[Truncated abstract] Cardiac surgery involving cardiopulmonary bypass is a complex procedure that results in significant changes to blood coagulation, fibrinolytic biochemistry, platelet number and function, and the vasculature. These are due to pharmacological agents which are administered, haemodilution and contact of the blood with artificial surfaces. Consequently there are significant risks of thrombosis and haemorrhage associated with this procedure. The research presented in this thesis utilises in vitro, in vivo, and a novel ex vivo model to investigate the nature of the haemostatic defect induced by cardiopulmonary bypass. The components studied include the drugs heparin, protamine sulphate, and aprotinin, different types of bypass circuitry (including heparin bonded circuits) and procedures such as acute normovolaemic haemodilution. Patient variables, such as Factor V Leiden, are also studied. Each of these components is assessed for the effects on a number of laboratory measures of haemostasis including activated partial thromboplastin time, prothrombin time, activated protein C ratio, antithrombin concentration, heparin concentration, thrombin-antithrombin complex formation, prothrombin fragment 1+2 formation, markers of platelet surface activation and secretion, activated clotting time, haemoglobin concentration and coagulation factor assays.

Sleep disruption has been implicated in morbidity after major surgery since 1974. Sleep-related upper airway obstruction has been associated with death after upper airway surgery and profound episodic hypoxaemia in the early postoperative period. There is also evidence for a rebound in rapid eye movement (REM) sleep that might be contributing to an increase in episodic sleep-related hypoxaemic events later in the first postoperative week. Speculation regarding the role of REM sleep rebound in the generation of late postoperative morbidity and mortality has evolved into dogma without any direct evidence to support it. The research presented in this thesis involved two main areas: a search for evidence of a clinically important contribution of REM sleep rebound to postoperative morbidity, and a re-examination of the role of sleep in the causation of postoperative episodic hypoxaemic events. To assess the latter, a relationship between airway obstruction under anaesthesia and the severity of sleep-disordered breathing was sought. In 148 consecutive sleep clinic patients, 49% of those with sleep-disordered breathing (SDB) had a number of events in non-rapid eye movement sleep (NREM) that was greater than or equal to that in REM and 51% had saturation nadirs in NREM that were equal to or worse than their nadirs in REM. This suggests SDB is not a REM-predominant phenomenon for most patients. Of 1338 postoperative deaths occurring over 6.5 years in one hospital only 37 were unexpected, most of which were one or two days after surgery with no circadian variation in the time of death, casting further doubt on the potential role of REM rebound. Five of nine subjects studied preoperatively had moderately severe SDB. Unrecognised and significant SDB is common in middle-aged and elderly patients presenting for surgery suggesting overall perioperative risk of important adverse events from SDB is probably small. In 17 postoperative patients, sleep macro-architecture was variably altered with decreases in REM and slow wave sleep while stage 1 sleep and a state of pre-sleep onset drowsiness, both associated with marked ventilatory instability, were increased. Sleep micro-architecture was also changed with an increase in power in the alpha-beta electroencephalogram range. These micro-architectural changes result in ambiguity in the staging of postoperative sleep that may have affected the findings of this and other studies. Twenty-four subjects with airway management difficulty under anaesthesia were all found to have some degree of SDB. Those with the most obstruction-prone airways while anaesthetised had a very high incidence of severe SDB. Such patients warrant referral to a sleep clinic.

