ABSTRAKT Bakgrund: Efter att regelbundet under studierna på sjuksköterskeprogrammet stöttpå informationen om att postoperativ mobilisering är en viktig omvårdnadsåtgärdhar författarna saknat information och kunskap kring vad för effekter denpostoperativa mobiliseringen faktiskt har på patienterna. Författarna valde attundersöka dessa effekter utifrån de patienter som undergått någon typ avbukkirurgiskt ingrepp. För att sjuksköterskor och övrig sjukvårdspersonal skallkunna arbeta evidensbaserat anser författarna att denna typ av information ärviktig att framföra och stärka med just evidens för att på ett så bra och säkert sättsom möjligt kunna implementeras i det postoperativa omvårdnadsarbetet. Syfte: Att belysa effekter av postoperativ mobilisering efter bukkirurgi. Metod: Examensarbetet är en litteraturstudie med kvantitativ ansats. Resultatetbaseras på totalt tio artiklar hämtade från databaserna Chinal, PudMed ochMedline. Alla artiklar har granskats via SBU:s kvalitetsgranskningsmall ochanalyserat enligt Fribergs (2006) analysmetod där teman och subteman skapades. Resultat: Resultatet redovisades via de teman som skapades under analysen.Längd på sjukhusvistelse, respiratorisk påverkan, cirkulatorisk påverkan ochgångförmåga. Ett samband av effekt mellan dessa teman och postoperativmobilisering efter bukkirurgi visades endast vid längd för sjukhusvistelsen, femav åtta P-värden visade på detta. Konklusion: Längden på sjukhusvistelsen sågs bli kortare hos patienter sommobiliserades postoperativt efter bukkirurgi i en högre grad än de sommobiliserades i mindre grad. Gällande övriga teman som tagits upp i studien krävsvidare studier då ett lågt antal artiklar inkluderade dessa och författarna anser attfler artiklar behövs för att kunna anse att resultatet är evidensbaserat. Nyckelord: Postoperativ, mobilisering, bukkirurgi. / ABSTRACT Background: During our studies at the nursing program the authors often heardand read that postoperative mobilization is an important part of postoperative care.The issue that the authors had regarding this information was that they never gotthe information regarding what kind of effect the postoperative mobilizationactually has on the patients. The authors decided to examine the postoperativeeffect of mobilization in patients that have undergone abdominal surgery. Thiskind of information is important both for nurses and other hospital staff so thatthey can work in an evidence based way and implement mobilization in a correctway in the postoperative care. Purpose: To illustrate the effect of postoperative mobilization after abdominalsurgery. Method: This is a literature study with a quantitative approach. The result is basedon ten articles retrieved from the databases, Chinal, PubMed and Medline. Allarticles have undergone a quality review template from SBU and they have alsobeen analyzed according to Fribergs ́s (2006) analysis method where themes andsub themes were created. Results: The results were presented in the themes that we created during theanalysis. Length of hospital stay, respiratory effects, circulation effects andwalking ability. The only connection that we saw was between postoperativemobilization after abdominal surgery and length of hospital stay, five out of eightP-values showed that. Conclusion: The length of stay was shorter in the patients that got mobilized morethan the patients in the test group. Regarding the other themes in this study theauthors think that it needs to be studied further with more articles to present aevidenced based result. Keywords: Postoperative, mobilization, abdominal surgery.

Gegenstand der vorliegenden Dissertation bilden persistierende und akute postoperative Schmerzen in der Herzchirurgie nach anterolateraler Thorakotomie und Sternotomie. Kardiochirurgische Eingriffe sind mit einer erwarteten hohen Schmerzintensität verbunden. Eine unzureichende Schmerzkontrolle hat sowohl psychologische als auch physiologische Konsequenzen für alle Körpersysteme, welche die Genesung der Patienten nach einer Operation beeinträchtigen. Dabei stehen mittelstarke und starke postoperative Schmerzen mit dem Auftreten von chronischen postoperativen Schmerzen in Zusammenhang. Als sicher und vorteilhaft haben sich in den meisten chirurgischen Disziplinen Operationstechniken mit einer Reduktion der Größe des Operationsgebietes erwiesen, wo die Minimierung des Gewebetraumas postoperativ zu einer weniger hoch ausgeprägten Schmerzsymptomatik führt. Zu minimalinvasiven Techniken in der Kardiochirurgie gehört unter anderem die anterolaterale Thorakotomie. Die vorliegende Studie wurde in Anbetracht mangelnder Daten zum Vergleich akuter und chronischer postoperativer Schmerzen nach Herzoperationen durch Sternotomie und anterolaterale Thorakotomie durchgeführt. Im Rahmen dieser prospektiven Studie wurden Daten von 202 Patienten analysiert, bei denen ein elektiver, kardiochirurgischer Eingriff minimalinvasiv oder konventionell mit perioperativer Betreuung gemäß dem Fast-TrackKonzept durchgeführt worden ist. Die aufgetretene Schmerzintensität sowie der Schmerzmittelbedarf wurden bis hin zu der Krankenhausentlassung sowie drei, sechs und zwölf Monate nach dem operativen Eingriff verfolgt. Die Studie kommt zu folgenden Ergebnissen: Es konnten keine signifikanten Vorteile des anterolateralen Thorakotomiezugangs im Vergleich zur Sternotomie zur kurz- oder langfristigen Schmerzlinderung unter Anwendung eines standardisierten opioidbasierten perioperativen Schmerzmanagementprotokolls nach dem Fast-Track-Konzept bei elektiven kardiochirurgischen Eingriffen festgestellt werden.:Inhaltsverzeichnis: Abkürzungsverzeichnis: 2 Bibliografische Beschreibung: 3 Einführung: 4 Akuter postoperativer Schmerz 4 1.1. Pathophysiologie 5 1.2. Konsequenzen unzureichender postoperativer Schmerzkontrolle 8 1.3. Schmerzerfassung 9 1.4. Risikofaktoren für das Auftreten starker APP 11 1.4.1. Patientenbezogene Risikofaktoren 11 1.4.2. Prozedurale Risikofaktoren 12 1.5. Therapie 14 2. Persistierender postoperativer Schmerz 17 2.1. Definition 17 2.2. Pathophysiologie 18 2.3. Konsequenzen 18 2.4. Risikofaktoren 19 2.4.1. Nichtmodifizierbare Risikofaktoren: 19 2.4.2. Modifizierbare Risikofaktoren 20 2.5. Therapie 21 3. Fast-track und ERACS Konzepte 23 3.1. Definition und Ziele 23 3.2. Rolle der Schmerzkontrolle 27 3.3. Operativer Zugangsweg als Teil der schmerzminimierenden Strategien 27 4. Die Zielsetzung der Arbeit 29 Publikationsmanuskript 30 Zusammenfassung der Arbeit 40 Literaturverzeichnis 44 Anlagen 54 Spezifizierung des eigenen Beitrags zur Publikation: 54 Erklärung zu den Beiträgen der Mitautorin bei diesem Publikationsmanuskript 55 Erklärung über die eigenständige Abfassung der Arbeit 56 Lebenslauf 57 Publikationen: 58 Mündliche und Poster Präsentationen in internationalen Kongressen: 58 Danksagung 59 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​

Bakgrund: Postoperativt delirium (POD) är ett allvarligt tillstånd som kan bidra till betydande negativa konsekvenser på både individ- och samhällsnivå. Samtidigt visar forskning att sjuksköterskor saknar kunskaper om tillståndet och känner sig osäkra i omvårdnaden relaterat till dessa patienter. Att undersöka patienternas upplevelser av POD, kan bidra till ökade kunskaper om fenomenet och i sin tur en bättre omvårdnad. Syfte: Syftet med denna litteraturstudie var att beskriva patienters upplevelser av postoperativt delirium. Metod: Resultatet baserades på åtta kvalitativa studier. Artikelsökningarna genomfördes i databaserna Cinahl, Pubmed och Scopus. Analysen utfördes med inspiration från Fribergs femstegsmodell. Resultat: Från analysen framkom fem huvudkategorier: ’’De befann sig i en förvirrande värld’’, ’’De upplevde sig isolerade och maktlösa’’, ’’De upplevde en närvaro av döden’’, ’’De upplevde ett känslomässigt kaos’’ och ’’Visuella intryck påverkade upplevelsen av delirium både positivt och negativt” Konklusion: Litteraturstudiens resultat visade att upplevelsen av POD kunde vara skrämmande och medförde en känsla av maktlöshet. Sjuksköterskan samt anhöriga hade en betydande roll för tryggheten i upplevelsen. Det behövs vidare forskning om stöd i efterförloppet av POD och undersökningar om preoperativ information. / Background: Postoperative delirium (POD) is a serious condition that can contribute to significant negative consequences at both an individual and societal level. At the same time, research shows that nurses lack knowledge about the condition and feel uncertain in the caring for these patients. A survey about patients' experiences of POD can contribute to increased knowledge of the phenomenon and may result in better care. Aim: The aim of this study was to describe patients' experiences of postoperative delirium. Methods: The result was based on eight qualitative studies. The article searches were performed in the databases Cinahl, Pubmed and Scopus. The analysis was conducted with inspiration from Friberg's five-step model. Results: The analysis revealed five main categories: ''They were in a confusing world'', ''They felt isolated and powerless'', ''They experienced a presence of death'', ''They experienced emotional chaos'' and "Visual impressions influenced the experience of delirium both positively and negatively" Conclusion: The results of the literature study showed that the experience of POD could be frightening and entailed a feeling of powerlessness. The nurse and relatives had an important role in helping the patients feel safe. Further research is needed on support in the aftermath of POD and investigations on preoperative information.

