Introduction: Knee osteoarthritis is one of the common causes leading to musculoskeletal disability of the elderly around the world. Total knee replacement (TKR) is an effective and common treatment for end stage knee arthritis. Most papers suggest that early rehabilitation could improve postoperative knee function. However, postoperative pain and local swelling are the complications that diminish range of motion (ROM) and inhibit patients’ recovery. A comprehensive review of the literature reveals that cryotherapy is an effective and safe method to overcome these complications. In this paper, a guideline of using cryotherapy in reducing postoperative pain and knee swelling so as to improve the ROM of patients and promote recovery after TKR has been developed. Objectives: The objectives of this translational research are: (1) to look for relevant papers that related to cryotherapy in reducing postoperative pain and knee swelling so as to improve the ROM of patients after TKR; (2) to gather and criticize the data obtained; (3) to develop a guideline of using cryotherapy in reducing pain, knee swelling and improving ROM of patients after TKR based on the evidence from the reviewed literature; (4) to assess the implementation potential of the newly developed guidelines; and (5) to establish the implementation and evaluation plans for the new innovation. Methods: An empirical literature search published from 2001 to 2011 by several searching engines regarding cryotherapy in reducing postoperative pain and knee swelling with the aim to improve the ROM of patients after TKR has been conducted. After that, the qualities of relevant studies were retrieved and criticized by using the appraisal checklist of the SIGN (2004). The derived evidences were then be summarized and synthesized. An evidence-based guideline was established with reference to the evidence from the reviewed literatures and the results of the quality assessment. Recommendations are graded by SIGN (2004). The implementation potential including transferability, feasibility and cost-benefit ratio of the innovation were assessed as well. Lastly, implementation and evaluation plans have been developed to assess and appraise the effectiveness of the new guideline. Results: Finally, seven studies were chosen as final references after methodological quality assessment. Four main types of comparison were made from these seven reviews including: (1) continuous compressive cryotherapy vs. compressive crepe bandage; (2) comparison in different temperature of cryotherapy; (3) outcome measures; and (4) complications in cryotherapy. After the summary, six main categories of recommendations were synthesized: (1) continuous compression cryotherapy; (2) effective temperature; (3) potential complications; (4) regular assessment; (5) duration; and (6) intermitted ice pack regimen. Based on these syntheses and recommendations, a guideline of using cryotherapy for patients after having TKR was developed. Conclusion: With the implementation of the newly developed evidence-based cryotherapy guidelines for patients after having TKR in local clinical settings, the improvement in the ROM of the knee joint will be anticipated as a result of the reduction in postoperative pain and knee swelling. / published_or_final_version / Nursing Studies / Master / Master of Nursing

Thoraxkirurgiska ingrepp har väldokumenterade ökade risker för svåra smärtor postoperativt och tidigare forskning visar om den postoperativa smärtlindringen underbehandlas ökar risken att utveckla en kronisk smärta (CPSP) som drabbar 30-50% av alla som genomgår thoraxkirurgi. Detta leder till högre vårdkostnader för samhället, en kraftig försämring av patientens livskvalitet och ett vårdlidande för patienten. Sjukvården borde fokusera på att möta patienternas lidande och ge redskap och möjlighet för vårdarna att lindra lidandet och stärka patientens förmåga till egenvård av smärta i hemmet. Syftet med denna litteraturstudie var att belysa sjuksköterskans upplevelse av vad som behövs för att ge en bra smärtbehandling till patienter som genomgått större kirurgi exempelvis thoraxkirurgi och vilka hinder som måste överstigas för att lyckas. Examensarbetet genomfördes som en systematisk litteraturstudie där innehållet från elva artiklar analyserades och sammanställdes. I analysen av resultatet framkom två teman; Upplevda hinder och sjuksköterskans strategier. De beskriver hur sjuksköterskan på olika sätt arbetar med smärtskattning och vilka hinder som kan uppstå. Resultatet visar på stora problem i smärtbehandling, både vad gäller att smärtskatta som att lindra lidandet och berodde bland annat på bristande kunskap hos både patient och sjuksköterska. Slutsatsen är att sjukvården borde satsa på mer individualiserad patientinformation både preoperativt och innan hemgång, så patienten förstår varför smärtlindring är viktigt. Om detta görs kan man förhindra postoperativa komplikationer och kronisk smärta, som leder till lägre vårdkostnader och minst lika viktigt att bibehålla en patient med god livskvalitet.

