In selected patients, surgical treatments such as cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have enabled curative treatment options for previously incurable diseases, such as peritoneal carcinomatosis (PC). The introduction of resource demanding surgery could affect the work process, efficiency, and productivity within a surgical department and factors influencing patient postoperative recovery processes may have an impact on the efficiency of patient care after major surgery. The aim of this thesis was to investigate operating room efficiency from the perspective of both staff and leaders’ in two different settings (Papers I and II) and the early postoperative recovery of patients with peritoneal carcinomatosis (Papers III and IV). Interviews were held with 21 people in a county hospital and 11 members of the PC team in a university hospital, and a phenomenographic approach was used to analysis the data (Papers I and II). The patients’ postoperative recovery and pulmonary adverse events (AE) were determined from data retrieved from the electronic health records of 76 patients (Papers III and IV). The concept of efficiency was understood in different ways by staff members and their leaders (Paper I). However, when working in a team, the team members had both organisation-oriented and individual-oriented understanding of efficiency at work that focused on the patients and the quality of care (Paper II). The patients with PC regained gastrointestinal functions and could be mobilised during early postoperative recovery phase, although many patients suffered from psychological disturbances, sleep deprivation, and nausea (Paper III). Postoperative clinical and radiological pulmonary AE were common, but did not affect the early recovery process (Paper IV). In conclusion, leaders who are aware of the variation in understanding the concept of efficiency are better able to create the same platform for staff members by defining the concept of efficiency within the organisation. In a team organisation, the team members have a wider understanding of the concept of efficiency with more focus on the patients. The factors affecting postoperative recovery and pulmonary AE should be considered when designing individualised patient care plans in order to attain a more efficient recovery.

Bakgrund: Utvecklingen inom kirurgi och anestesi har bidragit till att allt fler operationer utförs dagkirurgiskt då det minskar sjukhusvistelse för patienten och är kostnadseffektivt för vården. Det finns många fördelar med dagkirurgiska ingrepp men nackdelen är att ansvaret för den postoperativa återhämtningen läggs på patient och eventuella anhöriga att bevaka. Det är viktigt att vården förbereder patient och anhöriga inför hemgång med specifik information och instruktioner utifrån patientgrupp för att patienterna ska känna sig trygga. Syfte: Att studera postoperativ återhämtning efter dagkirurgisk operation. Metod: Studien har en randomiserad kontrollerad design. Studien omfattade 565 patienter som randomiserats till en interventions- och kontrollgrupp. Alla inkluderade svarade på Svensk Post-discharge Surgical Recovery Scale preoperativt och dag 28 postoperativt. Interventionsgruppen svarade även på mobilfrågor dag 1 – 14, 21 och 28 postoperativt. Resultat: I resultatet framkom att kvinnor hade sämre återhämtning jämfört med män och att den postoperativa återhämtningen skiljde sig mellan olika operationsgrupper. Ortopedpatienterna behövde längre tid för återhämtning, hade mer smärta, mer behov av vila, sämre rörlighet och behövde mer hjälp med ADL än övriga grupper. Det positiva med resultatet var att alla patienter uppgav lite besvär med illamående och yrsel vilket kan tyda på att patienterna fått bra PONV profylax inför hemgång. Konklusion: Författarna anser att det behövs fler studier som undersöker kvinnors postoperativa återhämtning. Resultatet styrker att ortopediska patienter kan behöva mer uppföljning efter hemgång och att mer specifik information utifrån ingrepp kan höja kvaliteten inom dagkirurgisk vård.