SAMMANFATTNING Introduktion: Postoperativ smärta är en naturlig följd av kirurgiska ingrepp, vilket kräver noggrann utvärdering och hantering av sjuksköterskor för att säkerställa optimal smärtlindring. Påtaglig smärtproblematik rapporteras ännu av nyopererade patienter, vilket kan resultera i påtagliga konsekvenser för både individ och samhälle. Patienters perspektiv kan ge kunskap om påverkande omständigheter och öka förståelsen för smärta.  Syfte: Syftet var att belysa patienters upplevelser av postoperativ smärta. Metod: En deskriptiv allmän litteraturöversikt med kvalitativ ansats tillämpades enligt Fribergs metod. Databaser som användes var PubMed och CINAHL. Resultat: Delaktighet och information gav patienten möjlighet att etablera trygga, realistiska förväntningar. Smärta som upplevdes oförutsedd och okontrollerad hämmade patientens återhämtning. Patientens vilja att kommunicera sin smärta påverkades av personalens tillgänglighet, engagemang, kontinuitet och attityder. Etablerade vårdrelationer underlättade kommunikationen. Smärtbedömningen varierade beroende på vilken vårdpersonal som tjänstgjorde. Det fanns blandade känslor för smärtstillande läkemedel relaterat till biverkningar och om medicineringen var tillräcklig. Patienter kompletterade smärtlindringen med icke-farmakologiska strategier där mobilisering, kyla eller värme var återkommande.  Slutsats: Postoperativ smärta kan innebära stor påfrestning för patienter, deras upplevelser är individuella och komplexa som påverkas av såväl yttre som inre omständigheter. Inom sjukvården kan utmaningar som hög arbetsbelastning bidra till otillräckligt informationsflöde och sämre patientupplevelser. Att vara välinformerad, delaktig och få personcentrerad vård med stöd från engagerad personal främjar positiva upplevelser. Genom att förstå och inkludera dessa aspekter i helhetsbilden kan det bidra till förbättrad vård för patienter med postoperativ smärta. Ytterligare forskning uppmuntras för att öka förståelsen för patientens perspektiv.  Nyckelord: omvårdnad, patientupplevelse, postoperativ smärta, påverkan, smärthantering / ABSTRACT Introduction: Postoperative pain is a natural consequence of surgical procedures, requiring careful evaluation and management by nurses to ensure optimal pain relief. Substantial pain issues are still reported by postoperative patients, impacting both the individual and society. The patient’s perspective provides valuable insights into the understanding of pain.  Aim: The aim was to illuminate patients’ experiences of postoperative pain. Method: A descriptive general literature review with a qualitative approach was applied according to Friberg’s method. The databases used were PubMed and CINAHL.  Result: Participation and information allowed the patient to establish safe, realistic expectations. Pain experienced as unexpected and uncontrollable inhibited patients’ recovery. Staff availability, commitment, continuity, and attitudes influenced patients’ willingness to communicate pain. Established care relationships facilitated communication. Pain assessment varied depending on which healthcare staff was on duty. Analgesic side effects and adequate medication received mixed feelings. Patients supplemented pain relief with non-pharmacological strategies like mobilization, cold or heat. Conclusion: Postoperative pain can be stressful for patients, their experiences are individual and complex and are affected by external as well as internal circumstances. Within healthcare challenges such as high workload can contribute to insufficient information and worse patient experiences. Being well-informed, involved and receiving person-centered care with the support of dedicated staff promotes positive experiences. Understanding and including these aspects in the overall picture can contribute to improved care for patients with postoperative pain. Further research is encouraged to increase the understanding of the patient’s perspective. Keywords: care, patient’s experience, postoperative pain, impact, pain management

No / Various techniques and drug regimes for thoracic paravertebral block (PVB) have been evaluated for post-thoracotomy analgesia, but there is no consensus on which technique or drug regime is best. We have systematically reviewed the efficacy and safety of different techniques for PVB. Our primary aim was to determine whether local anaesthetic (LA) dose influences the quality of analgesia from PVB. Secondary aims were to determine whether choice of LA agent, continuous infusion, adjuvants, pre-emptive PVB, or addition of patient-controlled opioids improve analgesia. Indirect comparisons between treatment arms of different trials were made using metaregression. Twenty-five trials suitable for metaregression were identified, with a total of 763 patients. The use of higher doses of bupivacaine (890¿990 mg per 24 h compared with 325¿472.5 mg per 24 h) was found to predict lower pain scores at all time points up to 48 h after operation (P=0.006 at 8 h, P=0.001 at 24 h, and P<0.001 at 48 h). The effect-size estimates amount to around a 50% decrease in postoperative pain scores. Higher dose bupivacaine PVB was also predictive of faster recovery of pulmonary function by 72 h (effect-size estimate 20.1% more improvement in FEV1, 95% CI 2.08%¿38.07%, P=0.029). Continuous infusions of LA predicted lower pain scores compared with intermittent boluses (P=0.04 at 8 h, P=0.003 at 24 h, and P<0.001 at 48 h). The use of adjuvant clonidine or fentanyl, pre-emptive PVB, and the addition of patient-controlled opioids to PVB did not improve analgesia. Further well-designed trials of different PVB dosage and drug regimes are needed.