The management of patients undergoing colorectal surgery has changed in recent decades. Efforts have been made to show that perioperative physiological stress to the patient can be minimised with standardised care programmes and thus improve short term outcome after colorectal surgery. Mechanical bowel preparation (MBP), for instance, has been questioned as part of standard management. There are studies highlighting the effect of cancer treatment and its side effects in the elderly, showing that geriatric patients benefit from oncological therapy in much the same way as younger patients. The impact of this information on surgical and oncological practice in Sweden today is not known. To assess the effectiveness of colorectal surgery we need both randomised controlled trials and population-based cohort studies. We have performed a trial on colonic surgery with and without preoperative mechanical bowel preparation, as well as a nation-wide register study comparing treatment and outcome of rectal cancer in two age groups. In a randomised controlled trial 1505 patients from 21 hospitals were randomised to MBP or no-MBP prior to open elective colonic resection. There were no differences in overall complication rates between the groups: cardiovascular 5.1% with MBP vs. 4.6% without MBP; general infection 7.9% vs. 6.8%; and surgical site complications 15.1% vs. 16.1%. The proportion of patients reaching at least one primary endpoint was 24.5% vs. 23.7% respectively. The patients experience of and postoperative recovery after MBP or no-MBP was evaluated in 105 of the patients in the bowel preparation trial at three of the participating hospitals. Sixty-five patients received MBP and 40 patients did not. In the MBP group 52% needed assistance with bowel preparation. Day 4 postoperatively patients in the no-MBP group perceived more discomfort than patients in the MBP group, p<0.05. Bowel emptying occurred significantly earlier in the no-MBP group than in the MBP group, p<0.05. In an experimental study the effect of MBP on intramucosal bacterial count was evaluated. Macroscopically normal colon mucosa was collected from 37 patients (20 MBP and 17 No-MBP) undergoing elective colorectal surgery at three hospitals. MBP did not influence the median colony count of E. coli, Bacteroides, or total median colony count, information that was previously unknown. These three studies imply that MBP can be omitted before elective colonic resection. In a population-based register study, treatment for rectal cancer in patients ≥ 75 years and those < 75 years was evaluated using data from the Swedish Rectal Cancer Register 1995-2004 (N=15104). This study revealed that preoperative radiotherapy was used less in patients > 75 years. There was also a higher threshold for surgery in this group, and they more often received a permanent stoma compared to younger patients. Outcome in terms of 5-year local recurrence rate and 5-year cancer-specific survival differed very little between the older and younger patient groups who underwent abdominal tumour resection with curative intent. We suggest future studies focusing on ways of reducing surgical and perioperative stress and on quality of life when assessing suitable treatment modalities for rectal cancer.

Live kidney donors are healthy volunteers who are exposed to major surgical procedure and physical harms with no direct therapeutic benefits. Efforts to minimize their risks and morbidity are therefore of utmost importance. The current thesis describes studies on donor evaluation, surgical procedure and postoperative management of live kidney donors. The overall purpose is to evaluate and possibly improve routines and treatments in order to reduce risks and the overall morbidity of live kidney donors. In Study I, we evaluated the assessment of kidney function during donor evaluation and found that the accuracy of iohexol glomerular filtration rate (GFR) is compromised by large variations in repeated measurements in presumably healthy donors. We proposed that there is a need for improvement of GFR measurements and that the assessment of predonation kidney function should be more comprehensive, involving GFR, laboratory investigations, functional and morphological examinations and sound clinical judgment. In Study II, we addressed the risk of perioperative venous thromboembolism (VTE) and concluded that expanding the standard screening protocol for VTE to include perioperative venous duplex can potentially decrease the VTE-related morbidity. In studies III and IV, we investigated the impact of hand-assisted retroperitoneoscopic (HARS) nephrectomy on donor safety and perioperative morbidity. The HARS nephrectomy uses the hand-assisted approach, which enables immediate manual compression for hemostasis in case of sudden and severe bleeding. Additionally, the pure retroperitoneal access further increases the safety margin of laparoscopic donor nephrectomy by 1) minimizing the risk of intestinal injury, and 2) exposure of the retroperitoneal nerves, making HARS suitable for continuous infusion of local anesthetics (CILA). CILA effectively reduces the need for opioid consumption and has the potential to totally obviate opiate analgesics postoperatively. Consequently, CILA in combination with HARS reduces morphine-related morbidity and promotes postoperative recovery. In accordance with these data, we recommend improvement and modification of the donor evaluation process as well as a broad introduction of HARS nephrectomy in combination with CILA to increase the safety margin for live kidney donors.

