats de plus grande qualité lors d’analyses biomécaniques de la locomotion. / In recent years, the prevalence of people suffering from joint cartilage degeneration, called osteoarthritis (OA), still increases. The joint pain and muscle stiffness related to this pathology have an impact on patients’ quality of life by limiting their functional capacities, mobility and autonomy. In order to relieve these patients, hip arthroplasty is a frequently used surgical procedure. Even if there is an improvement in quality of life and a restoration of functional capacities in these patients, some impairment seem to persist during the post-operative period. The walking velocity is slower when compared to healthy subjects, a hip abductor muscle weakness is observed and trunk compensations lasted during the post-operative period. The aim of this thesis is to evaluate patients undergoing hip arthroplasty during locomotion. More specifically, gait pattern adaptations will be quantified pre and post-operatively to revise rehabilitation programs in order to promote a healthy gait pattern. Three separate studies were conducted to meet this objective. The first study compared the effect of a large femoral head hip prosthesis and a hip resurfacing prosthesis to healthy subjects. During this study, the trunk control was analyzed using the distance between the body center of mass and the hip prosthetic joint center. The results obtained show no major difference between the two types of prosthesis and the healthy control one year post-operatively. During the second study, biomechanics parameter symmetry of the lower limb of gait pattern in patients undergoing hip arthroplasty was characterized following a peri-operative (pre and post-operatively) exercise program. The exercise program was complementary to the medical center standard rehabilitation program. Based on the results of this exploratory study, the peri-operative exercise program seems to improve the symmetry of the muscular power and work of the hip, knee and ankle which promote a healthy gait pattern without compensations. Finally, for the third study, the predictive and the functional approaches, used to locate the hip joint center, were compared to radiographic measurements in patients undergoing hip arthroplasty. The results of this study demonstrated that the functional approach was more appropriate for these patients. This individualized approach is more accurate which leads to quality improvement during biomechanical analysis of gait pattern.

A quantitative, descriptive and contextual research study was conducted to establish the impact of the South African Nursing Council regulation number 212 on the training of theatre nurses in the Northern are of the Eastern Cape Province. A survey was conducted, using a questionnaire as research instrument. Convenience sampling was used to select the required sample of registered theatre nurses employed in the area. The data analysis revealed that the way theatre nurses are utilized in the area does not yet show an impact in terms of the aim of this course namely to develop their knowledge, skills and attitudes in order to be effective practitioners. However, the respondents felt positive about the curriculum. / Health Studies / MA (Health Studies)