<p>Smärta är ett fenomen som inte bara påverkar patienter fysiskt utan även psykiskt. Kvinnor som genomgått mastektomi upplever att smärta påverkar deras livskvalité. Humörsvängningar, dålig sömn, depression, ångest och rörelsehinder är vanligt förekommande symtom som följd på postoperativ smärta. Syftet: Syftet med denna studie var att belysa vad sjuksköterskan kan ge för olika behandlingar och omvårdnadsåtgärder vid smärta efter mastektomi. Metod: Studien genomfördes som en litteraturstudie där författarna granskade sexton vetenskapliga studier. Resultat: Resultatet i studien visade att god kommunikation, information och sjuksköterskans kunskap är grundförutsättningar för att kunna ge adekvat smärtbehandling. Oro förstärker den postoperativa smärtan och genom att i ett tidigt stadium få patienten trygg kan depression och ångest undvikas. Konkreta behandlingsmetoder med god effekt på smärta som framkommer i studien är individuella rehabiliteringsprogram, PCA pump och att tidig hemgång i många fall bidrar till bättre livskvalité. Det som även framkom i studien var avsaknaden av forskning kring konkreta behandlingsmetoder trots att efterfrågan är stor.</p> / <p>Pain is a phenomenon which not only affects patients physically but also mentally. Women who have undergone mastectomy feel that pain affects their quality of life. Mood swings, poor sleep, depression, anxiety and physical impairments are common symptoms that result in postoperative pain. The purpose: The purpose of this study was to illustrate what different treatments and nursing treatments the nurse can give in pain after mastectomy. Method: The study was conducted as a literature study where the authors examined sixteen scientific studies. Results: The results of the study showed that good communication, information, and the nurse's knowledge are vital to be able to provide adequate pain treatment. Concern reinforces the post-operative pain, and through early secures the patients anxiety and depression can be avoided. Concrete treatment methods with good effect on the pain that emerges in this study are individual rehabilitation, PCA pump, and that early outcomes in many cases contributes to a better quality of life. What also emerged in the study was the lack of research into practical treatments, despite high demand.</p>

Postoperative heart failure (PHF) remains a major determinant of the outcome after cardiac surgery. However, characteristics of and risk factors for PHF after valve surgery have received little attention. Post-ischaemic disturbances of myocardial metabolism that may contribute to PHF and are amenable to metabolic treatment have been identified early after coronary surgery (CABG). Knowledge derived from these studies may not be applicable to other patient groups. We therefore studied myocardial energy metabolism in 20 elective patients undergoing aortic valve replacement (AVR) for isolated aortic stenosis (AS). The metabolic studies indicated that myocardial oxidative metabolism had not fully recovered when the procedure was completed. Free fatty acids were the only major substrates taken up by the heart. Signs of preoperative and postoperative metabolic adaptation with substantial uptake of glutamate, previously demonstrated in patients with coronary artery disease, were found. Postoperative infusion of glutamate, (2 mL/kg body weight and hour of 0.125 M solution) based on assessment of myocardial glutamate requirements in CABG patients, resulted in a two-fold increase in myocardial glutamate uptake and a seven-fold increase in AV differences across the leg. This was associated with a significant myocardial uptake of lactate and metabolic changes in the leg suggesting mitigation of net amino acid loss and peripheral tissue lipolysis. Characteristics of and risk factors for PHF were evaluated in 398 patients undergoing isolated AVR for AS from 1 January 1995 to 31 December 2000. These were compared with 398 patients, matched for age and sex, undergoing on-pump isolated CABG. Forty-five AVR and 47 CABG patients fulfilled criteria for PHF and these were studied in detail. PHF usually presented at weaning from cardiopulmonary bypass. After CABG it was closely associated with preoperative ischaemic events and intraoperatively acquired myocardial infarction. Potential causes and eliciting events of PHF after AVR for AS were obvious only in one-third of the patients. Risk factors for PHF after AVR for AS indicated either pre-existing myocardial dysfunction, increased right or left ventricular after-load, or intraoperatively acquired myocardial injury. PHF was associated with high early mortality after CABG, whereas the consequences of PHF after AVR for AS became evident only with time, resulting in a 42% five-year mortality. Although PHF had a different temporal impact on late mortality after CABG and AVR for AS, it emerged as the statistically most significant risk factor for mortality occurring within 5 years from surgery both after AVR for AS and after CABG. Potential implications of our findings include needs for greater focus on preoperative surveillance of patients with AS for optimal timing of surgery, mitigation of intraoperatively acquired myocardial injury and tailoring of treatment for PHF. Furthermore, the findings have implications for long-term follow up of AS patients after surgery.