Mycket forskning inom ämnet postoperativ smärta är gjord. Det är ett komplext ämne och studier visar att det förekommer att patienter smärtlindras otillräckligt. Syftet med den här studien var att beskriva vilka metoder sjuksköterskan använder sig av för att bedöma akut postoperativ smärta, och vilka för och nackdelar som finns med de olika metoderna. Vi ansåg att en litteraturstudie var mest lämpad för vår studie och har använt oss av tolv artiklar i resultatet. Där identifierade vi fyra kategorier som beskriver hur sjuksköterskan bedömer postoperativ smärta. (1) Hur patienten ser ut, (2) Kommunikation, (3) Erfarenheter och (4) Smärtskattningsskalor. Ofta vägs flera av dessa kategorier in när sjuksköterskan bedömer smärta. Resultatet visar att sjuksköterskan har en tendens att bedöma smärtan utifrån tidigare erfarenheter och det händer att de ibland undervärderar patientens smärtnivåer. Det framgår också att patientens verbala beskrivning om smärtupplevelsen är den mest tillförlitliga indikatorn i bedömningen av akut postoperativ smärta. / There has been a lot of research conducted on the subject matter of postoperative pain. It’s a complex subject matter with studies showing the presence of inadequate pain relief. The purpose of this study is to describe the methods and tools nurses use to assess acute postoperative pain, and the pros and cons of the various methods. A literature review was conducted and twelve articles where used for the results. Four categories describing how nurses assess postoperative pain were identified. (1) What the patient looks like, (2) Communication, (3) Previous experiences and (4) Pain rating scales. It’s common for multiple categories to be used by nurses assessing pain. Results show nurses have a tendency to assess pain from previous experiences, and in the process sometimes underestimating the patients’ true pain levels. Results also show that the most accurate indicator of a postoperative pain in patients is their own verbal expression of said pain.

No description available.

Skrandžio vėžys yra ketvirta pagal dažnį ir antra pagal mirtingumą onkologinė liga pasaulyje. Sergančių šia liga 5 metų išgyvenamumas siekia tik 25 proc. Esant didelei ligos atkryčio rizikai dažniausiai skiriama adjuvantinė chemoterapija, nors daugumoje atsitiktinių imčių studijų statistiškai reikšmingo išgyvenamumo pagerėjimo nenustatyta. Dažniausia skrandžio vėžio gydymo nesėkmės priežastis yra lokoregioninis recidyvas (40-65 proc. ligonių, kuriems atliktos radikalios operacijos) ir pilvaplėvės metastazės. Siekiant sumažinti lokoregioninių recidyvų dažnį, pradėtas taikyti suderintas chemospindulinis gydymas. Šio tyrimo tikslas- nustatyti adjuvantinio gydymo efektyvumą po radikalių skrandžio vėžio operacijų su D2 limfadenektomija ir pagrįsti šio gydymo metodo tikslingumą. Darbo tikslui įgyvendinti buvo suformuluoti šie uždaviniai. 1. Įvertinti radikaliai dėl skrandžio vėžio operuotų su D2 limfadenektomija pacientų išgyvenamumą taikant adjuvantinį chemospindulinį gydymą arba adjuvantinę chemoterapiją. 2. Įvertinti adjuvantinio chemospindulinio gydymo toksiškumą po radikalių operacijų su D2 limfadenektomija, palyginti jį adjuvantinės chemoterapijos 5-fluoruracilu ir leukovorinu sukeliamu toksiškumu. 3. Įvertinti ankstyvos pooperacinės intraperitoninės chemoterapijos toksiškumą ir palyginti jos efektyvumą taikant su adjuvantiniu chemospinduliniu gydymu. 4. Palyginti gyvenimo kokybę po radikalių operacijų dėl skrandžio vėžio atliekant gastrektomiją ir subtotalinę skrandžio... [toliau žr. visą tekstą] / Gastric cancer is the fifth most common cancer and the second leading cause of cancer-related death worldwide. The 5-year survival rate of these patients is approx. 25. Adjuvant chemotherapy is frequently used for treatment, despite the fact that many randomized studies failed to demonstrate a better patient survival. The high rate of recurrence, even in patients undergoing state-of-the art curative resection, suggests that effective adjuvant chemoradiation and chemotherapy might indeed be an attractive concept to improve the overall outcomes of patients with gastric cancer. The aim of this study was to evaluate the effectiveness of the adjuvant therapy after curative resection with D2 lymphadenectomy for gastric cancer and determine its role in the treatment of cancer patients. The goals of this study were: 1. To compare the survival of patients receiving adjuvant chemoradiation or adjuvant chemotherapy after the curative resection with D2 lymphadenectomy for gastric cancer. 2. To evaluate the toxicity of the adjuvant chemoradiation after the curative resection with D2 lymphadenectomy for gastric cancer and to compare it with the toxicity caused by adjuvant chemotherapy with 5- Fluorouracil and Leucovorin. 3. To assess the toxicity of the early postoperative intraperitoneal chemotherapy and compare its effectiveness with the combined intraperitoneal chemotherapy and adjuvant chemoradiation therapy. 4. To compare the quality of life after the total and subtotal... [to full text]

