Existe na literatura um número apreciável de trabalhos clínicos experimentais concernentes com a utilização de intervenções preemptivas objetivando abolir ou minimizar o desenvolvimento da hipersensibilidade central, decorrente do trauma cirúrgico possibilitando, como consequência, a otimização do controle analgésico pós-operatório. No entanto, considerando a contradição entre resultados apresentados, que não convergem em direção favorável a um consenso de ampla aceitação de utilização de intervenções preemptivas, desenvolvemos esse ensaio clínico, a fim de testar se a administração pré- operatória de ibuprofeno, isolado ou associado à dexametasona apresentaria vantagem relevante no controle da dor pós exodontia dos terceiros molares, comparado com a ausência de intervenção analgésica pré-operatória. Para tanto, foram selecionados 42 pacientes com inclusões simétricas dos terceiros molares. Esses pacientes foram aleatoriamente divididos em dois grupos: G1 recebeu apenas o ibuprofeno ou placebo, e G2 associação do ibuprofeno e dexametasona ou placebo. Todos os pacientes foram submetidos a dois procedimentos cirúrgicos, direito e esquerdo sendo que, um dos lados recebeu a medicação ativa e o outro placebo, de forma randomizada de modo que todos os pacientes funcionaram como controles de si mesmos (boca dividida). As demais medicações de analgesia pós-operatória, (associação de codeína mais paracetamol), fornecida como resgate, bem como a antibioticoterapia foram idênticas para todos os pacientes. As variáveis analisadas foram a escala visual analógica de dor (EVA) e o número total de analgésicos de resgate consumidos com os respectivos horários de ingestão durante as primeiras 72 horas do pós-operatório. Como resultados, não encontramos diferença estatisticamente significante para nenhuma das variáveis no o grupo 1. No grupo 2, houve diferença estatisticamente significante no consumo total de analgésicos de resgate (p<0,05) e, sem diferença estatisticamente significante para a EVA, embora a distribuição gráfica desses valores, especialmente quando associada à distribuição da ingestão de medicação de resgate, nos permita interpretar uma clara tendência de melhor controle analgésico no grupo experimental. Sentimos nitidamente a dificuldade em se estabelecer parâmetros ideais para aferição de controle analgésico, tendo em vista as limitações éticas e consequente obrigatoriedade da medicação de resgate que passa a ser, então, o parâmetro mais confiável, uma vez que a sua utilização aproxima as curvas de dor dos procedimentos experimentais e controles, podendo eventualmente até invertê-las. Pudemos concluir que a administração de ibuprofeno isolado no pré-operatório não tem potência analgésica suficiente para coibir os fenômenos de sensibilização central e hipersensibilidade desencadeados pela exodontia de terceiros molares mas, a associação dele com a dexametasona mostrou-se eficaz nesse sentido, resultando em menor consumo de analgésicos e na avaliação subjetiva de um pós-operatório mais confortável para 76% dos pacientes. A associação de diferentes drogas, com mecanismos de ação diferentes e que atuem em nichos distintos na via aferente dolorosa, denominadas intervenções multimodais, parece ser o melhor caminho para se alcançar uma intervenção suficientemente potente para inibir ou controlar os mecanismos neurais que levam à hipersensibilidade pós-operatória sem aumento da toxicidade e efeitos colaterais. / Our literature search found that there were a considerable number of experimental clinical studies pertaining to the use of pre-emptive measures, in order to eliminate or minimize the development of central hypersensitivity resulting from surgical trauma, allowing as a consequence, an optimal post surgery analgesic control. However we found that the results are contradictory and do not appears favourable to the use of pre-emptive interventions. Therefore, we designed this clinical trial in order to test whether preoperative administration of ibuprofen alone or in combination with dexamethasone was advantageous in controlling pain after the extraction of third molars, when compared with the absence of preoperative analgesic intervention. To test this hypothesis we selected 42 patients with symmetrical inclusions of third molars. These patients were divided randomly into two groups, where group 1 received ibuprofen and group 2 received a combination of ibuprofen an dexamethasone. All patients underwent two surgical procedures, right and left, and for the intervention on one randomly defined side active medication was administered while, on de other side a placebo was given. Thus all patients acted as their control. The other medications for postoperative analgesia, including the association of paracetamol and codeine, delivered