Introdução: O nível de segurança da anestesia moderna permitiu um novo tipo de investigação clínica com revelação de novo indicador em saúde, obtido pela abordagem de aspectos subjetivos gerados a partir das opiniões dos próprios pacientes. Foram objetivos deste estudo: verificar a qualidade de recuperação e os níveis de satisfação com período pós-operatório de pacientes adultos submetidos à anestesia geral, no Hospital de Reabilitação de Anomalias Craniofaciais da Universidade de são Paulo (HRAC-USP). Método: Após aprovação do comitê de ética e obtenção do consentimento informado, foram avaliados 305 pacientes com fissuras de lábio e palato, maiores de 18 anos, submetidos à anestesia geral para cirurgias plásticas. O escore QoR-40 e escala visual analógica (VAS) de 100 mm foram usados para medida do estado de saúde, nível de satisfação e nível de dor nas primeiras 24 horas do período pós-operatório. Os pacientes foram entrevistados na enfermaria após pleno despertar, em um tempo nunca inferior a seis horas após alta da SRPA. O QoR-40 original em Inglês foi traduzido e adaptado à cultura brasileira. O QoR-40 é composto por 40 perguntas simples que abrangem cinco dimensões: bem-estar físico, estado emocional, independência física, apoio psicológico e dor; a pontuação mínima possível é de 40 e a máxima é de 200. Resultados: Após ajustes para a análise estatística, devido à distribuição da amostra, os dados dos 305 pacientes foram analisados. A versão brasileira do QoR-40 apresentou propriedades psicométricas aceitáveis: validade convergente entre QoR-40 e escala analógica visual para nível de satisfação (r = 0,79, p <0,0001); confiabilidade testereteste (r = 0,94; p <0,0001) e consistência interna ( Cronbach = 0,90). A resposta média padronizada quanto ao escore total e subscores variou de 0,2 a 0,5. Fatores preditivos de nível de satisfação abaixo do valor da mediana foram: sexo feminino, tempo em SRPA e esquema analgésico com cetoprofeno. O nível global de satisfação foi elevado (média QoR-40 total ). O mínimo QoR-40 pontuação encontrada foi de 138, o valor da mediana foi de 196. Houve uma correlação negativa entre dor e pontuação QoR-40 total. Conclusão: A versão brasileira do QoR-40 apresentou propriedades psicométricas adequadas e revelou um nível de satisfação elevado quanto ao período pósoperatório. Houve correlação entre dor pós-operatória e diminuição na pontuação total de QoR-40; e o esquema analgésico utilizando cetoprofeno foi fator preditivo de menor pontuação total de QoR-40. / Introduction: the modern anesthesia safety levels allowed a new kind of research using patient-focused assessments as new health indicators. This study aimed to check the quality of recovery and satisfaction levels of adult patients undergoing general anesthesia at the Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo (HRAC-USP). Method: After obtaining ethics committee approval and consent, 305 cleft lip and palate patients aged more than 18 yr, who underwent general anesthesia for plastic surgeries were approached. A 40-item quality of recovery score (QoR-40) and a 100- mm visual analog scale (VAS) were used to measure health status, satisfaction level and pain level on first 24 hours of the postoperative period. Patients were interviewed on the ward after full awakening, in a time never less than six hours after Post-Anesthesia Care Unit discharge .The original english QoR-40 questionnaire was translated and adaptated to Brazilian culture. The QoR-40 has 40 simple questions that cover five dimensions: physical comfort, emotional state, physical independence, psychological support and pain. The minimum score possible is 40 and the maximum is 200. Results: After adjustments for statistical analysis due to the sample distribution the 305 patients data were analysed. The Brazilian version of QoR-40 psychometric properties were acceptable: convergent validity between QoR-40 and 100-mm visual analog scale (r=0,79; p<0,0001); test-retest reliability (r=0,94; p<0,0001); and internal consistency (Cronbach =0,90). Regarding global QoR-40 score and subscores the standardized means ranged from 0,2 to 0,5. Predictive factors of satisfaction level under median value were feminine sex, PACU time and analgesic scheme using ketoprofen. The overall level of satisfaction was high (mean QoR-40 scores 193.3; standart deviation 9.2). The minimum QoR-40 score found was 138; the median scorevalue was 196. There was a negative correlation between pain level and global QoR-40 score. Conclusion: The Brazilian version of QoR-40 showed adequate psychometric properties; a high level of satisfaction with the postoperative period was observed. Postoperative pain was correlated with a decrease in global QoR-40 score; the analgesic scheme using ketoprofen was predictive of lower global QoR-40 scores.

