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.

Orientadores: Desanka Dragosavac, Luciana Castilho de Figueiredo / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-27T10:18:25Z (GMT). No. of bitstreams: 1 Rodrigues_CristianeDelgadoAlves_D.pdf: 6776527 bytes, checksum: 911dcad00f3a4026901b992e7babcae5 (MD5) Previous issue date: 2015 / Resumo: OBJETIVO: Estudo de coorte retrospectivo realizado com o objetivo de verificar a presença de Disfunção Transitória da Troca Gasosa (DTTG) no pós-operatório de cirurgia cardíaca e determinar se esse transtorno está relacionado a eventos cardiorrespiratórios. MÉTODOS: Foram incluídos 942 pacientes consecutivos submetidos à cirurgia cardíaca e procedimentos cardíacos, encaminhados para a UTI, entre junho de 2007 e novembro de 2011. RESULTADOS: A Síndrome do Desconforto Respiratório Agudo (SDRA) foi observada em 15 pacientes (2%), apresentaram Disfunção Transitória da Troca Gasosa (DTTG) leve 199 (27.75%) pacientes, DTTG moderada em 402 (56.1%) pacientes e DTTG grave em 39 (5.4%) pacientes. A presença de hipertensão arterial e choque cardiogênico foram associadas ao surgimento de DTTG moderada no período pós-operatório (p=0.02 e p=0.019, respectivamente) e foram considerados fatores de risco para esta disfunção (p=0.0023 e p=0.0017, respectivamente). A presença de diabetes mellitus também foi considerada um fator de risco para DTTG (p=0.03). Houve correlação entre a presença de pneumonia e a presença de DTTG moderada em 8.9% dos casos (p = 0.001). A presença de DTTG grave foi associada a pacientes que necessitaram de terapia de substituição renal (p=0.0005), hemoterapia (p=0.0001), nutrição enteral (p=0.0012), ou arritmia cardíaca (0.0451). CONCLUSÕES: A presença de hipertensão pré-operatória e choque cardiogênico foram associados com a ocorrência de DTTG pós-operatória. Os fatores de risco pré-operatórios foram hipertensão, choque cardiogênico e diabetes. No pós-operatório, a pneumonia, pneumonia associada à ventilação (PAV), terapia de substituição renal, hemoterapia e arritmia cardíaca foram associados com o aparecimento de certo grau de DTTG, que foi fator de risco para reintubação, pneumonia, PAV e terapia de substituição renal no pós-operatório de cirurgia cardíaca e procedimentos cardíacos / Abstract: OBJECTIVE: A retrospective cohort study was preformed aiming to verify the presence of transient dysfunction of gas exchange (TDGE) in the postoperative period of cardiac surgery and determine if this disorder is linked to cardiorespiratory events. METHODS: We included 942 consecutive patients undergoing cardiac surgery and cardiac procedures who were referred to the ICU between June 2007 and November 2011. RESULTS: Fifteen patients had acute respiratory distress syndrome (2%), 199 (27.75%) had mild TDGE, 402 (56.1%) had moderate TDGE, and 39 (5.4%) had severe TDGE. Hypertension and cardiogenic shock were associated with the emergence of moderate TDGE postoperatively (p = 0.02 and p = 0.019, respectively) and were risk factors for this dysfunction (p = 0.0023 and p = 0.0017, respectively). Diabetes mellitus was also a risk factor for TDGE (p = 0.03). Pneumonia was present in 8.9% of cases and correlated with the presence of moderate TDGE (p = 0.001). Severe TDGE was associated with patients who had had renal replacement therapy (p = 0.0005), hemotherapy (p = 0.0001), enteral nutrition (p = 0.0012), or cardiac arrhythmia (0.0451). CONCLUSIONS: Preoperative hypertension and cardiogenic shock were associated with the occurrence of postoperative TDGE. The preoperative risk factors included hypertension, cardiogenic shock, and diabetes. Postoperatively, pneumonia, VAP, renal replacement therapy, hemotherapy, and cardiac arrhythmia were associated with the appearance of some degree of TDGE, which was a risk factor for reintubation, pneumonia, VAP, and renal replacement therapy in the postoperative period of cardiac surgery and cardiac procedures / Doutorado / Fisiopatologia Cirúrgica / Doutora em Ciências