as rescue, and the antibiotic were identical for all patients. The variables analyzed were the visual analogue scale (VAS) and the total number of rescue analgesic consumed, with respective times of intake during the first 72 hours postoperatively. We found no statistically significant difference for any of the variables in group 1. In group 2, we found a statistical difference of p< 5% for total consumption of rescue analgesics, and no statistically significant difference for the VAS, although the graphical distribution these values, especially when associated with the distribution of intake of rescue medication suggests a tendency for better analgesic control in the experimental group. It is clearly difficult to establish optimal parameters for measurement of analgesic control, in view of ethical constrains and the consequent requirement of rescue medication, which then becomes the more reliable parameter, since its use may reverse the pain curves of the experimental procedures and controls. We conclude that the administration of ibuprofen alone has insufficient analgesic power to inhibit the establishment of central sensitization and consequent hypersensitivity triggered by the extraction of third molars while its association with dexamethasone was effective, resulting in lower analgesic consumption and a more comfortable post surgery subjective evaluation in 76% of the patients. However, the combination of different drugs with different mechanisms of action, which act in different territories of the pain pathway, known as multimodal interventions, seems to be the best way to achieve a sufficiently powerful intervention to minimize or inhibit the neural mechanisms underlying postoperative hypersensitivity without increased toxicity and side effects.

Orientador: Renato Mazzonetto / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba / Made available in DSpace on 2018-08-12T10:10:54Z (GMT). No. of bitstreams: 1 SerenaGomez_Eduardo_D.pdf: 2061440 bytes, checksum: 1ab59aa7174f893ad9f6ce83cccaef0e (MD5) Previous issue date: 2008 / Resumo: Existem várias pesquisas na literatura que relatam fatores considerados de risco para o insucesso dos implantes dentais. Porém, alguns estudos têm gerado controvérsia nos resultados. Alguns autores inclusive contra-indicam o tratamento de implantes dentais na presença destes fatores tais como doenças sistêmicas, abuso de substâncias nocivas à saúde, procedimentos reconstrutivos prévios à implantodontía, complicações pós-operatórias, entre outros fatores, quando alguns estudos demonstram que estes isoladamente representam apenas uma pequena parcela dos insucessos na implantodontia, sendo não significativos. Assim, o objetivo desse trabalho foi avaliar os fatores que podem influenciar na perda tardia dos implantes dentais, por meio de prontuários clínicos dos pacientes que foram tratados com implantes osseointegráveis para reabilitação implantossuportada no período de junho de 2001 a julho de 2006 pela Área de Cirurgia Buco-Maxilo- Facial da Faculdade de Odontologia de Piracicaba . Unicamp. Foram estudados diversos fatores dos pacientes em todos os grupos, tais como gênero, idade, queixa principal, história médica, procedimentos reconstrutivos, procedimentos implantodônticos, desenho do implante, complicações, procedimentos protéticos, acompanhamento mínimo de um ano após carga protética e perda dos implantes. Além disso, cada um destes fatores foi avaliado nos pacientes que apresentaram alguma perda tardia nos tratamentos implantodônticos, com a finalidade de obter a relação destes e sua influência na perda tardia dos tratamentos com implantes dentais. Forem incluídos 432 pacientes na avaliação deste estudo com um índice de 89,3% de sucesso no tratamento com implantes dentais. Perda primaria foi apresentada em 28 pacientes (6,4%) e Perda Tardia em 21 pacientes (4,8%). Dos pacientes que apresentarem perda tardia, nenhum deles relatou consumir substâncias nocivas à saúde, sete apresentavam alguma doença sistêmica e seis forem submetidos a procedimentos reconstrutivos prévios à colocação dos implantes dentais. Os fatores tabagismo, doenças sistêmicas, procedimentos reconstrutivos e complicações nos tratamentos cirúrgicos não resultaram ser significativos nos índices de perda tardia. Estudos prospectivos são necessários para um maior entendimento desses insucessos no tratamento de implantes dentais. / Abstract: Researches in literature considered some factors to be related to failure of dental implants treatments. However, some other studies have generated controversy in those results. Some authors also contraindicated dental implants treatment in presence of these factors like systemic diseases, substance abuse, bone grafting before implant installation, postoperative complications and others