Introdução: O nível de segurança da anestesia moderna permitiu um novo tipo de investigação clínica com revelação de novo indicador em saúde, obtido pela abordagem de aspectos subjetivos gerados a partir das opiniões dos próprios pacientes. Foram objetivos deste estudo: verificar a qualidade de recuperação e os níveis de satisfação com período pós-operatório de pacientes adultos submetidos à anestesia geral, no Hospital de Reabilitação de Anomalias Craniofaciais da Universidade de são Paulo (HRAC-USP). Método: Após aprovação do comitê de ética e obtenção do consentimento informado, foram avaliados 305 pacientes com fissuras de lábio e palato, maiores de 18 anos, submetidos à anestesia geral para cirurgias plásticas. O escore QoR-40 e escala visual analógica (VAS) de 100 mm foram usados para medida do estado de saúde, nível de satisfação e nível de dor nas primeiras 24 horas do período pós-operatório. Os pacientes foram entrevistados na enfermaria após pleno despertar, em um tempo nunca inferior a seis horas após alta da SRPA. O QoR-40 original em Inglês foi traduzido e adaptado à cultura brasileira. O QoR-40 é composto por 40 perguntas simples que abrangem cinco dimensões: bem-estar físico, estado emocional, independência física, apoio psicológico e dor; a pontuação mínima possível é de 40 e a máxima é de 200. Resultados: Após ajustes para a análise estatística, devido à distribuição da amostra, os dados dos 305 pacientes foram analisados. A versão brasileira do QoR-40 apresentou propriedades psicométricas aceitáveis: validade convergente entre QoR-40 e escala analógica visual para nível de satisfação (r = 0,79, p <0,0001); confiabilidade testereteste (r = 0,94; p <0,0001) e consistência interna ( Cronbach = 0,90). A resposta média padronizada quanto ao escore total e subscores variou de 0,2 a 0,5. Fatores preditivos de nível de satisfação abaixo do valor da mediana foram: sexo feminino, tempo em SRPA e esquema analgésico com cetoprofeno. O nível global de satisfação foi elevado (média QoR-40 total ). O mínimo QoR-40 pontuação encontrada foi de 138, o valor da mediana foi de 196. Houve uma correlação negativa entre dor e pontuação QoR-40 total. Conclusão: A versão brasileira do QoR-40 apresentou propriedades psicométricas adequadas e revelou um nível de satisfação elevado quanto ao período pósoperatório. Houve correlação entre dor pós-operatória e diminuição na pontuação total de QoR-40; e o esquema analgésico utilizando cetoprofeno foi fator preditivo de menor pontuação total de QoR-40. / Introduction: the modern anesthesia safety levels allowed a new kind of research using patient-focused assessments as new health indicators. This study aimed to check the quality of recovery and satisfaction levels of adult patients undergoing general anesthesia at the Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo (HRAC-USP). Method: After obtaining ethics committee approval and consent, 305 cleft lip and palate patients aged more than 18 yr, who underwent general anesthesia for plastic surgeries were approached. A 40-item quality of recovery score (QoR-40) and a 100- mm visual analog scale (VAS) were used to measure health status, satisfaction level and pain level on first 24 hours of the postoperative period. Patients were interviewed on the ward after full awakening, in a time never less than six hours after Post-Anesthesia Care Unit discharge .The original english QoR-40 questionnaire was translated and adaptated to Brazilian culture. The QoR-40 has 40 simple questions that cover five dimensions: physical comfort, emotional state, physical independence, psychological support and pain. The minimum score possible is 40 and the maximum is 200. Results: After adjustments for statistical analysis due to the sample distribution the 305 patients data were analysed. The Brazilian version of QoR-40 psychometric properties were acceptable: convergent validity between QoR-40 and 100-mm visual analog scale (r=0,79; p<0,0001); test-retest reliability (r=0,94; p<0,0001); and internal consistency (Cronbach =0,90). Regarding global QoR-40 score and subscores the standardized means ranged from 0,2 to 0,5. Predictive factors of satisfaction level under median value were feminine sex, PACU time and analgesic scheme using ketoprofen. The overall level of satisfaction was high (mean QoR-40 scores 193.3; standart deviation 9.2). The minimum QoR-40 score found was 138; the median scorevalue was 196. There was a negative correlation between pain level and global QoR-40 score. Conclusion: The Brazilian version of QoR-40 showed adequate psychometric properties; a high level of satisfaction with the postoperative period was observed. Postoperative pain was correlated with a decrease in global QoR-40 score; the analgesic scheme using ketoprofen was predictive of lower global QoR-40 scores.

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.