<p>UVOD. Bilijarna kalkuloza je najče&scaron;će oboljenje hepatobilijarnog sistema, a holecistektomija predstavlja jedan od najče&scaron;će izvođenih operativnih zahvata. Laparoskopska holecistektomija je danas zlatni standard lečenja holelitijaze. Laparoskopska holecistektomija je pokazala pobolj&scaron;anje u klinički značajnim ishodima kao &scaron;to su skraćenje operativnog vremena, kraća hospitalizacija, smanjenje jačine i trajanja postoperativnog bola i brži povratak dnevnim i radnim aktivnostima. Postoperativna bol i vreme potpunog oporavka ostaju dva glavna problema posle nekomplikovane laparoskopske holecistektomije koje bi trebalo pobolj&scaron;ati. Bol koji je povezan sa laparoskopskom holecistektomijom je kompleksan i multifaktorijalan. On nastaje o&scaron;tećenjem tkiva, disekcijom i uklanjanjem žučne kesice iz svoje lože, stimulacijom periportalnih nerava, iritacijom dijafragme, mehaničkim i hemijskim interakcijama gasa i pneumoperitoneuma, incizijama portova. Istraživanja su označila parijetalni i visceralni bol kao dva glavna mehanizma nastanka bola kod laparoskopske holecistektomije. Bol se ne može meriti nego proceniti jer je subjektivni osećaj. Pokazalo se potrebnim da se na čvr&scaron;ćim naučnim osnovama da odgovor na pitanje da li je moguće blokirati parijetalni i visceralni bol posle laparoskopske holecistektomije u akutnoj fazi. CILJEVI. Cilj studije je da uporedi standardnu analgeziju (ne-opioidnu) (grupa O) sa davanjem parijetalne blokade (grupa P), ili davanjem visceralne blokade (grupa V), ili sa obe date blokade (grupa P+V). Primarni ishodi studije su bolesnikov procenjeni bol pre operacije i posle operacije na 1, 2, 4, 6, 12, 24, 48 sati i 7. dana. Sekundarni ishodi studije su bolesnikova procenjena mučnina na 1,2,4,6,12 sati i bolesnikova procenjena mobilnost 1. 2. i 7. dan. HIPOTEZA. Blokada postoperativnog visceralnog bola i blokada postoperativnog parijetalnog bola posle laparoskopske holecistektomije putem intraperitonealne lokalne infiltracije anestetikom i putem lokalne infiltracije anestetikom pristupnih laparoskopskih portova može značajno smanjiti rani postoperativni bol. MATERIJAL I METODE. Ova prospektivna, randomizirana jednostruko slepa studija je započela septembra 2014. godine i trajala je do januara 2016. godine. Istraživanje je sprovedeno na Klinici za abdominalnu, endokrinu i transplantacionu hirurgiju i Urgentnom centru Kliničkog centra Vojvodine u Novom Sadu kod bolesnika operisanih metodom laparoskopske holecistektomije. Rad je podeljen u nekoliko celina. 1. Procena veličine uzorka; 2. Procena podobnosti za studiju; 3. Anketiranje i uključivanje u studiju; 4. Razvrstavanje u grupe i operativni rad; 5. Period postoperativnog praćenja; 6. Statistička obrada i pisanje rada.<br />1. Procena veličine uzorka. Studija je realizovana podelom bolesnika u 4 grupe. Neophodni broj bolesnika je izračunat uzimajući podatke iz pilot istraživanja slične studije iz 2012. godine. Veličina uzorka je računata za primarni ishod studije&nbsp; (bolesnikov procenjen bol sa NAS) na pretpostavci da treba biti 20% smanjenja bola u prvom postoperativnom satu, uz verovatnoću Tip 1 gre&scaron;ke &alpha;=0.05 i Tipa 2 gre&scaron;ke &beta;=0.10 da postigne adekvatnu statističku snagu oko 80% i da otkrije 20% razlike u srednjoj vrednosti procenjenog bola jedan sat nakon laparoskopske&nbsp; holecistektomije. Procenjeni broj ispitanika po grupama prema zadatim kriterijumima je bio (P+V=65; P=68; V=68; O=65). Studija je započela uključivanjem prvog bolesnika u studiju a zavr&scaron;ena ispunjenim periodom praćenja sve dok poslednji bolesnik nije doneo upitnike o bolu, mučnini i kretanju. 2. Procena podobnosti za studiju. U periodu studije ukupan broj holecistektomiranih bolesnika je bio 1024 (440 klasično i 584 laparoskopski). Samo pogodni bolesnici su anketirani (584) i pročitali su informacioni list o istraživanju. Uključivanje ili procena podobnosti bolesnika za studiju sprovedena je na osnovu uključnih i isključnih kriterijuma. U studiju nije uključeno ukupno 226 bolesnika. Od tog broja 82 bolesnika je odbilo učestvovati u studiji a 144 bolesnika nije ispunilo uključne postavljene kriterijume. Svojim potpisom potvrdilo je uče&scaron;će u studiji 358 bolesnika. 3. Anketiranje i uključivanje u studiju. Nakon prijema bolesnika u bolnicu ispitivači su uzimali anamnezu i bolesnicima je ponuđen informacioni list i informisani pristanak. Nakon čitanja informacije, potpisivanja informisanog pristanka i zadovoljavanja&nbsp; uključnih i isključnih kriterijuma 358 bolesnika je uključeno u studiju. Obavljena je preoperativna priprema i ispitivači su popunili deo podataka u individualnom listu. 4. Razvrstavanje u grupe i operativni rad. Neposredno preoperativno od strane nezavisne osobe neuključene u studiju napravljena je randomizacija izabranih (n=358) u studijske grupe tablicama slučajnog izbora, tako da bolesnici nisu znali kojoj grupi pripadaju, dok su operater i osoblje to znali na početku operacije (jednostruko slepa studija). Nakon randomizacije i operacije bolesnici pripadaju jednoj od sledeće 4 grupe: Kontrolna grupa O=89, u kojoj su bolesnici sa urađenom laparoskopskom&nbsp; holecistektomijom bez visceralne blokade anestetikom i bez parijetalne blokade anestetikom. Eksperimentalna grupa P=88, u kojoj su bolesnici sa urađenom laparoskopskom holecistektomijom bez visceralne blokade anestetikom i sa parijetalnom blokadom anestetikom. Eksperimentalna grupa V=92, u kojoj su bolesnici sa urađenom laparoskopskom holecistektomijom sa visceralnom blokadom anestetikom i bez parijetalne blokade anestetikom. Eksperimentalna grupa P+V=89, u kojoj će biti bolesnici sa urađenom laparoskopskom holecistektomijom sa visceralnom blokadom anestetikom i sa parijetalnom blokadom anestetikom. Primenjivan je uobičajni, standardni protokol anestezije za laparoskopske operacije kod svih ispitanika. Svim bolesnicima plasirana je orogastrična sonda koja se nakon operacije odstranjivala. Kod&nbsp; bolesnika kod kojih je primenjivan lokalni anestetik neposredno pre početka operacije pravio se rastvor lokalnog anestetika (Marcaine&reg; 0,25%). Bolesnici su otpu&scaron;teni sa bolničkog lečenja prvog postoperativnog dana, pod uslovom da nisu imali komplikacija. 5. Postoperativno praćenje i ispunjavanje upitnika. Po dolasku na odeljenje&nbsp; bolesnicima je odmah uključivana ista analgezija. Tokom ispunjavanja informisanog pristanka, bolesnici su dobili upitnik na kojoj će sami procenjivati nivo bola, mučnine i kretanja tokom ležanja u bolnici i vremena praćenja od 7 dana kući. Bolesnici su dolazili na unapred zakazane postoperativne kontrole 7 do 10 dana posle operacije i donosili ispunjene upitnike. Otpu&scaron;teno je i za praćenje ostalo n=302 laparoskopski operisanih bolesnika a isključeno iz studije n=20 bolesnika. 6. Statistička obrada i pisanje rada. Ukupno je analizirano 274 listića operisanih bolesnika: u Grupi P+V =67; u Grupi P =70; u Grupi V =70 i u Grupi O =67. Od osnovnih deskriptivnih statističkih parametara za kvalitativnu i kvantitativnu procenu dobijenih rezultata su kori&scaron;ćeni apsolutni brojevi, relativni brojevi, mediana, mod, aritmetička sredina i standardna devijacija (SD). Obrada podataka se vr&scaron;ila&nbsp; osnovnim i naprednim statističkim metodama i programima. Rezultati su prikazani tabelarno i grafički. REZULTATI. Demografski podaci. Ukupno je bilo 188 žena i 86 mu&scaron;karaca, u odnosu 2,2 : 1. Prosečna starost cele grupe je bila 52,1 &plusmn; 15,72 godine. Ukupno je bilo 179 zaposlenih i 95 nezaposlenih. Ukupno je bilo 45 ispitanika sa osnovnim obrazovanjem, 153 ispitanika sa srednjim obrazovanjem i 76 ispitanika sa visokim obrazovanjem. Ukupno je bilo 186 nepu&scaron;ača i 88 pu&scaron;ača. Prosečna vrednost BMI cele grupe je bila 27,24 &plusmn; 4,21 kg/m2. Prosečna vrednost ASA u celoj grupi je bila 2,03 (mediana=2, mod=2). Ne postoji statistički značajna razlika između posmatranih grupa u odnosu na posmatrane parametre. Laboratorijski podaci. Postoji statistički značajna razlika u vrednosti leukocita između posmatranih grupa (p=0,039), u vrednosti uree između posmatranih grupa (p=0,040). Ne postoji statistički značajna razlika u vrednosti eritrocita, trombocita, hemoglobina, &Scaron;UK-a, kreatinina i bilirubina posmatranih grupa. Operativni i postoperativni podaci. Ne postoji statistički značajna razlika u količini upotrebljenog Fentanila između posmatranih grupa. Postoji statistički značajna razlika u dužini trajanja operacije između posmatranih grupa (p=0,003), u trajanju postavljenog abdominalnog drena između posmatranih grupa (p=0,024), u trajanju hospitalizacije između posmatranih grupa (p=0,027), u broju dana do povratka uobičajenim aktivnostima između posmatranih grupa (p=0,000), u broju uzetih tableta između posmatranih grupa (p=0,000). Prosečna ocena zadovoljstva bolesnika posle operacije u celoj grupi je bila 8,80 (mediana=9; mod=10). Najbolju ocenu zadovoljstva bolesnika posle operacije je imala grupa P+V. Procena bola, mučnine i kretanja. Postoji statistički značajna razlika između posmatranih grupa u proceni jačine bola pre operacije (p=0,003). Postoji statistički značajna razlika između posmatranih grupa u proceni jačine bola 1h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 2h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 4h posle operacije (najbolju procenu bola je imala grupa P); u proceni jačine