factors; when some studies demonstrate that these factors, separately, represent only one small parcel of failures in the dental implantology, being not significant. Thus, the objective of this work was to evaluate the factors that can influence in the delayed failure of dental implantations, by means of formularies of patients who had been treated with dental implants in the period of June of 2001 through July of 2006 at the Oral and Maxillofacial Surgery Department of the Piracicaba Dental School - Unicamp. The groups, such as gender, age, main complaint, medical history, reconstructive procedures, dental implant procedures, complications, prosthetic procedures, a minimum follow-up of one year after prosthetic load and implants failure, had been studied in this research. Moreover, each of these factors had been evaluated in the patients who had presented some delayed failure on dental implants treatments, with the purpose to establish any relation of these factors and their influence in the delayed failure of dental implant treatments. 432patients were included on the evaluation of this study with a success rate of 89.3% on dental implants treatment. Primary failure on dental implants presented on 28 patients (6.4%) and 21 patients (4.8%) presented delayed failure. Patients who presented delayed failure did not abuse substances, seven patients had a systemic disease and six treated previously with bone graft. Smoke, systemic disease, reconstructive procedures and complications during surgical treatments had not resulted to be significant on delayed failure indices. Prospective studies are necessary for a best comprehension of these failures in the treatment of dental implants. / Doutorado / Cirurgia e Traumatologia Buco-Maxilo-Faciais / Doutor em Clínica Odontológica

Orientador: Roger William Fernandes Moreira / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba / Made available in DSpace on 2018-08-24T16:06:55Z (GMT). No. of bitstreams: 1 Marchiori_EricaCristina_D.pdf: 484604 bytes, checksum: 57495eb26b1ce8df8060445371d9671a (MD5) Previous issue date: 2014 / Resumo: Objetivos: Avaliar a prevalência, fatores de risco e curso clínico da dor neuropática (DN) após osteotomia sagital dos ramos mandibulares (OSRM) em uma grande amostra de pacientes. Materiais e Métodos: Estudo retrospectivo realizado em dois centros médicos do Hospital Kaiser Permanente da Norte da Califórnia, no período de janeiro de 2007 até setembro de 2012, nos pacientes submetidos à OSRM. Fatores demográficos, clínicos e cirúrgicos foram identificados nos prontuários dos pacientes, bem como comorbidades associadas. A prevalência, sinais e sintomas, características da dor e a resposta ao tratamento nos pacientes afetados foram analisados. Resultados: Os autores identificaram 1.778 pacientes que foram submetidos à OSRM e, destes, 107 foram excluídos de acordo com critérios pré-definidos. A média de idade dos pacientes (1.671) foi de 24 anos (intervalo interquartil de 19 a 35 anos) e 62,4% eram do gênero feminino. Sete pacientes desenvolveram DN após OSRM, cuja prevalência foi de 0,42%. Todos eles eram mulheres, cuja média de idade foi de 48 anos. Os fatores de risco para o desenvolvimento de DN após OSRM incluíram: idade superior a 40 anos (p = 0.0098), depressão (p = 0.0100), e gênero feminino (p = 0.0497). O inicio da DN ocorreu em uma média de 30 dias de pós-operatório (18 a 56 dias), com média de duração de 52 dias (30 a 69,5 dias). Todos os pacientes responderam favoravelmente à medicações anticonvulsivantes (n = 6) ou antidepressivas tricíclicas (n = 1), além de nenhum dos pacientes ter desenvolvido dor crônica pós-cirúrgica. Conclusões: A dor de origem neuropática é uma complicação infrequente após OSRM, acometendo 1 a cada 238 pacientes nesta amostra. A curta duração e a reposta favorável às medicações empregadas reforça esse achado. Os resultados dessa investigação chamam a atenção para a necessidade de futuros estudos prospectivos para melhor compreensão da DN pós-operatória / Abstract: Purpose: To estimate the prevalence of, risk factors for, and clinical course of neuropathic pain (NPP) after sagittal split ramus osteotomy (SSRO) of the mandible in a large cohort of patients. Materials and Methods: A retrospective cohort of all patients who underwent SSRO at 2 medical centers within Kaiser Permanente Northern California from January 2007 through September 2012 was assembled. Demographic, clinical, and surgical factors were collected from medical records and relevant comorbidities were identified. The prevalence of NPP in the cohort was calculated and the clinical signs, symptoms, temporal characteristics and treatment response in affected patients were noted. Results: The authors identified 1.778 patients who underwent SSRO and excluded 107 