Tonsillectomy is one of the most frequently performed surgical procedures in children and youths. The aim of this thesis was to study children and youths in relation to tonsil surgery with the goal of improving the care, and to describe partial tonsillectomy/tonsillotomy (TT) using radiofrequency technique (RF) (Ellman International) in comparison with the more commonly used total tonsillectomy (TE). The thesis covers studies of wo age-groups with obstructive problems, with or without recurrent tonsillitis. Randomization to surgery was done from the existing waiting list; 92 children, 5-15 years old to 49/TT and 43/TE, (I-III) and 76 youths, 16-25 years old to 32/TT and 44/TE (IV-V). The first purpose (I, IV) was to compare the two surgical techniques with respect to pain and postoperative morbidity. Pain measures were for the children the Face Pain Scale and for the youths and parents and staff a verbal-pain-rating-scale. From the first day, the TT-groups scored significantly less pain than the TE-groups. The doses of pain-killing drugs (paracetamol and diclofenac) taken were significantly less for the children and youths receiving the TT-surgery, they could stop taking pain-killers sooner, and were back to normal activity three (5-15yrs) or four (16-25yrs) days earlier compared with TE-groups. Paper II focused on the child’s behavior (Child Behavior Checklist/CBCL), experience of pain, anxiety (State-Trait-Anxiety Inventory for Children /STAIC), previous experiences of surgery/tonsillitis, and the management of pain. The children scored higher on CBCL than a normative group before surgery, but no connection was observed between CBCL rating and experience of pain reported post surgically. There was no relation between preoperative anxiety and reported pain, but the postoperative anxiety level correlated with pain. The Egroup scored higher anxiety after surgery. Previous experience of surgery or tonsillitis did not influence the postoperative pain. The nurses scored pain lower than the parents/children and under-medicated. The second purpose was to compare the long-term effects of TT and TE-surgery after one and three years (5-15yrs) and one year (16-25yrs) (III, IV). The effect on snoring was the same for both TT and TE-groups and the rate of recurrence of throat infections was low after both surgical techniques. After one year, all children (TT/TE) showed improvements on CBCL to the same degree and there was no longer a difference between total behavior and normative values. They also scored improvements in health-related quality of life (HRQL) with Glasgow-Children-Benefit-Inventory. For both TT and TE, the older group reported lower HRQL preoperatively on all dimensions of Study-Short-Form (SF-36) compared with a normal population. After one year, a large improvement was found in HRQL in both groups and there were no differences compared with a normal population. Conclusion: Preoperative obstructive problems, in combination with recurrent tonsillitis have a negative impact on HRQL. Both after TE and TT there are large improvements in HRQL, infections, obstructive, and behavior problems one to three years after surgery, indicating that both surgical methods are equally effective. With fewer postoperative complications, less pain, shorter recovery time, and lower cost, TT with RF should be considered as method of choice.

Postoperativ smärta fortsätter att vara ett stort och svåridentifierat problem. Omfattningen av okontrollerad smärta hos patienterna har inte förändrats märkbart de senaste decennierna. Sjuksköterskor tenderar att underskatta patientens smärta. Syftet med denna studie är att undersöka olika faktorer som påverkar sjuksköterskans sätt att bedöma postoperativ smärta. För att uppnå vårt syfte valdes litteraturstudie som metod. Sökning av litteraturen gjordes utifrån syfte och problemformulering i databaserna Academic Search Elite, CINAHL och SweMed +. Sex artiklar valdes ut och analyserades i fem steg. I resultatet framkommer sju faktorer som påverkar sjuksköterskans sätt att bedöma postoperativ smärta: kommunikation, erfarenheter och attityder, sjuksköterskans kunskap, information och förberedelser, att tolka smärta, hinder i smärtbedömningen och uppföljning av smärtbedömningen. Trots att omfattande forskning finns inom detta område, bör forskning bedrivas även i framtiden. En utökad smärtutbildning för sjuksköterskor kan vara gynnsamt. / Postoperative pain is still a major problem that is difficult to identify. The extent of uncontrolled pain in patients has not improved noticeably over the last decades. Nurses tend to underestimate the patients pain. The aim of this study was to examine factors influencing nurses’ assessment of postoperative pain. To obtain the aim a literature review was chosen. Search of literature was carried out in the databases: Academic Search Elite, CINAHL, SweMed +. Six articles were analysed according to a five-step- method. The result of the selected articles showed seven factors influencing how nurses assess postoperative pain: communication, experiences and attitudes, nurses knowledge, information and preparation, to interpreting pain, obstacles in pain assessment and following-up the pain assessment. Despite extensive research in this subject, there is a need for the research to continue. It would be favourable to increase the pain education for nurses.

