I NTRODUÇÃO: Apesar da importância do tabagismo no processo de doença cardiovascular da sociedade moderna, os estudos de avaliação de risco cardíaco pré-operatório não têm demonstrado a associação entre o hábito de fumar (como variável independente) e os eventos cardíacos pós-operatórios. Nestas pesquisas, as variáveis independentes continuam sendo infarto do miocárdio prévio, insuficiência renal crônica, diabetes, angina, idade, dentre outras. OBJETIVO: Avaliar o papel do tabagismo nas complicações cardíacas pós-operatórias de operações não cardíacas. MÉTODOS: Trata-se de uma coorte retrospectiva de um Hospital Geral, onde foram incluídos 1072 pacientes. Estes foram estratificados em Tabagistas Atuais (n=265), Ex- Tabagistas (n=335) e Não Tabagistas (n=472). Os três grupos foram analisados para os desfechos cardiovasculares combinados no pós-operatório (infarto, edema pulmonar, arritmia com instabilidade hemodinâmica, angina instável; morte cardíaca) e mortalidade em 30 dias. Foram usados o teste quiquadrado e Regressão logística, considerando-se p<0,05 como significante. RESULTADOS: Os desfechos cardiovasculares combinados no pós-operatório e a mortalidade em 30 dias foram 71 (6,6%) e 34 (3,2%), respectivamente. Os Tabagistas Atuais e Pregressos apresentaram 53 (8,8%) eventos cardíacos combinados enquanto que os Não Tabagistas 18 (3,8%), p=0,002. Em relação à mortalidade, Tabagistas Atuais e Pregressos apresentaram 26 (4,3%) enquanto que os Não Tabagistas 8 (1,7%), p=0,024. Na análise multivariada, faixa etária, cirurgia de emergência, insuficiência cardíaca, sobrecarga ventricular esquerda, revascularização do miocárdio e extra-sístole ventricular associaram-se independentemente aos eventos cardiovasculares perioperatórios enquanto que faixa etária, cirurgia de emergência, insuficiência cardíaca, alterações laboratoriais, história de hepatopatia, operações por neoplasia e tabagismo se associaram a mortalidade em 30 dias após a operação de alto risco. CONCLUSÃO: Os Tabagistas atuais e pregressos apresentaram mais eventos cardíacos e mortalidade do que os Não tabagistas. Entre as variáveis independentes associadas a eventos cardíacos e mortalidade em 30 dias, o tabagismo Atual foi á única variável modificável detectada. / I NTRODUCTION: Despite the importance of smoking in the process cardiovascular disease in modern society, the assessments of cardiac risk preoperative haven´t demonstrated an association between smoking (as independent variable) and postoperative cardiac events. Generally, in the researches, indicate as independent variables : myocardial infarction, chronic renal failure, diabetes, angina, age, etc. OBJECTIVE: To assess the impact of smoking in postoperative cardiac complications of non-cardiac surgery. METHODS: A retrospective cohort study designed at General Hospital with 1072 patients. The patients were divided into Current Smokers (n = 265), Past Smokers (n = 335) and Nonsmokers (n = 462). The three groups were analyzed for combined cardiovascular outcomes in postoperative (infarction, pulmonary edema; arrhythmia with hemodynamic instability, unstable angina, cardiac death) and 30-days mortality. The chi-square test and logistic regression were used, considering p<0.05 as significant. RESULTS: The combined cardiovascular outcomes in postoperative and 30-days mortality were 71 (6.6%) and 34 (3.2%), respectively. The Current and Past Smokers presented 53 (8.8%) combined cardiac events than Nonsmokers which showed 18 (3.8%), p = 0002. The 30-days mortality, Current and Past Smokers presented 26 (4.3%) while Nonsmokers 8 (1.7%), p= 0024. At multivariate analysis, age, emergency operation, cardiac failure, left ventricular hypertrophy, coronary-artery revascularization and ventricular premature contractions were independent variables associated with postoperative cardiac events. Another hand, age, emergency operation, cardiac failure, left ventricular hypertrophy, operation of cancer, liver failure, and abnormality laboratories tests were independent variables associated with 30-days mortality after surgery. CONCLUSION: There are more cardiac events and high mortality with Current and Past smokers when compared to nonsmokers. Many independent variables were associated with cardiac postoperative cardiac events and 30-days mortality. However, Current Smoking was unique modifiable variable find out.