patients according to predefined criteria. The remaining 1.671 patients had a median age of 24 years (interquartile range from19 to 35 years) and 62.4% were women. Seven patients developed NPP after SSRO, which was an overall prevalence of 0.42%. All patients with NPP in this cohort were women and had a median age of 48 years. The risk factors for developing NPP after this surgery were age over 40 years (p = 0.0098), depression (p = 0.0100), and female gender (p = 0.0497). NPP developed an average of 30 days postoperatively (range, 18 to 56 days) and persisted for a median duration of 52 days (range, 30 to 69.5 days). All patients responded favorably to anticonvulsant (n = 6) or tricyclic (n = 1) medications, and no patients developed chronic postsurgical pain. Conclusions: NPP was an infrequent complication after SSRO, occurring in 1 of 238 patients in this cohort. The short duration and positive response to medication are reassuring findings. The results of this investigation highlight the need for prospective studies to further understand the spectrum of postoperative NPP / Doutorado / Cirurgia e Traumatologia Buco-Maxilo-Faciais / Doutora em Clínica Odontológica

Bakgrund: Delirium är ett vanligt förekommande tillstånd inom somatisk vård. År 2016 var 85 % av patienterna som diagnosticerades med delirium i Sverige 70 år eller äldre. Det finns många olika faktorer som bidrar till uppkomsten av delirium, bland annat hög ålder, hypertoni, att genomgå kirurgi, tidigare hjärtsjukdom eller stroke och kognitiva nedsättningar.  Syfte: Syftet med studien var att undersöka patienters upplevelse av delirium. Metod: En litteraturstudie där resultatet grundas på tio kvalitativa originalartiklar med intervjustudie som metod. Artiklarna söktes i databaserna PubMED, CINAHL och PsycINFO. Resultat: Fyra huvudkategorier framkom vid granskning av resultatet; Upplevelser av en förändrad verklighet, Upplevelser av starka känslor, Upplevelser av att minnas tillbaka och Upplevelser av bemötande. Patienterna beskrev starka känslor av rädsla, oro och ilska i samband med delirium. Känslor av isolering och otrygghet förekom när patienternas verklighetsuppfattning var nedsatt. Rädsla kunde uttryckas genom aggressivitet vilket kan bidra till stigmatisering och försvårande omständigheter för patienten. Lugn, närvaro och säkerhet hos sjuksköterskan ingav patienterna trygghet. Att minnas tillbaka på delirium orsakade känslor av skam, skuld och ånger. Några förnekade att de haft delirium medan andra uppskattade att samtala om sina upplevelser. Sjuksköterskans kompetens hade stor betydelse för patienternas upplevelser av bemötande. Slutsats: Upplevelsen av delirium är individuell. Att bli bekräftad och sedd som en unik individ beskrevs av patienterna leda till ökat välbefinnande. Sjuksköterskan har en viktig roll i att informera och stötta patienten för att minska stigmatisering och lidande. Det är också betydelsefullt att sjuksköterskan behandlar patienternas upplevelser med respekt. / Background: Delirium is a common condition within somatic care. In 2016 85 % of patients diagnosed with delirium in Sweden were 70 years of age or older. There are many different factors that contribute to the onset of delirium, including high age, hypertension, undergoing surgery, previous heart disease orr stroke and cognitive impairments. Aim: The aim of the study was to explore patients’ experiences of delirium. Method: A literature study where the result is based on ten qualitative original articles with interviews as a method. The articles were searched in the databases PubMED, CINAHL and PsycINFO. Results: Four main categories emerged when reviewing the results; Experiences of a Changed Reality, Experiences of Strong Emotions, Remains of Remembrance and Experiences of Personal Treatment. Patients described strong feelings of fear, concern and anger associated with delirium. Feelings of isolation and insecurity occurred when the patient's perception of reality was reduced. Fear could be expressed through aggressiveness, which could contribute to stigmatization and aggravating circumstances for the patient. The calm, presence and safety of the nurse provided patients with security. Recalling delirium caused feelings of shame, guilt and regret. Some denied that they had delirium while others appreciated talking about their experiences. Nursing skills were of great importance to the patient's experiences of treatment. Conclusion: The experience of delirium is individual. Becoming confirmed and seen as a unique individual was described by patients leading to increased well-being. The nurse has an important role in informing and supporting the patient to reduce stigmatization and suffering. It is also important that the nurse treats the patient's experiences with respect.