bola 6h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 12h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 24h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 48h posle operacije (najbolju procenu bola je imala grupa P) i u proceni jačine bola 7 dana posle operacije (najbolju procenu bola je imala grupa P). Procenjena bol se pojačava otprilike 2,5 sata posle operacije sa vrhom 3 sata posle operacije, a smanjuje se na istu vrednost kao 2. sata posle operacije, otprilike 5. sata posle operacije. U vremenskim intervalima 1, 2. i 7. postoperativni dan postoji značajno pobolj&scaron;anje u postoperativnoj mobilnosti bolesnika. U vremenskim intervalima 1, 2, 4, 6 i 12 sati postoji značajno pobolj&scaron;anje u procenjenoj vrednosti mučnine bolesnika. Korelacije. Statistički značajna pozitivna korelacija ocene bola posle 1. sata, posle 2. sata, posle 6. sata, posle 12. sata je utvrđena sa brojem uzetih tableta (p=0,000), kao i procene mučnine (p=0,000). Statistički značajna pozitivna korelacija procene bola posle 4. sata je utvrđena sa brojem uzetih tableta (p=0,006), kao i aktivnosti (p=0,014). Statistički značajna korelacija procene bola posle 24. sata je utvrđena sa brojem uzetih tableta (p=0,000; pozitivna) i trajanjem operacije (p=0,028; negativna). Statistički značajna pozitivna korelacija procene bola posle 48. sata i posle 7 dana je utvrđena sa brojem uzetih tableta (p=0,000). ZAKLJUČCI: Primena lokalnog anestetika datog na bilo koji način značajno smanjuje bol posle laparoskopske holecistektomije. Primena lokalnog anestetika datog i&nbsp; portalno i visceralno (P+V) značajno smanjuje bol u odnosu na samo portalnu (P) ili visceralnu (V) primenu u vremenskim intervalima 2, 6, 12 sat posle laparoskopske holecistektomije. Portalna (P) primena sa ili bez visceralne (V) primene lokalnog anestetika značajno smanjuje bol u vremenskim intervalima 1, 4, 24, 48 sati i 7 dana posle laparoskopske holecistektomije. Najbolje kretanje je bilo u grupi P+V posle laparoskopske holecistektomije. Najbolje smanjenje procenjene mučnine je bilo u grupi P posle laparoskopske holecistektomije. Najraniji povratak uobičajenim aktivnostima zabeležen je u grupi P+V. Najbolja ocena zadovoljstva bolesnika hirur&scaron;kim lečenjem bila je u grupi P+V. Postoperativna bol ima najznačajniju pozitivnu korelaciju sa procenjenom mučninom i brojem tableta uzetih od momenta otpusta do prve kontrole bolesnika.</p> / <p>INTRODUCTION: Biliary calculosis is the most frequent disease of the hepatobiliary system, and cholecystectomy is one of the most frequently performed surgical procedures. Today laparoscopic cholecystectomy represents the golden standard in treating cholelithiasis. Laparoscopic cholecystectomy showed improvement in the clinically significant outcomes, such as: reducing the duration of the surgery, shorter hospital stay, reducing the intensity and duration of postoperative pain and faster return to normal daily and working activities. Postoperative pain and the time of full recovery remain the two major problems after a non-complicated laparoscopic cholecystectomy and they should be improved. The pain related to laparoscopic cholecystectomy is complex and multi-factorial in origin. The pain occurs due to damaged tissues, dissection and removal of gallbladder from its cavity, stimulation of periportal nerves, irritation of the diaphragm, mechanical and chemical interaction of gases and pneumoperitoneum and port incisions. Researches have denoted parietal and visceral pains as two major mechanisms in occurrence of pain in laparoscopic cholecystectomy. Pain cannot be measured, but estimated, as it is a subjective feeling. It was considered necessary to find the answer, based on solid scientific evidence, if it was possible to block parietal and visceral pain after laparoscopic cholecystectomy in its acute phase. OBJECTIVES: The aim of this study is to compare standard, non-opioid, analgesia (group O) with applying parietal blockade (group P), or visceral blockade (group V), or compare with both applied blockades (group P+V). The primary outcomes of the study are the patient&acute;s estimated pain before surgery and 1, 2, 4, 6, 12, 24, 48 hours and 7th day after the surgery. The secondary outcomes of this study are the patient&acute;s estimated nausea level during 1, 2, 4, 6, 12 hours, along with the patient&acute;s estimated mobility 1st, 2nd and 7th day, postoperatively. HYPOTHESIS. Blockade of postoperative visceral pain and blockade of postoperative parietal pain following laparoscopic cholecystectomy, applying intraperitoneal local infiltration with anesthetic and also by local infiltration with anesthetic through accessible laparoscopic ports, can significantly reduce early postoperative pain. MATERIAL AND METHODS: This prospectively randomized single-blinded study started in September 2014 and lasted up to January 2016. The research was carried out at the Clinic for Abdominal, Endocrine and Transplantation Surgery and Emergency Center, Clinical Center of Vojvodina in Novi Sad and it involved patients who underwent laparoscopic cholecystectomy. This study has been divided into several units. 1. Assessment of sample size; 2. Assessment of eligibility for the study; 3. Survey and inclusion in the study; 4. Group formation and operational work; 5. Period of postoperative follow-up; 6. Statistical processing and writing the paper.1. Assessment of sample size. The study was realized by dividing the patients into 4 groups. The number of patients necessary was determined based on the data taken as pilot study from a similar study from 2012. Sample size was calculated for the primary outcome of the study (patient&acute;s estimated pain with NAS) based on the assumption that a pain reduction of 20% should occur during the first postoperative hour, with the probability of Type 1 error &alpha;=0.05 and Type 2 error &beta;=0.10 to reach the adequate statistical power of about 80%, and to reveal 20% difference in the average value of the estimated pain one hour after the laparoscopic cholecystectomy. The assessed number of respondents in groups according to the set criteria was (P+V =65;P =68;V =68; O =65). The study started when the first patient was included and it ended with the complete follow-up period when the last patient handed in the survey about pain, nausea and mobility. 2. Assessment of eligibility for the study. During the study the number of patients undergoing surgery applying the method of cholecystectomy was 1024 (440 classical and 584 laparoscopic). Only the suitable patients were surveyed (584) and given to read the information leaflet about the study. Inclusion and assessment of patients&acute; eligibility was performed on the basis of inclusion and exclusion criteria. A total of 226 patients was not included in the study. Out of that number 82 patients refused to participate in the study and 144 did not fulfill the inclusive criteria set. By signing 358 patients confirmed their participation in the study. 3. Survey and inclusion in the study. After admitting the patients to hospital the surveyors took their anamnesis and the patients were offered an information leaflet and informed consent. Following the reading of the information leaflet, signing the informed consent and satisfying the criteria for inclusion and exclusion, 358 patients were included in the study. Preoperative preparations were performed and the surveyors filled in some of the data on the individual list. 4. Group formation and operational work. Prior to the surgery an independent person not included in the study carried out the randomisation of the patients chosen (n=358) into study groups by random selection tables. The patients did not know which group they belonged to, while it became known to the surgeon and the operation stuff at the beginning of the surgery (singleblinded study). After randomization and surgery the patients belonged to one of the following groups: Control group O=89 of patients with performed laparoscopic cholecystectomy without visceral blockade by anesthetic and without parietal blockade by anesthetic. Experimental group P=88 of patients with performed laparoscopic cholecystectomy without visceral blockade by anesthetic but with parietal blockade by anesthetic. Experimental group V=92 of patients with performed laparoscopic cholecystectomy with visceral blockade by anesthetic but without parietal blockade by anesthetic. Experimental group P+V=89 of patients with performed laparoscopic cholecystectomy with visceral blockade by anesthetic and with parietal blockade by anesthetic. The standard protocol of anesthesia for laparoscopic cholecystectomy was applied to all patients. An orogastric tube used during the surgery, was removed after it. In patients with applied local anesthetic immediately before surgery a solution of local anesthetic was made (Marcaine&reg; 0,25%). The patients were discharged from hospital the first postoperative day, provided that no complications occurred. 5. Postoperative follow-up and completing the questionnaire. When admitted to the ward the patients were given the same kind of analgesia. While completing the informed consent the patients were given a questionnaire for estimating their pain level, nausea and mobility during their stay in hospital and during the 7-day follow-up period at home. The patients were required to come for 7 and 10-day postoperative check-ups by appointment and then they handed in the questionnaires. n=302 patients with performed laparoscopic cholecystectomy were released and designated for follow-up, and n=20 patients were excluded from the study. 