Introdução: O jejum prolongado pré-operatório aumenta a resistência periférica à insulina. Foi investigado se a abreviação do jejum pré-operatório com uma bebida contendo carboidrato e glutamina melhora a resposta orgânica ao trauma cirúrgico. Métodos: Quarenta e oito pacientes adultas, do sexo feminino (19-62 anos) candidatas a colecistectomia videolaparoscópica eletiva. As pacientes foram aleatoriamente divididas em quatro grupos: grupo jejum convencional (grupo Jejum), ou em três grupos para receber três tipos diferentes bebidas oito horas (400 mL) e duas horas antes da indução anestésica (200ml): água pura (grupo Placebo), água mais dextrinomaltose (grupo carboidrato; 12,5% de dextrinomaltose) e grupo glutamina (grupo glutamina; 12,5% de dextrinomaltose e respectivamente 40 e 10g de glutamina). As amostras de sangue foram coletadas no período pré e pós-operatório. Resultados: não houve nenhum evento de aspiração ou regurgitação do conteúdo gástrico manifesto por sinais e sintomas clínicos, durante a indução anestésica, ou em qualquer outro momento do estudo. Também não houve nenhum óbito ou complicação pós-operatória. A média e o erro padrão médio da resistência à insulina determinada pelo HOMA-IR realizada no pós-operatório foi maior (p<0,05) no grupo que permaneceu em jejum (4,3±1,3) quando comparado com os outros três grupos de pacientes (Placebo, 1,6±0,3); carboidrato, (2,3±0,4) e glutamina, (1,5±0,1). A medida da glutationa peroxidase sérica, medida nos dois períodos foi maior no grupo glutamina (40±3,0) que nos grupos carboidrato (32±2,0) e jejum (32±2,0) (p<0,01). Ao se comparar o comportamento da IL-6 sérica em cada grupo estudado no período pré e pós-operatório, observou-se que o grupo glutamina foi o único sem diferença, enquanto nos demais a IL-6 aumentou no pós-operatório (p<0,01). No período pós-operatório a razão proteína-C-reativa/albumina foi maior no grupo jejum quando comparado com os grupos carboidrato (p=0,04) e glutamina (p=0,01). O balanço nitrogenado acumulativo foi menos negativo no grupo glutamina (-2,5±0,8 gN) que nos grupos placebo (-9,0±2,0 gN; p=0,001) e jejum (-6,6±0,4 gN; p=0,04). Conclusão: A abreviação do jejum pré-operatório com uma bebida contendo carboidrato e glutamina melhora a resistência periférica a insulina, a resposta anti-oxidativa e diminui a resposta inflamatória de pacientes submetidas à colecistectomia videolaparoscópica eletiva / Introduction: Prolonged preoperative fasting increases insulin resistance. We investigated whether an abbreviated preoperative fast with glutamine plus a carbohydrate based beverage would improve the organic response after surgery. Methods: Forty-eight female patients (19-62 years) candidates for video-cholecystectomy were randomized to either standard fasting (fasting group) or to fasting with one of three different beverages. Beverages were consumed 8 hours (400 mL; placebo group: water; glutamine group: water with 50 g maltodextrine plus 40 g glutamine; and carbohydrate group: water with 50 g maltodextrine) and 2 hours (200 mL; placebo group: water; glutamine group: water with 25 g maltodextrine plus 10 g glutamine; and carbohydrate group: water with 25 g maltodextrine) before anesthesia. Blood samples were collected pre- and postoperatively. Results: There were no cases of regurgitation during anesthesia. The mean [SEM] postoperative HOMA-IR was greater (p<0,05) in fasted patients (4,3±1,3) than in the other groups (placebo, 1,6±0,3); carbohydrate, (2.3±0,4); and glutamine, (1,5±0,1). Glutathione peroxidase (U/g hemoglobin) was significantly higher (40±3,0) in glutamine group than both carbohydrate (32±2,0) and fasting (32±2,0) groups (p< 0,01). Interleukin-6 increased in all groups except the glutamine group. The C-reactive protein/albumin ratio was higher in fasting subjects than carbohydrate (p=0,04) and glutamine (p=0,01) groups. The nitrogen balance was less negative in glutamine (-2,5±0,8 gN) than both placebo (-9,0±2,0 gN; p=0,001) and fasting (-6,6±0,4 gN; p=0,04) groups. Conclusions: Preoperative intake of a glutamine-enriched carbohydrate beverage improves insulin resistance and antioxidant defenses, and decreases the inflammatory response after videolaparoscopic cholecystectomy