Sammanfattning Bakgrund: Postoperativ ileus är en allvarlig komplikation som kan uppstå, ofta till följd av smärtstillande läkemedel eller inflammation i tarmvävnaden. Tarmmotoriken avstannar och gas- och tarmavgång upphör. Symtomen är kraftiga buksmärtor, kräkningar och utspänd buk. Patienten utsätts för smärta, oro och förlängd sjukhusvistelse. Syfte: Att beskriva omvårdnadsåtgärder sjuksköterskan kan vidta för att förebygga postoperativ ileus samt att beskriva urvalsgrupperna i de inkluderade artiklarna. Metod: En litteraturstudie av deskriptiv design som grundas på elva vetenskapliga artiklar, samtliga med kvantitativ ansats. Huvudresultat: Omvårdnadsåtgärder som tidigt oralt vätske- och födointag, tugga tuggummi, mobilisering, gunga gungstol, akupressur och sjuksköterskeledd information har visats påskynda läkning av tarmen och reducera risken av postoperativ ileus. Omvårdnadsåtgärderna visade bäst resultat gällande tarmljud, tarmrörelser, gas- och tarmavgång och tolerans av normal föda. Slutsats: Omvårdnadsåtgärder har visats ha god effekt vid förebyggande av postoperativ ileus. Tydliga tecken på att tarmen återhämtat sig och att den postoperativa tarmparalysen upphört är gas- och tarmavgång, tarmljud och tarmrörelser, vilket samtliga påskyndas av omvårdnadsåtgärder. Att kontinuerligt ta del av kunskap genom forskning möjliggör för sjuksköterskan att utföra professionell omvårdnad av hög standard. Det är sjuksköterskans ansvar att utföra omvårdnadsåtgärder som förebygger risker, minskar lidande och främjar hälsa. / Abstract Background: Postoperative ileus is a serious complication, often due to pain relief medication or the inflammation of intestinal tissue. Bowel movements stop and the gastrointestinal tract ceases and the resulting symptoms are: severe abdominal pain, vomiting and tensioned abdomen. This result in pain, anxiety and long-term hospitalization for the patient. Aim: To describe nursing interventions which prevent postoperative ileus and describe the selection groups of included articles. Method: A literature study of descriptive design based on eleven articles, all of which take a quantitative approach. Main result: Nursing interventions such as; early oral fluid and food intake, chewing gum, mobilization, swing rocking chair, acupressure and nurse information have been shown to accelerate healing of the intestine and reduce the risk of postoperative ileus. Nursing interventions had best result relating to: bowel sound, bowel movement, defecation and tolerance of normal food. Conclusion: Nursing interventions have been shown effective in the prevention of postoperative ileus. Clear indications of intestinal recovery and postoperative paralysis recovery include first flatus, bowel sound, bowel movement and defecation, all of which are more likely to occur if the patient has had nursing intervention. Continuously acquiring knowledge through research enables nurses to perform professional care of high standard. It is the nurse's responsibility to carry out nursing interventions that prevent risks, reduce suffering and promote healing.