6. Statistical processing and writing the paper. In total 274 operated patients&acute; slips were analysed, by groups as follows: in Group P+V =67; in Group P =70; in Group V =70 and in Group O =67. From the basic descriptive statistical parametres for qualitative and quantitative assessment of results obtained, absolute numbers, relative numbers, the median, mode, arithmetic mean and standard deviation (SD) were used. Data processing was carried out using basic and advanced statistical methods and programmes. The results are presented in tabular and graphical manner. RESULTS. Demographic data. In total there were 188 women and 86 men, in proportion 2,2 : 1. The average age of the whole group was 52,1 &plusmn; 15,72 years. In total there were 179 employed and 95 unemployed persons. In total there were 45 surveyed patients with primary education, 153 surveyed patients with secondary education and 76 surveyed patients with higher education. In total there were 186 nonsmokers and 88 smokers. The mean BMI value of the whole group was 27,24 &plusmn; 4,21 kg/m2. The mean value of ASA of the whole group was 2,03 (the median=2, mode=2). There is no significant difference among the groups observed considering the observed parametres. Laboratory data. There is a statistically significant difference in the value of leukocytes among the observed groups (p=0,039), and in the value of urea among the observed groups (p=0,040). There is no statistically significant difference in the value of the erythrocyte, platelets, hemoglobin, blood glucose, creatinine and bilirubin of the&nbsp; observed groups. Operative and postoperative data. There is no statistically significant difference in the amount of Fentanyl&reg; applied among the observed groups. There is statistically significant difference in the length of the surgery among the observed groups (p=0,003), in the duration of the positioning of abdominal drainage among the observed groups (p=0,024), in the duration of hospital stay among the observed groups (p=0,027), in the number of days until getting back to regular activities among the observed groups&nbsp; (p=0,000), in the number of taken pills among the observed groups (p=0,000). The patients&acute; average satisfaction grade after surgery in the whole group was 8,80 (the median=9; mode=10). Group P+V had the best patient&lsquo;s satisfaction grade after the surgery. Assessment of pain, nausea and mobility. There is statistically significant difference in the estimation of pain intensity before surgery among the observed groups (p=0,003). There is statistically significant difference in the estimation of pain intensity 1 hour after surgery among the observed groups (P+V having the best estimated pain); in the estimation of pain intensity 2 hours after&nbsp; surgery (P+V having the best estimated pain); in the estimation of pain intensity 4 hours after surgery (P having the best estimated pain); in the estimation of pain intensity 6 hours after surgery (P+V having the best estimated pain); in the estimation of pain intensity 12 hours after surgery (P+V having the best estimated pain); in the estimation of pain intensity 24 hours after surgery (P+V having the best estimated pain); in the estimation of pain intensity 48 hours after surgery (P having the best estimated pain) also in the estimation of pain intensity 7 days after surgery (P having the best estimated pain). The estimated pain intensifies at about 2,5 hours after surgery and peaks 3 hours after surgery, and decreases to the same level as it was during 2nd hour after surgery approximately during 5th hour after surgery. There is considerable improvement in mobility of patients in the time interval 1st, 2nd and 7th postoperative days. There is considerable improvement in estimated nausea level of patients in the time interval 1, 2, 4, 6 and 12 hours. Correlations. Statistically significant positive correlation in estimated pain after 1st hour, after 2nd hour, after 6th hour and after 12th hour was determined by the number of tablets taken (p=0,000), just like the estimated nausea level (p=0,000). Statistically significant positive correlation in estimated pain after 4th hour was determined by the number of tablets taken (p=0,006), just like the activities (p=0,014). Statistically significant positive correlation in estimated pain after 24th hour was determined by the number of tablets taken (p=0,000; positive), and by the duration of the surgery (p=0,028; negative). Statistically significant positive correlation in estimated pain after 48th hour and after 7 days was determined by the number of tablets taken (p=0,000). CONCLUSIONS: The application of local anesthetic, regardless of how it was applied, considerably reduces pain after laparoscopic cholecystectomy. The application of local anesthetic by port or viscerally (P+V) considerably reduces pain compared to only by port (P) or only visceral (V) application in the time intervals of 2, 6, and 12 hours after laparoscopic cholecystectomy. The application of local anesthetic by port (P), with or without visceral (V), considerably reduces pain in the time intervals of 1, 4, 24, and 48 hours and 7 days after laparoscopic cholecystectomy. The best mobility was shown by group P+V after laparoscopic cholecystectomy. Estimated nausea was most reduced in group P after laparoscopic cholecystectomy. Group P+V presented the earliest return to regular activities. The best patients&acute; satisfaction grade with surgical treatment was shown by group P+V. Postoperative pain is most considerably positively correlated with the estimated nausea and pills taken, from the moment of patient&acute;s release from hospital to the first check-up.<br />&nbsp;</p>

Introduction : Il a été démontré que les enfants opérés pour une amygdalectomie éprouvaient des niveaux de douleur modérée à sévère, et ce pendant plusieurs jours suite à la chirurgie. Suite au retour à domicile, plusieurs parents ont tendance à administrer l’analgésie de façon non-optimale à leur enfant et ce pour diverses raisons, ce qui contribue au maintien de niveaux de douleur élevés et à l’incidence de complications postopératoires. But : Cette étude avait pour but d’évaluer l’effet d'un suivi infirmier téléphonique, effectué auprès de parents d'enfants opérés pour une amygdalectomie, sur la gestion de la douleur et la prévention de complications postopératoires. Méthode : Cette étude clinique randomisée a comparé un groupe expérimental (suivi infirmier téléphonique) à un groupe contrôle (traitement standard) (n = 52). Le suivi infirmier téléphonique fut effectué au 1er, 3e, 5e et 10e jour postopératoire et permettait d’évaluer l’évolution du client et d’offrir un enseignement personnalisé selon un cadre prédéfini. Les critères d’évaluation furent l’intensité de la douleur, la quantité d’analgésie administrée à l’enfant, les complications postopératoires et le recours à des services de santé non-planifiés. Résultats : Les enfants du groupe expérimental ont présenté une intensité de douleur plus faible au 3e jour postopératoire, le matin (P= 0.041) et le soir (P= 0.010). Les enfants de ce groupe ont reçu davantage de doses d’analgésiques au 1er jour postopératoire (P= 0.007) et au 5e jour postopératoire (P= 0.043). Ils ont eu moins de vomissements au congé de l’hôpital (P= 0.040) et au 3e jour postopératoire (P= 0.042), moins de somnolence au 1er jour postopératoire (P= 0.041), une meilleure hydratation au 1er (P= 0.014) et 3e jour postopératoire (P= 0.019), mais ont souffert davantage de constipation au 3e jour postopératoire (P< 0.001). Aucune différence significative n’a été observée quant au recours à des services de santé. Conclusion : Le suivi infirmier téléphonique, effectué auprès de parents d'enfants opérés pour une amygdalectomie, a certains effets bénéfiques sur la gestion de la douleur et la prévention de complications postopératoires, mais n’a pas eu d’effet significatif sur le recours à des services de santé. / Background: After tonsillectomy, children experience moderate to severe pain for several days. Following discharge from the hospital, many parents give insufficient analgesia to their child, based on numerous misguided beliefs. This contributes to more pain and an increase of postoperative complications. Aim: Evaluation of the efficacy of a nurse telephone follow-up with parents of children who underwent tonsillectomy, on pain intensity, occurrence of postoperative complications and frequency of resort to other health services. Methods: This randomised clinical trial compared an intervention group (nurse telephone follow-up) with a control group (standard care, without follow-up) (n=52). Nurse telephone follow-up was made on the 1st, 3rd, 5th and 10th postoperative day and included advice and explanation regarding problems experienced by parents, using an algorithm of interventions. Outcomes evaluated were pain intensity, frequency of analgesics administered to the child, occurrence of postoperative complications and resort to health services. Data was collected at hospital discharge, and on the 1st, 3rd, 5th and 10th postoperative days (POD). Results: Children in the experimental group had lower pain intensity scores after medication than the control group in the morning (P= 0.041) and evening (P= 0.010) of POD 3. Children in the nurse follow-up group received more doses of analgesics on POD 1 (P= 0.007) and POD 5 (P= 0.043). Significant differences were observed, in favour of the nurse follow-up group, regarding vomiting at POD 0 (P= 0.040) and POD 3 (P= 0.042), dizziness at POD 1(P= 0.041), and fluid intake at POD 1(P= 0.014) and POD 3 (P= 0.019) - although, constipation was more frequent in the nurse follow-up group at POD 3 (P< 0.001). There was no significant difference, between both groups, regarding resort to other health services. Conclusion: Nurse telephone follow-up with parents of children who underwent tonsillectomy was beneficial for some aspects of pain management and occurrence of some postoperative complications, but did not decrease resort to other health services.