Bakgrund: Akut postoperativ smärta är en vanlig men också förväntad konsekvens efter kirurgiska ingrepp som ger negativ påverkan på den efterföljande postoperativa återhämtningen. Syfte: Syftet med studien var att undersöka genomsnittlig självskattad smärtintensitet som gav vuxna patienter problem med att vila, sova och röra sig under det första postoperativa dygnet samt om det hos män/kvinnor, yngre/äldre och kirurgi/ortopedpatienter förekom olika hanterbara smärtnivåer i förhållande till vila och aktivitet under tidig postoperativ återhämtning. Metod: En kvantitativ empirisk deskriptiv studie genomfördes av ett datamaterial från 479 elektiva kirurg- och ortopedpatienter. Resultat: Resultatet visade att ortopedpatienterna i genomsnitt skattade högre värden av smärta jämfört med kirurgpatienterna men att kirurgpatienterna redan vid låga smärtnivåer fick problem med vila, sömn och rörelse. Slutsats: Resultatet understryker att smärta är en subjektiv upplevelse och att smärtbehandlingen i hög grad behöver individualiseras för att därigenom minska smärtans negativa effekter, förbättra den tidiga postoperativa återhämtningen och därmed öka patientsäkerheten. / Background: Acute postoperative pain is a common but also expected consequence after surgery that gives negative impact on the following postoperative recovery. Study objectives: The purpose was to investigate the average level of self-assessed intensity of pain that gave adult patients problem to rest, sleep or mobilize during the first postoperative day and if men/women, younger/older and surgical or orthopedic patients had different manageable levels of pain related to rest, sleep and mobilization during the early postoperative recovery. Design: A quantitative empirical descriptive study was performed from datasets from 479 elective surgical and orthopedic patients. Results: The result showed that the orthopedic patients self-assessed higher levels of postoperative pain than the surgical patients, but also that the surgical patients earlier got problems with recovery at low pain levels.  Conclusions: The result underlines that pain is a subjective experience and that the pain treatment has to be individualized just to prevent the negative impact of pain but also to enhance the postoperative recovery and improve patient safety.

Generell anestesi kan ges som inhalationsanestesi eller total intravenös anestesi (TIVA). En förutsägbar anestesi med snabbt uppvaknande och bibehållen vakenhet är en högt önskvärd egenskap oavsett anestesiform. Det råder en klinisk och vetenskaplig diskussion om vilken anestesiform som ger snabbast tidig postoperativ återhämtning. syftet med studien var att jämföra patienters tidiga postoperativa återhämtning efter inhalationsanestesi respektive efter total intravenös anestesi (TIVA). Metoden var en litteraturstudie baserad på 15 vetenskapliga artiklar. Dessa analyserades utifrån frågeställningen: Vilken anestesiform som ger den snabbaste tidiga postoperativa återhämtningen. Det framkom en indelning av resultatet i tre kategorier: snabbare tidig postoperativ återhämtning efter inhalationsanestesi, lika lång tid till återhämtning efter inhalationsanestesi som efter TIVA samt snabbare tidig postoperativ återhämtning efter TIVA. Resultatet visade att inhalationsanestesi gav snabbast tdiig postoperativ återhämtning. Anestesisjuksköterskans handhavande, planering och erfarenhet påverkar patientens uppvakande. därför skulle vidare forskning istället jämföra dessa båda anestesiformer på ett annat sätt. Tiden kunde istället mätas från det att anestesisjukskäterskan extuberat patienten och till payienten verkar adekvat orienterad för att erhålla ett mer jämförbart resultat. / General anesthesia includes both inhalations anesthesia and total intravenous anesthesia (TIVA). After any anesthetic technique a de sirable characteristics is a predictably rapid emergence and sustained alertness. There is a clinical and scientific debate about which anesthetic technique who gives the most rapid emergence in the early postoperative recovery. The aim of this study was to compare patients early postoperative recovery after inhalations anesthesia and after total intravenous anesthesia (TIVA). The methods are based on 15 research articles. They where analysized from the questionnaire: which anesthetic technique gives the most rapid emergence in the early postoperative recovery. The results showed that inhalations anesthesia gave the most rapid emergence in the earky postoperative recovery. The nurse anesthetist handling, planning and experience affect the patients awakening. Therefore further research instead could compare these anesthetic techniques in another way. The time after the nurse anesthetist has extubate the patient until the patient is adequate orientated, could be measured to find a more comparable result.