This thesis aims to present a multi-dimensional instrument for self-assessment of progress in postoperative recovery. The author employs different research paradigms and methodologies to achieve this aim. Walker and Avant’s approach to concept analysis was used to examine the basic elements of postoperative recovery (Study I). The analysis identified different recovery dimensions and developed a theoretical definition showing postoperative recovery to be an energy-requiring process of returning to normality and wholeness, defined by comparative standards. Fourteen patients and 28 staff members participated in individual and focus group interviews aimed at describing patient and staff experiences of patient recovery (Study II). The essence of the postoperative recovery process was described as a desire to decrease unpleasant physical symptoms, reach a level of emotional wellbeing, regain functions, and re-establish activities. In Study III, 5 dimensions and 19 items were identified as a part of the operationalization process of the concept postoperative recovery. Fifteen staff members and 16 patients participated in the evaluation of content validity. On average, 85% of the participants considered the items as essential to the recovery process. In a test run of the questionnaire, 14 of 15 patients considered the questionnaire to be easy to understand and easy to complete. Twenty-five patients participated in the evaluation of intra-patient reliability. Percentage agreement (PA), systematic disagreement (RP, RC), and individual variability (RV) between the two assessments were calculated. PA measures ranged from 72% to 100%. The observed disagreement could be explained mainly by systematic disagreement. In total, 158 patients participated in the evaluation of construct validity, the ability to discriminate between groups, and the investigation of important item variables (Study IV). A rank-based statistical method for evaluation of paired, ordered categorical data from rating scales was used to evaluate consistency between the assessments of the Postoperative Recovery Profile (PRP) questionnaire and a global recovery scale. The number of months needed by participants to be regarded as fully recovered was studied by means of recovery profiles displayed by the cumulative proportion of recovered participants over time. A ranking list based on the participant’s appraisal of the five most important item variables in the PRP questionnaire was compiled to illustrate the rank ordering of the items. In comparing the assessments from the PRP questionnaire and the global recovery scale, 7.6% of all possible pairs were disordered. Twelve months after discharge 73% in the orthopaedic group were regarded as fully recovered, compared to 51% of the participants in the abdominal group (95% CI: 6% to 40%). The pain variable appeared among the top five most important items on eight measurement occasions, of eight possible, in both study groups. In conclusion, the PRP questionnaire was developed and support was given for validity and reliability. The questionnaire enables one to evaluate progress in postoperative recovery.

Submitted in fulfillment of the requirements for the degree of Masters of Health Sciences in Clinical Technology, Durban University of Technology, Durban, South Africa, 2016. / Introduction: The immediate post-cardiopulmonary bypass (CPB) immune responses and organ injuries in immune- compromised patients remain poorly documented. We conducted a prospective clinical study to determine whether or not human immunodeficiency virus (HIV) seropositive patients generate higher acute systemic inflammatory response and suffer greater myocardial injury, compared to HIV seronegative patients. Methodology: Sixty-one consecutive patients i.e. Thirty HIV seropositive patients and Thirty-one seronegative, undergoing elective cardiac valve(s) replacement were enrolled, over a period of nine months from a single center hospital, after informed consent was acquired. The C-reactive protein (CRP) and Erythrocyte sedimentation rate (ESR) were used as biomarkers of acute inflammatory response, and cardiac troponin I (cTnI) as a biomarker for measuring postoperative myocardial injury. Single tests were measured preoperatively and postoperatively, in both groups, and these were compared and correlated to perioperative events and CPB parameters. Results: The mean age group was similar between the HIV seropositive and negative group (37.8 and 37.1 years, respectively). Preoperatively both groups had relatively equal CRP levels (p=0.388), ESR levels (p=0.817) and cTnI (p=0.489). The CPB events and durations were significantly different between the two groups, CPB duration (p=0.021). Other CPB events include, clamp aortic duration (p=0.026), CPB