ABSTRACT Atrial fibrillation (AF) is frequently detected in the setting of an acute physiologic stressor, such as medical illness or surgery. It is uncertain if AF detected in these settings (AFOTS: AF occurring transiently with stress) is secondary to a reversible trigger or is simply paroxysmal AF. This distinction is critical for clinicians and patients, as they must decide if AFOTS can be dismissed as a reversible phenomenon, or if it justifies the need for chronic therapy; in particular, anticoagulation to reduce the risk of disabling stroke. The uncertainty in the management of AFOTS is exacerbated by a poor understanding of its epidemiology. How frequently does AFOTS occur? Are there higher risk groups? What is the natural history of this condition? Across 8 chapters, this thesis systematically assesses previously published literature on this topic, focusing on patients who have an acute medical illness or have undergone noncardiac surgery, and addresses knowledge gaps therein. Chapter 1 is an introduction that outlines the justification of each of the studies in the thesis. Chapter 2 is a narrative review that defines AFOTS conceptually and outlines research priorities. Chapter 3 is a systematic review that explores the incidence and recurrence of AFOTS associated with acute medical illness. Chapter 4 is a systematic review and meta-analysis that explores the incidence and recurrence of AFOTS associated with acute noncardiac surgery. iii Chapter 5 examines the profiles of pacemaker-detected “subclinical” AF occurring before and after a hospitalization for medical illness or noncardiac surgery Chapter 6 reports the design, rationale and final results of a prospective study that aimed to provide a precise and accurate estimate of the incidence of AFOTS in critically ill patients. Chapter 7 reports the design and rationale of a matched prospective cohort study designed to estimate the rate of recurrence of AF following hospitalization with AFOTS and to compare it to similar patients who did not have AFOTS. Finally, Chapter 8 outlines the conclusions, discusses the limitations, and presents the implications of the research in this PhD thesis. / Thesis / Doctor of Philosophy (PhD) / Atrial fibrillation (AF) is the most common abnormal heart rhythm. AF is often diagnosed when a patient is hospitalized for an illness or after surgery. When AF is first found in this setting, it is unclear whether it has the same prognosis as other forms of the disease or is reversible. This thesis examines this problem and designs and executes studies to address it.

Almost half of patients recovering from open chest surgery experience atrial fibrillation (AF) that results principally from inflammation in the pericardial space surrounding the heart. Given that post-operative AF is associated with increased mortality, effective measures to prevent AF after open-chest surgery are highly desirable. In this study, we tested the concept that extracellular vesicles (EVs) isolated from human atrial explant-derived cells can prevent post-operative AF. Middle-aged female and male rats were randomized to undergo sham operation or induction of sterile pericarditis followed by trans-epicardial injection of human EVs or vehicle into the atrial tissue. Pericarditis increased the probability of inducing AF while EV treatment abrogated this effect in a sex independent manner. EV treatment reduced infiltration of inflammatory cells and production of pro-inflammatory cytokines. Atrial fibrosis and hypertrophy seen after pericarditis was markedly attenuated by EV pre-treatment; an effect attributable to suppression of fibroblast proliferation by EVs. Our study demonstrates that injection of extracellular vesicles at the time of open-chest surgery shows prominent anti-inflammatory effects and prevents AF due to sterile pericarditis. Translation of this finding to patients might provide an effective new strategy to prevent post-operative AF by reducing atrial inflammation and fibrosis.

No description available.

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.

