Thesis advisor: Dorothy A. Jones / The purpose of this qualitative research study was to answer the following questions: What is the life pattern manifested by individuals caring for spouses who have had coronary artery bypass surgery? What are the thematic expressions of life patterns among individuals caring for spouses who have had coronary artery bypass surgery? The theoretical framework guiding this study was Margaret Newman’s Health as Expanding Consciousness. The research method created by Newman facilitated the understanding of the individual participant’s experience, pattern identification, similarities in pattern across participants and the potential for expansion of consciousness. The study sample included ten women and two men whose spouses were recovering at home following cardiac surgery. These twelve spousal caregivers shared their life stories and their spousal caregiving experience in the first two weeks at home following their spouses discharge from the hospital. There were various levels of potential for expansion of consciousness for these spousal caregivers. Looking across participants six themes emerged from the data. First, disruption in the spousal caregivers’ roles and responsibilities impacts the relationship between the spousal caregivers and their spouses and shifts life patterns. Second, spousal caregivers face coping challenges with changes in lifestyle and response to illness. Third, Spousal caregivers experience vigilance in an effort to ease the uncertainty of the recovery process. Fourth, knowledge helps spousal caregivers gain a sense control in the face of uncertainty. Fifth, mutuality within the partnership of nurse and the spousal caregiver relationship impacts the potential for transformation. Sixth, Spousal caregivers’ awareness of their life pattern gives meaning and offers the caregivers a new perception on life they have left to live. Findings from this study have important implications for nursing theory, practice, research, education and health care policy. The study adds empirical support to Newman’s Theory of Health as Expanding Consciousness and provides a new way to examine spousal caregiving and the nurse-client relationship. / Thesis (PhD) — Boston College, 2008. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

In a systematic review and random effects meta-analysis, we evaluated whether obesity is associated with postoperative atrial fibrillation (POAF) in patients undergoing cardiac surgery. Eighteen observational studies that excluded patients with preoperative AF were selected until December 2011 (n=36,147). Obese patients had a modest higher risk of POAF in comparison to non-obese (OR 1.12, 95%CI 1.04-1.21, p=0.002). The association between obesity and POAF did not vary substantially by type of cardiac surgery, study design or year of publication. POAF was significantly associated with higher risk of stroke, respiratory failure, and operative mortality. / Revisión por pares

Lintérêt actuel suscité par la contribution des prostanoïdes en général et par le TXA2 en particulier à lhoméostasie cardio-vasculaire, nous a conduit à mener une série de procédures expérimentales chez le porc. Nous avons ainsi étudié son effet sur la vasomotricité systémique qui se résume en une élévation des résistances vasculaires systémiques (R2) et une diminution de la compliance vasculaire (C). Nous avons également démontré son action pro coagulante et pro inflammatoire dans un processus dischémie myocardique induit par application topique de FeCL3. Dans ce processus, le TXA2 nexerce aucun effet sur lévolution des paramètres hémodynamiques systémiques. Enfin, il joue un rôle mineur dans lischémie-reperfusion myocardique mais il est important de rappeler que dans notre procédure expérimentale, linduction de lischémie se faisait de façon abrupte par application dun clamp coronaire ce qui rend les mécanismes thrombotiques et dont la libération de TXA2 moins prépondérants.Lutilisation d'un modulateur du thromboxane A2, le BM-573, savère efficace dans la prévention des effets de lagoniste du TXA2, lU-46619, sur les résistances vasculaires périphériques. Le BM-573 exerce de plus un effet cardioprotecteur en cas dischémie myocardique, mais aucun effet bénéfique nest observé en cas dischémie-reperfusion myocardique.Le TXA2 joue donc un rôle important dans lhoméostasie cardiovasculaire et intervient avec dautres médiateurs dans la physiopathologie de lhypertension artérielle et de lischémie myocardique. Nous navons cependant pas démontré sa contribution exacte au processus dischémie-reperfusion myocardique / Prostanoids in general and thromboxane A2 in particular appear to play a crucial role in cardiovascular homeostasis. To address this issue, we have carried out a number of experimental procedures in the pigs. We were able to show that the effects of TXA2 on sytemic vascular hemodynamic, consist in an increase of vascular resistance and a decrease of vascular compliance. Additionnaly, TXA2 had a procoagulant and proinflammatory effects in a model of myocardial ischaemia induced by topical application of FECL3 on the left anterior descending coronary artery. No effects were noticed concerning the evolution of systemic hemdynamics parameters. Finally, TXA2 appeared to play a minor role in a myocardial ischaemia-reperfusion model. The use of a TXA2 modulator, BM-573, prevented the systemic vascular effects of TXA2. It also had a cardioprotective effect in the model of myocardial ischaemia, but failed to prevent reperfusion injury in acutely ischemic pigs. We conclude that TXA2 plays an important role in cardiovascular homeostasis and that it intervenes along with others mediators in the physiopathology of hypertension and myocardial ischaemia.

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.