blood transfusion (p=0.013), CPB total urine output (p=0.035) and CPB peak lactate (p=0.040). Postoperatively we observed significant increased biomarkers level in both groups, with no significant difference between the groups: mean CRP (p=0.115), mean ESR (p=0.214) and cTnI (p=0.363). We observed a significant negative correlation between the mean change in CRP levels and mechanical ventilation (r=- 0.548, p=0.002) in the seropositive group, but not in the uninfected group (r=0.025, p=0.893). The correlation between the difference in CRP and ICU stay was not significant between in both group (r=-0.231, p=0.229 and r=0.25, p=0.975, respectively). A significant positive correlation between postoperative cTnI and the inotropic support duration (r=0.384, p=0.040) was seen in the seropositive groups, but not in the negative group (r=0.092, p=0.622). Furthermore we observed a significant drop in CD4 cells postoperatively (p=<0.001) in the HIV seropositive group. Antiretroviral treatment appeared to influence the degree of change in CD4 cells postoperatively. Conclusion: We conclude that HIV positive patients’ postoperative reactions to cardiac surgery supported by CPB are similar to those of HIV seronegetive patients. We further report non-paralleling correlations between the biomarkers and perioperative events; however these do not seem to affect the overall outcomes between the two groups. / M

Bakgrund: Hypotermi, låg kroppstemperatur, i samband med operation är ett vanligt förekommande problem. För patienten medför hypotermi ett flertal fysiologiska konsekvenser, men kan även bidra till ett försämrat välbefinnande. För att förebygga hypotermi i samband med operation kan passiva och aktiva uppvärmningsmetoder vidtas. Syfte: Syftet med litteraturstudien var att undersöka vilka aktiva och passiva filtar som förebyggde iatrogen hypotermi och medföljande shivering. Metod: Studien gjordes som en litteraturstudie efter sökningar i databaserna PubMed och Cinahl.  Elva randomiserade kontrollerade studier och en kvasiexperimentell studie inkluderades. Resultat: Forced air warming, FAW, var mer effektiv i att öka kärntemperaturen och bevara normotermi postoperativt. FAW var också den mest effektiva uppvärmningsmetod i att minska intensiteten av shivering. Litteraturstudien visar motstridiga resultat om vilken uppvärmningsmetod som var mest effektiv i det intraoperativa skedet. Det fanns ingen signifikant skillnad mellan de olika uppvärmningsmetoderna i att minska incidensen av shivering. Slutsats: Att motverka iatrogen hypotermi är en väsentlig del för patientens välbefinnande. Forced air warming, FAW, var mer effektiv att förebygga hypotermi och minska intensiteten av shivering. Det fanns däremot ingen signifikant skillnad mellan de olika uppvärmningsmetoderna i det intraoperativa skedet eller i att minska incidensen av shivering. Dock är litteraturstudiens omfång begränsad och det krävs därför mer omfattande studier för att uppdatera kunskapsläget och ge patienten den mest lämpade vården. / Background: Hypothermia, low body temperature, is a common problem associated with surgery. For the patient, hypothermia involves a high frequency of physiological consequences, but may also contribute to a reduced wellbeing. In order to prevent iatrogen hypothermia - that is to say hypothermia associated with surgery, passive and active rewarming systems can be used. Aim: The aim of the litterature study was to investigate which rewarming system of active and passive blankets that prevent iatrogen hypothermia with supplied shivering. Method: The study was made as a literature study after a research on the databases PubMed and Cinahl. Eleven randomized controlled studies and a quasi-experimental study were included. Results: Forced air warming, FAW, was the most effective rewarming system in raising the core temperature and maintaining normothermia in postoperative patients. FAW was also the most effective rewarming method in decreasing the intensity of shivering. The literature study also showed contradictory results regarding which rewarming system that was most efficient during surgery. There were no significant differences between the rewarming systems in preventing the incidence of shivering. Conclusions: Preventing hypothermia is an essential part for the patient’s wellbeing. FAW were the rewarming systems that were most efficient in preventing hypothermia and decreasing the intensity of shivering. In contrast, there were no significant differences between the rewarming systems during surgery, nor regarding decreased incidence of shivering. However the range of the literature study is limited and therefore more extensive studies are required to update the state of knowledge to be able to give the most adequate care for the patient.