Bakgrund: Studier har visat sig att barns postoperativa smärta i många fall är otillräckligt behandlad och barnen upplever ofta smärta som något obehagligt och skrämmande. Barn kan påverkas negativt av smärta och de kan utveckla skadliga beteendeförändringar efter en operation på grund av otillräckligt behandlad postoperativ smärta. Syfte: Syftet med den här studien är att undersöka hur barnen, på en specifik kirurgavdelning, mår under det första dygnet efter en operation då de blivit sövda, avseende deras postoperativa smärta. Om möjligt ska grupper som har ökad risk för otillräcklig postoperativ smärtlindring försöka identifieras. Metod: En kvantitativ tvärsnittsstudie baserad på ett konsekutivt urval. Deltagarna består av barn på en kirurgavdelning i åldrarna 4-16 år som alla har genomgått en operation där de blivit sövda. De har fått besvara en enkät om sin smärta ett dygn efter operation. Resultat: I studien deltog 32 barn med en medelålder på 9,25 år. Medelvärdet av smärta just nu var 2,59. Medelvärdet av smärta som mest var 7,56. Medelvärdet av minsta smärtan var 1,03. De äldre barnen skattade sin smärta högre än de yngre. Pojkarna skattade sin smärta högre än flickorna. Allmän kirurgi skattade sin smärta högre än de andra kirurgityperna vid två av tillfällena. Urologi skattade sin smärta högst vid ett av tillfällena. Alla deltagande barn uppgav att den ordinerade smärtlindringen hjälpte. Inga signifikanta skillnader kunde ses mellan könen, åldrarna eller de olika kirurgityperna. Slutsats: En större studie, med fler tillfrågade barn, hade gett ett tydligare resultat. Mer forskning behövs inom området. Sjuksköterskorna måste bli bättre på att använda sig av smärtskattningsskalor. / Background: It has been shown that children's postoperative pain, in many cases, is inadequately treated. The children often experience pain as something unpleasant and frightening. Children might be affected in destructive ways by the pain and they can develop adverse behavioral changes because of inadequately treated postoperative pain. Aim: The aim of this study is to investigate how the children, at a specific surgical ward, are feeling during the first day after a surgery where they have been anesthetized, regarding their postoperative pain. Groups with increased risk of inadequate postoperative pain treatment are Method: A quantitative cross-sectional study based on a consecutive sample. The participants consist of children on a surgical ward aged 4-16 years who all had surgery where they were anesthetized. They have answered a questionnaire one day after the surgery. Results: 32 children participated in the study. Their mean age was 9.25 years. The mean of pain right now was 2.59. The mean of the worst pain was 7.56. The mean of the minimum pain was 1.03. The older kids rated their pain higher than the younger ones. The boys rated their pain higher than the girls. General surgery rated their pain higher than the other surgery types at two occasions. Urology rated their pain highest at one of the occasions. All participating children reported that the prescribed pain relief helped. No significant differences were seen between the sexes, ages or different surgery types. Conclusion: A larger study with more responding children, would have given a clearer result. More research is needed in this area. The nurses have to improve their usage of pain measurement instruments.