Les arthroplasties totales de la hanche (ATH) et du genou (ATG) sont souvent offertes aux patients atteints de dégénérescence articulaire sévère. Bien qu’efficace chez la majorité des patients, ces interventions mènent à des résultats sous-optimaux dans de nombreux cas. Il demeure difficile d’identifier les patients à risque de résultats sous-optimaux à l’heure actuelle. L’identification de ces patients avant la chirurgie pourrait permettre d’optimiser la gamme de soins et de services offerts et de possiblement améliorer les résultats de leur chirurgie. Ce mémoire a comme objectifs : 1) de réaliser une revue systématique des déterminants associés à la douleur et aux incapacités fonctionnelles rapportées par les patients à moyen-terme suivant ces deux types d’arthroplastie et 2) de développer des modèles de prédiction clinique permettant l’identification des patients à risque de mauvais résultats en terme de douleur et d’incapacités fonctionnelles suivant l’ATH et l’ATG. Une revue systématique de la littérature identifiant les déterminants de la douleur et de la fonction suivant l’ATH et l’ATG a été réalisée dans quatre bases de données jusqu’en avril 2015 et octobre 2014, respectivement. Afin de développer un algorithme de prédiction pouvant identifier les patients à risque de résultats sous-optimaux, nous avons aussi utilisé des données rétrospectives provenant de 265 patients ayant subi une ATH à l’Hôpital Maisonneuve-Rosemont (HMR) de 2004 à 2010. Finalement, des données prospectives sur 141 patients recrutés au moment de leur inclusion sur une liste d’attente pour une ATG dans trois hôpitaux universitaires à Québec, Canada et suivis jusqu’à six mois après la chirurgie ont permis l’élaboration d’une règle de prédiction clinique permettant l’identification des patients à risque de mauvais résultats en terme de douleur et d’incapacités fonctionnelles. Vingt-deux (22) études d’une qualité méthodologique moyenne à excellente ont été incluses dans la revue. Les principaux déterminants de douleur et d’incapacités fonctionnelles après l’ATH incluaient: le niveau préopératoire de douleur et de fonction, un indice de la masse corporelle plus élevé, des comorbidités médicales plus importantes, un état de santé générale diminué, une scolarité plus faible, une arthrose radiographique moins sévère et la présence d’arthrose à la hanche controlatérale. Trente-quatre (34) études évaluant les déterminants de douleur et d’incapacités fonctionnelles après l’ATG avec une qualité méthodologique moyenne à excellente ont été évaluées et les déterminants suivant ont été identifiés: le niveau préopératoire de douleur et de fonction, des comorbidités médicales plus importantes, un état de santé générale diminué, un plus grands niveau d’anxiété et/ou de symptômes dépressifs, la présence de douleur au dos, plus de pensées catastrophiques ou un faible niveau socioéconomique. Pour la création d’une règle de prédiction clinique, un algorithme préliminaire composé de l’âge, du sexe, de l’indice de masse corporelle ainsi que de trois questions du WOMAC préopératoire a permis l’identification des patients à risque de résultats chirurgicaux sous-optimaux (pire quartile du WOMAC postopératoire et percevant leur hanche opérée comme artificielle avec des limitations fonctionnelles mineures ou majeures) à une durée moyenne ±écart type de 446±171 jours après une ATH avec une sensibilité de 75.0% (95% IC: 59.8 – 85.8), une spécificité de 77.8% (95% IC: 71.9 – 82.7) et un rapport de vraisemblance positif de 3.38 (98% IC: 2.49 – 4.57). Une règle de prédiction clinique formée de cinq items du questionnaire WOMAC préopratoire a permis l’identification des patients en attente d’une ATG à risque de mauvais résultats (pire quintile du WOMAC postopératoire) six mois après l’ATG avec une sensibilité de 82.1 % (95% IC: 66.7 – 95.8), une spécificité de 71.7% (95% IC: 62.8 – 79.8) et un rapport de vraisemblance positif de 2.9 (95% IC: 1.8 – 4.7). Les résultats de ce mémoire ont permis d’identifier, à partir de la littérature, une liste de déterminants de douleur et d’incapacités fonctionnelles après l’ATH et l’ATG avec le plus haut niveau d’évidence à ce jour. De plus, deux modèles de prédiction avec de très bonnes capacités prédictives ont été développés afin d’identifier les patients à risque de mauvais résultats chirurgicaux après l’ATH et l’ATG. L’identification de ces patients avant la chirurgie pourrait permettre d’optimiser leur prise en charge et de possiblement améliorer les résultats de leur chirurgie. / Total joint arthroplasties (TJA) are commonly performed procedures for patients afflicted with hip and knee osteoarthritis (OA), and although successful, these surgeries can yield suboptimal results in a non-negligible proportion of patients. In order to improve surgical outcomes, patients at risk of poor results could be targeted with focused interventions. However, the evidence regarding the ability to identify which patients are at risk of poor outcomes is scarce. The objectives of this memoir were 1) to systematically review the literature of preoperative determinants of medium-term patient-reported pain and physical function after total hip arthroplasty (THA) and total knee arthroplasty (TKA) and 2) to develop clinical prediction models allowing the individual identification of patients at risk of poor outcomes following THA and TKA. Systematic literature searches targeting studies evaluating all studied determinants of pain and function following THA and TKA were performed in four important databases until April 2015 and October 2014 respectively. Moreover, retrospective data from 265 patients having undergone THA at the Hôpital Maisonneuve-Rosemont from 2004 to 2010 was used to develop a preliminary prediction algorithm (PA) to identify patients at risk of poor surgical results. Finally, prospective data from 141 patients recruited at their inclusion on a preoperative waitlist for TKA in three hospitals in Québec City, Canada and followed 6 months postoperatively was used to develop a clinical prediction rule (CPR) to identify patients at risk of poor outcomes Twenty-two (22) studies evaluating determinants of poor pain and function after THA with moderate-to-excellent methodological quality found that preoperative levels of pain and function, higher body mass index (BMI), greater medical comorbidities, worse general health, lower education level, lower OA radiographic severity and contralateral hip OA were consistently associated with poor THA outcomes. Thirty-four (34) studies evaluating determinants of poor pain and function after TKA with moderate-to-excellent methodological quality identified preoperative levels of pain and function, greater medical comorbidity, lower general health, greater levels of depression and/or anxiety, presence of back pain, greater pain catastrophizing and greater socioeconomic deprivation as consistently associated with worse outcomes. A preliminary PA consisting of age, gender, BMI and three items of the preoperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was able to identify patients at risk of suboptimal outcomes (worst quartile of the postoperative WOMAC score and perceiving their operated hip as artificial with minor or major limitations) on an average±standard deviation (SD) of 446±171 days after THA with a sensitivity of 75.0% (95% CI: 59.8 – 85.8), a specificity of 77.8% (95% CI: 71.9 – 82.7) and a positive likelihood ratio of 3.38 (98% CI: 2.49 – 4.57). A CPR consisting of five items of the preoperative WOMAC was able to predict the identity of patients awaiting TKA at the highest risk of poor outcomes (worst quintile of the postoperative WOMAC score) six months postoperatively with a sensitivity of 82.1 % (95% CI: 66.7 – 95.8), a specificity of 71.7% (95% CI: 62.8 – 79.8) and a positive likelihood ratio of 2.9 (95% CI: 1.8 – 4.7). This memoir led to the identification of a list of determinants of pain and disability following TKA and THA with the highest level of evidence to date. Moreover, two clinical prediction models with good predictive capabilities were developed in order to allow the identification of patients at risk of poor outcomes following TKA and THA. These findings could help target the patients most likely to benefit from interventions aimed at diminishing their risk profile and improving surgical outcomes of hip or knee arthroplasties. External validation of these rules is warranted before clinical implementation.