Litteraturen beskriver larynxmask som ett skonsamt alternativ till intubation med endotrakealtub. Tidigare studier visar dock att det inte är ovanligt med halsbesvär postoperativt, i form av halsont och/eller heshet. Syftet med studien var att undersöka förekomst och karaktär av halsbesvär postoperativt efter användning av två olika larynxmasker. Författarna genomförde en pilotstudie där nitton vuxna patienter, både män och kvinnor, som erhållit Pro-Breathe® eller I-gel® larynxmask under anestesin ingick. Patienterna intervjuades 60 minuter respektive 24 timmar efter uttagandet av larynxmasken. Intervjun bestod av två slutna frågor om halsont och heshet samt en öppen fråga om hur det kändes i halsen. Den öppna frågan visade att andra typer av halsbesvär förekommer, bland annat irritabilitet, svårigheter att svälja, torrhet och svullnadskänsla. Pilotstudiens metod lämpade sig att använda och svarade mot studiens syfte. Resultatet visade att olika typer av halsbesvär var vanligt postoperativt. Åtta av tio patienter som haft Pro-Breathe® samt sju av nio patienter som haft I-gel® hade någon typ av halsbesvär. / The literature describes the laryngeal mask as a gentle alternative to intubation with endotracheal tube. Previous studies show that it is not unusual with throat discomfort postoperatively, in terms of sore throat and/or hoarseness/dysphonia. The aim of this study was to investigate the presence and nature of throat discomfort postoperatively after the use of two different laryngeal masks. The authors conducted a pilot study in which nineteen adult patients, both men and women, who received Pro-Breathe® or I-gel® laryngeal mask during anesthesia was included. The patients were interviewed 60 minutes and 24 hours after the laryngeal mask were removed. The interview consisted of two sealed questions about sore throat and hoarseness/dysphonia and one open question about how it felt in the throat. The open question showed that other types of throat discomforts occurred, including irritability, difficulty swallowing, dryness and swelling sensation. The method of the pilot-study was suitable to use and responded to the study's purpose. The results showed that different types of throat discomfort were common postoperatively. Eight out of ten patients who received Pro-Breathe® and seven out of nine patients who received I-gel® had some type of throat discomfort.

Contemporary hepatobiliary surgery practice must accurately assess operative risk in increasingly elderly populations with greater co-morbidity. Current methods fail to identify patients at high risk of postoperative complications. Cardiopulmonary exercise testing (CPET) derived anaerobic threshold (AT) and ventilatory equivalence of carbon dioxide (VE/VCO2) are validated predictors of postoperative outcome in major intra-abdominal surgery and outperform contemporary tools of risk evaluation. Despite evidence of improved in-hospital postoperative survival in large centres offering complex curative hepatobiliary surgery, morbidity remains high and long-term survival in the high-risk subset remains poor. This thesis investigated the role of validated CPET-derived markers in predicting perioperative outcomes for a high-risk hepatobiliary surgery population. It was also utilised to study the impact of malignant obstructive jaundice on peripheral oxygen extraction. In a prospective cohort of high-risk patients undergoing liver resection, an AT of 9.9 ml O2/kg/min predicted in-hospital mortality and long-term survival. Below this threshold, AT was 100% sensitive and 75.9% specific for in-hospital mortality (PPV 19%, NPV 100%). Long-term survival below the threshold of 9.9 was significantly worse when compared to those above (mortality HR 1.81). The VE/VCO2 was the most significant predictor of postoperative complications and a threshold of 34.5 provided 84% specificity and 47% sensitivity (PPV 76%, NPV 60%). Amongst the high-risk pancreaticoduodenectomy patients, VE/VCO2 was the single most predictive marker of in-hospital postoperative mortality with an AUC of 0.850 (p=0.020); a threshold value 41 was 75% sensitive and 94.6% specific (PPV 50%, NPV 98.1%). The VE/VCO2 41 was also the only predictor of poor long-term survival (HR 1.90). Notably, AT, Revised Cardiac Risk Index and Glasgow Prognostic Score did not predict outcome after pancreaticoduodenectomy. Patients with malignant obstructive jaundice, evaluated for peripheral oxygen extraction using CPET, showed lower mean peak oxygen consumption (peak VO2) at 63±17.4% of the predicted value. This was noted in absence of any significant pre-existing cardiopulmonary disease and normal respiratory reserve. Normal patterns of oxygen extraction were seen at rest, during incremental work rate and peak exercise levels. Levels of oxygen partial pressure and saturation exceeded baseline values after exercise signifying normal microcirculatory responses. Thus, aerobic capacity was limited by dysfunction in delivery (cardiac output) rather than oxygen extraction. CPET provides useful prognostic adjuncts for early and long-term outcomes in the high-risk patients undergoing major hepatobiliary surgery. These findings provide useful tools for perioperative optimisation of the high-risk patient and plan appropriate level of postoperative care to address mortality and morbidity after surgery.