Introduction: Hysterectomy is the most common major gynecological operation in the Western World and approximately 5000 benign hysterectomies are performed in Sweden every year. Consequently it is a surgical procedure that affects many women. The procedure comprises challenges concerning perioperative health care, perceived postoperative symptoms, quality of life aspects and health economics. The concept of fast track is a multimodal strategy to reduce hormonal surgical stress response and achieve an enhanced postoperative recovery and is today considered to be evidence based in relation to colorectal surgery. Spinal anesthesia, as an important part of fast track, provides benefits of extended effect on analgesia and reduced postoperative morbidity. It is reasonable to believe that employing the strategies of fast track including spinal anesthesia could also provide substantial benefits for women requiring surgical removal of the uterus. Aims: To determine whether duration of hospital stay, presence and intensity of postoperative symptoms, duration of sick leave and cost-effectiveness differ between women undergoing benign fast track abdominal hysterectomy in spinal anesthesia with intrathecal morphine (SA) and in standard general anesthesia (GA). Material &amp; Methods: 180 women participated in this open randomized multicenter study with five participating hospitals in the southeast region of Sweden. One hundred and sixty two completed the study; 82 women were randomized to SA and 80 to GA. A fast track model comprising premedication without sedatives, intravenous fluid regulation, analgesics based on non-opioids, pre-emptive antiemetic therapy, early enteral nutrition and mobilization and standard criteria for discharge were used. End points were duration of hospital stay, use of analgesics, perceived postoperative symptoms, occurrence of postoperative complications, duration of sick leave and health economic evaluations. Results: Duration of hospital stay did not differ between the two modes of anesthesia. Vomiting and pruritus occurred significantly more often after SA. Complication rates did not differ between groups. Women with SA experienced less overall discomfort and had a reduced need for opioids postoperatively. Abdominal pain, drowsiness and fatigue occurred less often and with lower intensity among the women in the SA group. Health related quality of life improved faster and the duration of sick leave was shorter in women after SA. Total costs (hospital costs plus costs for productivity loss) were lower for the SA group. Within the first 29 days after hysterectomy the women in the SA group gained more QALYs than women in the GA group. Conclusions: The duration of hospitalisation after fast track abdominal hysterectomy was less than 50 hours and mode of anesthesia did not influence this. SA displayed considerable advantages regarding postoperative symptoms and recovery. SA was considered cost-effective in comparison with GA due to lower total costs and more QALYs gained. Our study indicates that SA should be recommended as the first choice of anesthesia in benign abdominal hysterectomy.

Intravenös anestesi med Propofol eller inhalationsanestesi med gasen Sevofluran är de två vanligaste anestesiformerna i Sverige. Syftet med studien vara att undersöka om patienters postoperativa återhämtning skiljer sig åt beroende på om de sövts med Propofol eller Sevofluran. Datainsamlingen till studien genomfördes med systematisk litteraturöversikt baserad på integrativ metod. Både kvalitativa och kvantitativa studier samlades in, men enbart kvantitativa artiklar inkluderades. Resultatet visade att det under den postoperativa återhämtningen var vanligt förekommande med två postoperativa komplikationer, smärta samt illamående och kräkningar. Resultatet visar inga statistiskt signifikanta skillnader när det gällde dessa beroende på val av anestesimedel. Men vidare studier behövs inom ämnet, framför allt om kön eller ålder kan vara ytterligare påverkande faktorer. / Intravenous anesthesia with Propofol or inhalation anesthesia with the gas Sevoflurane are the two most common forms of anesthesia in Sweden. The purpose of the study was to investigate whether patient's postoperative recovery differs depending on whether they have been anesthetized with Propofol or Sevoflurane. The data collection for the study was carried out with a systematic literature review based on integrative research Both qualitative and quantitative studies were collected, but only quantitative articles were included. The results showed that during postoperative recovery it was common with two postoperative complications, pain, nausea, and vomiting. The results show no statistically significant differences in these depending on the choice of anesthetic agents. However, further studies are needed in the subject, especially if gender or age can be additional influencers.

Total hip replacement is one of the most common surgeries in orthopedics. Complete hip replacement can be addressed with several different types of surgical approaches. In this work we deal mainly with the anterior and anterolateral approach. The theoretical part of this work summarizes the basic knowledge about the anatomy, kinesiology of the hip joint and the prearthrotic causes leading to complete hip replacement. Furthermore, the types of surgical approaches, types of total endoprostheses are mentioned and the knowledge about soft tissue healing and early postoperative rehabilitation is summarized. The aim of this work is to determine whether rehabilitation will be faster in the first days after surgery in patients operated by the anterior approach, depending on the gentle approach and respect for anatomical structures, compared to the anterolateral approach. We present a group of 24 patients, 12 of whom underwent anterior approach and 12 anterolateral approach. In the practical part we evaluate and compare early postoperative rehabilitation in both approaches. The parameters we evaluate are the muscular strength of abduction, flexion and extension in the hip joint. Furthermore, the passive and active range of motion in the hip joint during abduction, flexion and extension. We also evaluate...