Syfte: Sammanställa och granska studier gällande postoperativ behandling vid ruptur av ligament patella. Detta för att beskriva effekt och kvalitet på studier om postoperativ behandling. Metod: En beskrivande litteraturstudie valdes som design, med sökorden: patellar ligament, patellar tendon, rupture, knee injuries, surgery. Av totalt 1240 träffar valdes 13 relevanta artiklar publicerade mellan 1999-2013 efter sökningar i databaserna PubMed, PEDro, COCHRANE, SCOPUS, CINAHL, SPORTDiscus och AMED. Artiklarna kvalitetsgranskades enligt PEDro scale. Resultat: Två postoperativa behandlingar beskrevs, tidig och sen mobilisering. Antingen placeras knäleden i ett stabiliserande knäskydd som till en början låser knäleden i full extension eller så påbörjas tidig mobilisering av den opererade knäleden. Ingen signifikant skillnad påvisades mellan tidig och sen mobilisering vad gäller effekten på muskelstyrka, rörelseomfång och återgång till tidigare aktivitetsnivå. Vidare var kvaliteten på de granskade artiklarna genomgående låg (PEDro scale ≤ 5). Konklusion: Ytterligare forskning krävs för att fastställa vilken postoperativ behandling som ger bäst effekt. / Objective: Summarize and examine studies regarding postoperative treatment following rupture of the patellar ligament. Further the aim was to evaluate the effect of the postoperative treatment and the quality of the studies. Method: As design, a descriptive review was chosen, keywords: patellar ligament, patellar tendon, rupture, knee injuries, surgery. From a total of 1240 items, 13 relevant articles published 1999-2013 were selected after search in the databases PubMed, PEDro, COCHRANE, SCOPUS, CINAHL, SPORTDiscus and AMED. The articles were quality-graded according to PEDro scale. Results: Two postoperative treatments were described, early and delayed mobilization. There was no significant difference between them regarding the effect on muscle strength, range of motion and return to preinjury level of activity. The quality-graded articles had overall low quality (PEDro scale ≤ 5). Conclusion: Further researches are required to determine which postoperative treatment has the best effect.

No description available.

No description available.

The aim of this study was to elucidate day surgery patients´ subjective experiences of postoperative pain after orthopedic and abdominal surgery and if there was any difference in the experience according to sex and age. Selection was not random and the study included 87 patients. Data were collected from patient questionnaires. VAS method was applied in the questionnaire to measure patients´ pain. The outcomes of the study show that there was no significant difference between women´s and men´s experiences of pain during days 1-7. It was found that patients undergoing orthopedic surgery had significantly more pain on day 7 compared to those patients who underwent abdominal surgery. There was a significant negative correlation between age and perceived pain on day 7. Patients in day surgery group had significantly less pain on day 7 compared with day 1. The patients who have undergone orthopedic surgery and younger patients had more pain on day 7 while the patients in day surgery group had a pain level decreased gradually and on day 7 was the lowest. It appears that pain relief on day 7 of younger patients and patients who have undergone orthopedic surgery is an area that can be improved.