Ce travail reprend les études d’évaluation d’une plateforme instrumentale dédiée à la chirurgie mitrale mini-invasive vidéo-assistée, et du télémanipulateur Da Vinci pour la réalisation d’anastomose mammaire interne / IVA à thorax fermé.) Evaluation du Portaclamp. Cette étude clinique a porté sur 20 patients opérés de chirurgie cardiaque sous CEC et a confirmé la simplicité d’utilisation du système, son efficacité et l’absence de morbidité ou complication induite. L’étude chez le porc des effets histologiques sur la paroi de l’aorte des trois clamps (l’endo-clamp, le clamp Chitwood et le Portaclamp) a révélé une atteinte majeure de l’endothélium aortique induite par l’endo-clamp . 2) Evaluation du Portapleg. Le Portapleg est un dispositif auto-suturant de cardioplégie antérograde constitué d’un clip en Nitinol restant implanté sur l’aorte. Une étude sur 20 patients a été rapportée avec comme critère principal le temps de saignement du site de ponction après injection de protamine. Le système a montré son efficacité hémostatique dans tous les cas sans événement secondaire. 3) Evaluation du Mitrax’s. C’est un cône en plastique polymère auto ajustable et auto expansible, qui repousse de façon symétrique et concentrique les parois de l’oreillette. Une étude prospective de son efficacité a été réalisée chez 62 patients opérés de chirurgie mitrale vidéo-assistée de façon consécutive. L’indice de satisfaction a été en moyenne 4.6, témoin d’une exposition optimale de la valve mitrale avec une vision endoscopique ou directe de la valve mitrale jugée excellente. 4) Analyse comparative des techniques mini-invasives de revascularisation de l’IVA par pontage mammaire (Port Access, MIDCAB, TECAB). Cette étude prospective a porté sur 160 patients ; à trois mois, le taux de réintervention sur l’IVA était : PA-CABG, 0% ; MIDCAB, 1.8% ; TECAB, 10% ; p<0.01. A trois ans, les taux actuariels de survie sans réintervention étaient : PA-CABG, 100% ; MIDCAB, 98±5 % ; TECAB, 88±8 % ; p<0.05. / This thesis is based on the evaluation studies of an instrumental platform dedicated to video assisted minimally invasive mitral valve surgery, and of the robotic Da Vinci system in LAD bypass with mammary artery in a closed chest approach. 1) Evaluation of Portaclamp. In 20 patients who underwent cardiac surgery with Portaclamp, a clinical study showed that the clamping system is safe, fast and easy and does not generate undue morbidity. In a pig model, severe lesions of the intima were observed on the clamping spot with the endoclamp, in comparison with Portaclamp and Chitwood clamp. 2) Evaluation of Portapleg. Portapleg is an auto-suturing system dedicated to antegrade cardioplegia delivery, and based on a Nitinol clip left implanted on the aorta. In 20 patients, the closure of the puncture aortic hole and the haemostasis after protamine were obtained in all cases. The procedure did not generate undue morbidity and there was no device-related adverse event. 3) Evaluation of Mitrax’s. The Mitrax’s retractor is a pattern cut polymer sheet, self-expanding and auto-adjusting. The effectiveness of Mitrax’s was evaluated in 62 patients who consecutively underwent a video-assisted mitral valve procedure. The global satisfaction index was 4.6±0.5, demonstrating the effectiveness of the device which provides optimal exposure and excellent direct vision. 4) Comparative analysis of minimally invasive techniques for LAD revascularization with mammary artery graft (Port Access, MIDCAB, TECAB). In a prospective study, 160 patients were included. At 3-month postoperatively, the end-point of LAD reintervention were PA-CABG, 0%; MIDCAB, 1.8%; TECAB, 10%; p=0.01. At 3-year, reintervention-free survival was significantly lower in the TECAB group: PA-CABG, 100% ; MIDCAB, 98±5 % ; TECAB, 88±8 % ; p<0.05.

Occupation of a general nurse belongs to demanding jobs in terms of professional preparation and performance. A nurse is expected to cope with professional activity, working with modern technology, administrative work, to bear the physical and mental load of her profession, to be able to influence and direct patients? feelings and behaviour and finally to be able to cope with professional as well as family problems she is faced to. All this is often dealt with in continuous operation on shift basis at various specialized workplaces. Questions how nurses working at a cardiac surgery department are satisfied or dissatisfied at their jobs, how the work experience length affects their satisfaction, whether possible discontent among nurses may affect quality of the nursing services provided by them and how the hospital management reduces the factors of discontent, became the subject of my thesis. The research was performed at the IKEM in Prague. Quantitative as well as qualitative research methods were used for data collection when mapping the problems in question. The quantitative part involved a questionnaire both, for general nurses working at the cardiac surgery department, aimed at investigation into the discontent factors involved in their occupation, and for the patients undertaking treatment at the cardiac surgery department, to examine their satisfaction with the nursing care. Analysis of the collected data was then performed. An interview with representatives of the hospital line, middle and top managements was the instrument of the qualitative research. It was focused on the question how they proceed in elimination or reduction the discontent factors. The following facts were found out by the quantitative research. Increased physical and mental load, non-cooperating patients and care about more patients at the same time, extensive administration related to patient care, insufficient remuneration, lack of communication from doctors and superiors, lack of auxiliary staff, projection of occupation to private life or the problem of sleeping after a night shift are the most frequent discontent factors. Despite the above negative factors nurses are satisfied with their jobs regardless the length of experience. The indentified factors of discontent do not affect quality of the care provided by the nurses. The qualitative research results show that personal talks, active interviews and direct communication from the staff are the most frequent methods the management uses to map staff satisfaction. The management representative is able to work herself on elimination or reduction of the discovered factors of discontent within her competences, which happens most often. She may also cooperate with the chief nurses or ward sisters. Unless she is able to solve a problem, it is passed to the authorized persons competent to deal with it (health care manager, social-legal department, HR department). The hospital director is also informed on the most serious cases. The management hardly ever cooperates with physicians on elimination or reduction of the discontent factors. The most important aspect of solving the problem of discontent factors is its subject, which affects the solution method, whether it is to be dealt with by an individual or the whole team. They inform the head physicians or the ward chief consultant on serious problems. The course of the problem solution is communicated to the employees by the ward sisters or chief nurses personally, orally.The goals of the thesis have been met, the set hypotheses have been refuted, and the research questions have been answered.