Die vorliegende retrospektive Studie zur postoperativen Radiochemothera-pie bei fortgeschrittenen Kopf-Hals-Tumoren sollte die eigenen Ergebnisse mit den prospektiv-randomisierten Studien vergleichend darlegen und dabei den Nutzen einer Radiochemotherapie überprüfen. Insgesamt wurden 155 Patienten in der retrospektiven Analyse eingeschlossen. Die Überlebens- und Rezidivraten des Patientengutes konnten anlehnend zu den publizier-ten Studien reproduziert werden. Ein Vorteil der Radiochemotherapie in Bezug nehmend auf den posttherapeutischen Verlauf konnte hierbei nicht festgestellt werden. Es traten signifikant vermehrt höhergradige Akutne-benwirkungen nach Applizierung der simultanen, systemischen Therapie auf. Die Arbeit konnte zeigen, dass sich durch die Reduzierung der Gesamt-behandungszeit als auch des Intervalls zwischen Operation und Beginn der adjuvanten Therapie das Gesamtüberleben sowie die lokoregionäre Rezidiv-rate signifikant verbessern ließen. Insgesamt scheinen die Fernmetastasie-rungen und die lokoregionären Rezidive maßgebend für die immer noch un-befriedigenden Überlebensraten zu sein. Gegenstand weiterer Untersu-chungen sollte daher die Optimierung der prätherapeutischen Diagnostik sowie der adjuvanten Therapie sein.

Inledning: Postoperativ smärta hos barn är fortfarande ett problem trots förbättrade arbetsrutiner och smärtbehandling. Smärtskattning på barn och speciellt barn med kognitiva nedsättningar kräver att sjuksköterskorna har kunskap om tillgängliga smärtskattningsinstrument. På så vis ges alla barn möjlighet att smärtskattas. Syfte: Att undersöka hur ofta sjuksköterskor smärtskattar barn som opereras för skolios postoperativt. Design: En retrospektiv studie. Metod: Journalgranskningen genomfördes på Universitetssjukhuset i Linköping. Alla barn som under 2008-2009 opererats för Idiopatisk eller Neuromuskulär skolios, var mellan 0-18 år och fanns med i journaldatasystemet inkluderades i studien. Resultat: Barn med Idiopatisk skolios smärtskattades oftare än barn med Neuromuskulär skolios. Barn som inte förstod instruktion smärtskattades inte lika ofta som de barn som förstod instruktion. Flickor smärtskattades oftare än pojkar inom gruppen som förstod instruktion. Konklusion: Det fanns en signifikant skillnad i frekvens smärtskattning mellan Idiopatisk skolios och Neuromuskulär skolios, utöver detta gjordes fyndet att flickor smärtskattades högre än pojkar. För att alla skall få möjlighet till lika god omvårdnad krävs att det finns tillgång till olika smärtskattningsinstrument. / Background: Despite improved guidelines and treatment of children, postoperative pain is still a problem. Painassessment in children and specially children with cognitive disibilities demands knowledge in existing pain measurement tools for nurses. Then all children have the opportunity to express their pain. Aim: To find out if there is a difference in the frequency of assessment in postoperative pain in children after surgery for scoliosis. Design: A retrospective study. Methods: The study was performed in Linköping University hospital. Children admitted 2008-2009 for Idiopatic scoliosis or Neuromuscular scoliosis surgery, in age 0-18 years and available via the data journal were included in the study. Results: Children with Idiopatic scoliosis had a higher freqvence of painassessment compared with Neuromuscular scoliosis. Children who didn´t understood verbal information had less frequence of painassesment compered with those who understood verbal information. Girls were assessed for pain significant more often as compared to boys in the group who understood verbal information. Conclusion: There was differences between children who were able to express themselves and those who weren´t in painassessment, but also gender matters and to ensure all children’s right to similar care it´s of importance to access different pain measurement tools.