Operationen mit großem Gewebetrauma können mit starken postoperativen Schmerzen und ausgeprägten perioperativen Homöostasestörungen einhergehen. Dabei werden sowohl hyperinflammatorische als auch immunparalytische Reaktionen beobachtet, die sich negativ auf den postoperativen Verlauf auswirken können. Um eine effektive und sichere Analgesie zu gewähren, werden alternativ zu der intravenösen Therapie mit Opioiden zunehmend epidurale Verfahren eingesetzt. In dieser prospektiven, randomisierten und doppelblinden Studie wurde die patientenkontrollierte epidurale Analgesie mit der patientenkontrollierten intra-venösen Schmerztherapie hinsichtlich der analgetischen Effektivität und der Beeinflussung der postoperativen Immunkompetenz verglichen. 54 Patienten erhielten bis zum Morgen des 4. postoperativen Tages entweder über einen intraoperativ gelegten epiduralen Katheter (PDK) Ropivacain und Sufentanil (PCEA-Gruppe) oder intravenös Morphin (PCIA-Gruppe). Cortisol, Leukozytenpopulationen, lymphozytäre Subpopulationen, monozytäre Oberflächenmarker und die löslichen Mediatoren TNF alpha, MCP-1, MIF, IL-8, IL-6 und IL-10 wurden perioperativ gemessen. Zudem wurde die Schmerzempfindung der Patienten in Ruhe und bei Mobilisation erhoben. Im Vergleich zur PCIA-Gruppe profitierten die Patienten der PCEA-Gruppe von einer deutlich besseren Analgesie. Cortisol wies postoperativ in beiden Studiengruppen einen ähnlich leichten Anstieg auf. Die monozytären Oberflächenmarker (HLA-DR, CD86) fielen im Verlauf deutlich ab mit einem Minimum am 1. postoperativen Tag, erholten sich bis zum 7. postoperativen Tag nahezu vollständig und zeigten keine signifikanten Gruppenunterschiede. Dagegen wurde der postoperative Abfall der CD4+ T-Lymphozyten, CD4/CD8 T-Zellratio, CD3+ Lymphozyten und CD19+ Lymphozyten bei den Patienten, die eine Epiduralanalgesie erhielten, signifikant vermindert. Hinsichtlich der löslichen Mediatoren gab es keine signifikanten Gruppenunterschiede. Somit scheint die epidurale Schmerztherapie die T-Zellkompetenz während der postoperativen Phase besser zu erhalten, während sich bei den monozytären Oberflächenmarkern und dem Stresshormon Cortisol kein Unterschied zwischen den beiden Analgesie-verfahren zeigte. / Surgeries accompanied by an extensive tissue trauma are associated with intense postsurgical pain and major perioperative homeostatic disorders. Both hyper-inflammatory and immuneparalytic reactions can be observed, what can negatively effect the postoperative course. To realise an effective and safe analgesia, epidural procedures are used to an increasing degree as an alternative method to the therapy with intravenous opioids. In this prospective, randomized, double-blinded trial we compared the patient-controlled epidural analgesia and the patient-controlled intravenous analgesia with respect to the analgesic efficiency and the influence on the postoperative immune competence. 54 patients received until the morning of the fourth postoperative day either ropivacaine plus sufentanil through an intraoperatively placed epidural catheter (PCEA-group) or intravenous morphine (PCIA-group). Cortisol, populations of leukocytes and lymphocytes, cell-surface molecules of monocytes and the soluble mediators TNF-alpha, MCP-1, MIF, IL-8, IL-6 and IL-10 were measured perioperatively. Additionally we determined the subjective pain scores of the patients in rest and with mobilisation. Patients of the PCEA-group had a better pain control compared to the patients of the PCIA-group. Cortisol showed a similar slight increase in both study-groups. The monocyte cell-surface molecules (HLA-DR, CD86) decreased in the observed period with a minimum on the first postoperative day and recovered until the seventh postoperative day without a significant difference between both groups. In contrast, the postoperative decrease in CD4+ T-lymphocytes, CD4+/CD8+ T-cell ratio, CD3+ lymphocytes and CD19+ lymphocytes was significantly reduced in patients receiving epidural analgesia. No group differences were found in soluble mediators. This implicates a better postoperative competence of T-cells induced by epidural analgesia, whereas no differences between both analgetic methods were found in cell-surface markers of monocytes and the stress hormone cortisol.