A cirurgia de cabeça e pescoço é uma importante abordagem terapêutica no tratamento do câncer de cabeça e pescoço, no entanto, além as seqüelas mais comuns decorrentes do processo cirúrgico, as complicações pulmonares são também causas importantes de morbidade e mortalidade no período pós-operatório, estando a ocorrência destas complicações associadas à existência de fatores de risco pré-operatórios. Este estudo teve por objetivo investigar a eficácia de uma proposta de protocolo de intervenções de fisioterapia respiratória pré-operatória, na prevenção de complicações pulmonares em pacientes submetidos à cirurgia por câncer de boca, laringe ou faringe. A amostra foi composta por 43 pacientes que foram avaliados prospectivamente no período pré-operatório e alocados em dois grupos estratificados de acordo com a localização do tumor. Os grupos foram compostos por 37 pacientes com diagnóstico de câncer em região de boca/orofaringe, e 6 pacientes com diagnóstico de câncer em região de laringe/hipofaringe. Para a aplicação do protocolo proposto, os pacientes foram randomizados em grupo A, onde o paciente recebeu a intervenção da fisioterapia no período pré-operatório 3 a 5 dias antes de ser submetido à cirurgia, incentivo quanto a cessação do fumo e do consumo de álcool e orientação verbal e por escrito, de execução da fisioterapia respiratória e da utilização do inspirômetro de incentivo; ou grupo B, onde o paciente recebeu incentivo quanto a cessação do fumo e do álcool, e orientação verbal e por escrito, de execução da fisioterapia respiratória. Após a randomização, foi realizada a avaliação fisioterapêutica pré-operatória que constou de anamnese completa do paciente e avaliação das condições física e respiratória. No período pós-operatório, os 43 pacientes receberam o atendimento padrão da instituição, e a coleta de informações referentes as complicações pulmonares foram monitoradas até 30 dias pós a cirurgia. Após 30 dias do procedimento cirúrgico foi realizada re-avaliação das condições física e respiratória dos pacientes. A maioria dos pacientes eram do sexo masculino com idade superior a 60 anos (média 61,4 anos), e apresentavam 2 ou mais comorbidades associadas (48,84%). Não foi observada associação entre a fisioterapia respiratória no pré-operatório com a prevenção de complicações pulmonares no pós-operatório (p=0,650). No entanto, verificou-se que os baixos valores obtidos na Pressão Expiratória Máxima no período pré-operatório (mediana 60cmH2O) demonstrou ser um fator de risco para complicações pulmonares no pós-operatório (p=0,006). Protocolos direcionados para a melhora da PE máxima devem ser testados em novos estudos / Surgery for head and neck is an important therapeutic approach in the treatment of head and neck cancer, however, beyond the most common sequel resulting from surgical procedure, pulmonary complications are important causes of morbidity and mortality in the postoperative period, and the occurrence of these complications closely related to the existence of risk factors pre-operatively. This study aimed to investigate the efficacy of a protocol of interventions preoperative respiratory therapy in the prevention of pulmonary complications in patients undergoing surgery for cancer of the mouth, larynx or pharynx. The sample comprised 43 patients who were prospectively evaluated the preoperative and assigned to two groups stratified according to tumor location. The groups were composed of 37 patients diagnosed with cancer in the region of mouth / oropharynx, and six patients diagnosed with cancer in the region of the larynx / hypopharynx. To implement the proposed protocol, patients were randomized into group A, where the patient received the intervention of physiotherapy in the preoperative period 3-5 days before undergoing surgery, as encouraging smoking cessation and alcohol consumption and verbal and written execution of respiratory therapy and the use of an incentive