<p>Uvod: Adenoidektomija sa tonzilektomijom je najče&scaron;će indikovana hirur&scaron;ka intervencija u dečjem uzrastu. Intervencija se izvodi u op&scaron;toj anesteziji. Endotrahealni tubus predstavlja &bdquo;zlatni standard&ldquo; za obezbeđenje disajnog puta u dečjoj otorinolaringolo&scaron;koj hirurgiji. Upotreba endotrahealnog tubusa nosi rizike od nastanka komplikacija koje se mogu javiti pri uvodu u op&scaron;tu anesteziju, u toku hirur&scaron;ke intervencije i nakon ekstubacije deteta. Učestalost komplikacija se može smanjiti upotrebom supraglotičnih sredstava. Fleksibilna laringealna maska spada u prvu generaciju supraglotičnih sredstava, koja omogućava zadovoljavajuću oksigenaciju i ventilaciju bolesnika u ORL hirurgiji. Cilj istraživanja: Utvrditi: efikasnost fleksibilne laringealne maske u za&scaron;titi disajnog puta od aspiracije krvi i sekreta gornjih disajnih puteva u odnosu na endotrahealni tubus u toku adenotonzilektomije; da li primena fleksibilne laringealne maske u zbrinjavanju disajnog puta u toku adenotonzilektomije utiče na učestalost postekstubacionih komplikacija u odnosu na zbrinjavanje disajnog puta endotrahealnim tubusom; da li zbrinjavanje disajnog puta fleksibilnom laringealnom maskom u toku adenotonzilektomije ima uticaj na intenzitet postoperativnog bola u odnosu na zbrinjavanje disajnog puta endotrahealnim tubusom; da li zbrinjavanje disajnog puta fleksibilnom laringealnom maskom u toku adenotonzilektomije ima uticaj na pojavu postoperativne mučnine i povraćanja u odnosu na zbrinjavanje disajnog puta endotrahealnim tubusom. Metodologija: Prospektivnom, randomizovanom, studijom bilo je obuhvaćeno 160 dečaka i devojčica uzrasta od 3 do 8 godina planiranih za elektivnu hirur&scaron;ku intervenciju adenotonzilektomiju u op&scaron;toj anesteziji. Bolesnici su bili podeljeni u dve grupe: 80 bolesnika kod kojih je disajni put bio obezbeđen endotrahealnim tubusum (ET grupa) i 80 bolesnika kod kojih je disajni put bio obezbeđen laringealnom maskom (LMA grupa). Na kraju hirur&scaron;ke intervencije, u obe grupe bolesnika, izvr&scaron;ena je provera prisustva krvi na larinksu i u traheji pomoću fiberoptičkog bronhoskopa. Postekstubacione respiratorne komplikacije vezane za upotrebu fleksibilne laringealne maske odnosno endotrahealnog tubusa (ka&scaron;alj, opstrukcija disajnog puta i laringospazam) bile su praćene neposredno nakon ekstubacije bolesnika. Procena postoperativnog bola bila je vr&scaron;ena pomoću Face, Legs, Activity, Cry, Consolability Scale 2 i 4 sata nakon hirur&scaron;ke intervencije kao i prvog postoperativnog dana u 7 sati ujutro. Postojanje postoperativne mučnine i povraćanja bilo je utvrđivano heteroanamnestički, anketom roditelja, dan nakon hirur&scaron;ke intervencije u 7 sati ujutro. Statistička analiza izvr&scaron;ena je pomoću statističkog paketa Statistical Package for Social Sciences &ndash; SPSS 21. Podaci su predstavljeni tabelarno i grafički, a statistička značajnost je određivana na nivou p&lt;0.05. Rezultati: Ni kod jednog deteta iz ET odnosno LMA grupe bolesnika nakon hirur&scaron;ke intervencije fiberoptičkim bronhoskopom nije uočeno prisustvo krvi, sekreta niti regurgitiranog želudačnog sadržaja na larinksu odnosno u traheji. Bolesnici iz ET grupe su imali statistički značajno vi&scaron;e komplikacija u odnosu na bolesnike iz LMA grupe (&chi;2=4.254; p=0.039; p &lt; 0.05). Ne postoji statistički značajna razlika u distribuciji bolesnika sa i bez respiratornih komplikacija izmeĊu ET i LMA grupe (&chi;2=3.413; p=0.065; p &gt; 0.05). U proceni postoperativnog bola FLACC skalom 2 sata nakon hirur&scaron;ke intervencije postoji statistički značajna razlika u intenzitetu postoperativnog bola kod bolesnika iz ET u odnosu na bolesnike iz LMA grupe (&chi;2=31.316; p=0.000; p&lt;0.05). Četiri sata nakon hirur&scaron;ke intervencije, statistički je značajno vi&scaron;e bolesnika sa umerenim bolom u ET grupi u odnosu na LMA grupu (&chi;2=40.705; p=0.000; p&lt;0.05). Na dan otpusta, statistički je značajno vi&scaron;e bolesnika sa blagim diskomforom u ET grupi bolesnika u odnosu na LMA grupu (&chi;2=8,012; p=0,005; p &lt; 0.05). U LMA grupi bolesnika jedan ili 1.49% bolesnika je imao postoperativnu mučninu i povraćanje, dok je u ET grupi troje ili 3.56% bolesnika imalo postoperativnu mučninu i povraćanje. Zaključak: Fleksibilna laringealna maska pruža podjednaku za&scaron;titu distalnih delova disajnog puta od krvi i sekreta tokom adenotonzilektomije kao i endotrahealni tubus. Učestalost postoperativnih komplikacija i intenzitet postoperativnog bola su manji kada se za obezbeđenje disajnog puta u toku adenotonzilektomije koristi fleksibilna laringealna maska. Primenom fleksibilne laringealne maske smanjuje se učestalost postoperativne mučnine i povraćanja u toku adenotonzilektomije.</p> / <p>Introduction: Adenoidectomy with tonsillectomy is the most indicated surgery in childhood. The intervention is performed under general anesthesia. Endotracheal tube represents the &bdquo;gold standard&ldquo; for airway management in paediatric ENT surgery. The use of endotracheal tube carries the risk of complications that may occur during the induction of general anesthesia, during the surgery and after extubation of the child. The frequency of complications may be reduced by the use of supraglottic airway devices. Flexible laryngeal mask is first generation of supraglottic airway devices, which allows sufficient oxygenation and ventilation of patients in ENT surgery. Aims: To determine the effectiveness of the flexible laryngeal mask which protectes the airway from aspiration of blood and secretions of the upper airways compared to the airway management with endotracheal tube during adenotonsillectomy; to determine does the usage of the flexible laryngeal mask in airway management during adenotonsillectomy affects the frequency of post extubation complications compared to the airway management with endotracheal tube, as wll as does the usage of the flexible laryngeal mask in airway management during adenotonsillectomy has an impact on the intensity of postoperative pain compared to the airway management with endotracheal tube, and does the usage of the flexible laryngeal mask in airway management during adenotonsillectomy has an impact on the incidence of postoperative nausea and vomiting compared to the airway management with endotracheal tube. Methodology: One hundred and sixty boys and girls aged from 3 to 8 years scheduled for elective surgical intervention adenotnosillectomy in general anaesthesia were included in this prospective, randomized study. Patients were divided into two groups: 80 patients in whom the airway was managed with a cuffed endotracheal tube (ET group) and 80 patients in whom airway was managed with a laryngeal mask (LMA group). At the end of surgical procedure, in both groups of patients, fiberoptic bronchoscopy was performed to verify the presence of blood in the larynx and trachea. Immediate respiratory complications associated with the use of flexible laryngeal mask or endotracheal tube (cough, airway obstruction and laryngospasm) were monitored following extubation of patients. Postoperative pain assessment was performed using Face, Legs, Activity, Cry, Consolability Scale 2 and 4 hours following surgery as well as the first postoperative day at 7 o&#39;clock a.m. The presence of postoperative nausea and vomiting was confirmed heteroanamnestically by polling the parents the day after surgery at 7 o&#39;clock a.m. The statistical analysis was performed using Statistical Package for Social Sciences - SPSS version 21. The data were presented in tables and graphs, statystical significance was set at p value of less than 0.05. Results: Following surgery there were no any patient in ET or LMA group in which the presence of blood, secretion or regurgitated stomach contents on larynx or in the trachea could be observed by using the fiberoptic bronchoscope. Patients in the ET group had statistically more significant complications compared to patients in the LMA group (&chi;2 = 4.254; p = 0.039; p &lt;0.05). There is no statistically significant difference in the distribution of patients with and without respiratory complications between ET and LMA groups (&chi;2 = 3.413; p = 0.065; p&gt; 0.05). In the assessment of postoperative pain using FLACC scale 2 hours following surgical intervention, there is a statistically significant difference in the intensity of postoperative pain in ET patients compared to patients in the LMA group (&chi;2 = 31.316, p = 0.000, p &lt;0.05). Four hours following surgical intervention, a statistically significant number of patients had mild pain in the ET group compared to the LMA group (&chi;2 = 40.705; p = 0.000; p &lt;0.05). On the day of release, statistically significant numbers of patients with mild discomfort in the ET group were compared to the LMA group (&chi;2 = 8,012; p = 0,005; p &lt;0.05). In the LMA group, one or 1.49% of the patients had postoperative nausea and vomiting, while in the ET group, three or 3.56% of the patients had postoperative nausea and vomiting. Conclusion: Flexible laryngeal mask provides equal protection of the distal parts of airway from the blood and secretions during adenotonsillectomy as the endotracheal tube. The frequency of postoperative complications and the intensity of postoperative pain are smaller when a flexible laryngeal mask is used for airway management during adenotonsillectomy. The usage of the flexible laryngeal mask reduces the frequency of postoperative nausea and vomiting during adenotonsillectomy.</p>