spirometer; group B, where the patient received incentive for smoking cessation and alcohol, and verbal and written execution of respiratory therapy. After randomization, we performed a preoperative physical therapy evaluation that consisted of complete history and evaluation of the patient\'s physical and respiratory conditions. In the postoperative period, 43 patients received standard care of the institution and the collection of information regarding pulmonary complications were monitored until 30 days after surgery. After 30 days of surgery was performed re-appraisal of the physical and respiratory patients. Most patients were males aged over 60 years (mean 61.4 years), and had two or more comorbidities (48,84%). No association was observed between the respiratory therapy preoperatively with the prevention of pulmonary complications postoperatively (p = 0.650). However, it was found that the low values obtained at maximal expiratory pressure in the preoperative period (median 60cmH2O) proved to be a risk factor for pulmonary complications postoperatively (p = 0.006). Protocols directed to improve in PE maximal should be tested in new studies

Submitted by Fabiana Gonçalves Pinto (benf@ndc.uff.br) on 2015-12-11T11:55:00Z No. of bitstreams: 1 Thalita Gomes do Carmo.pdf: 1449238 bytes, checksum: 36ba4ec665b7ebb30bea7e692a81f261 (MD5) / Made available in DSpace on 2015-12-11T11:55:00Z (GMT). No. of bitstreams: 1 Thalita Gomes do Carmo.pdf: 1449238 bytes, checksum: 36ba4ec665b7ebb30bea7e692a81f261 (MD5) Previous issue date: 2010 / Mestrado Acadêmico em Ciências do Cuidado em Saúde / O objeto desta pesquisa reside na Visita Pré-Operatória do enfermeiro com o Idoso que será submetido à Cirurgia Cardíaca. A visita de enfermagem pré-operatória enquanto rotina, em muito contribui para a redução de algumas complicações no pós-operatório de cirurgia cardíaca, a qual por vezes, tem sua base no medo do desconhecido e na ansiedade ocasionadas possivelmente pela falta de informações e orientações. Tendo em vista o aumento da expectativa de vida e sua relação com as doenças cardiovasculares, que acometem consideravelmente os idosos, levando-os a um maior risco de serem submetidos à cirurgia cardíaca, consideramos importante a assistência de enfermagem pré – operatória, nesta faixa etária. Este estudo trata-se de uma dissertação correspondente ao Mestrado Acadêmico em Ciências do Cuidado em saúde da Universidade Federal Fluminense, com o objetivo de: descrever a necessidade dos idosos em relação ao pré-operatório de cirurgia cardíaca a partir do discurso deles. E, discutir os discursos produzidos pelos idosos e as implicações para o atendimento aos padrões de conhecimento do enfermeiro no pré-operatório de cirurgia cardíaca. É uma pesquisa do tipo descritiva e exploratória, com perspectiva crítico-reflexiva, com abordagem qualitativa, do tipo pesquisa de campo. Foi realizada no Instituto Nacional de Cardiologia – RJ. Os sujeitos foram idosos de ambos os sexos internados para realizarem cirurgia cardíaca. Foram entrevistados 10 idosos, sendo 6 homens e 4 mulheres. Três deles se encontram na faixa etária entre 60 aos 65 anos, seis na faixa etária entre 66 aos 70 anos, um na faixa etária acima de 70 anos, três possuem o ensino fundamental incompleto, dois o ensino médio incompleto, quatro possuem o ensino médico completo e um possui o ensino superior. Quatro realizaram troca de válvula aórtica (TVAo), três revascularização do miocárdio (RVM), um troca de válvula aórtica com revascularização do miocárdio, um idoso submeteu-se a troca de válvula aórtica com revascularização do miocárdio mais plastia de tricúspide e um troca de válvula mitral com plastia de tricúspide. A técnica empregada foi à análise do discurso do sujeito coletivo segundo Lefèvre. Os aspectos éticos foram respeitados conforme a resolução 196/96 e a pesquisa obteve aprovação nº. 0268/26.02.2010 do Comitê de Ética em Pesquisa referente a Instituição pesquisada. Os resultados foram apresentados e discutidos a partir das cinco questões discursivas: rede de apoio familiar, padrão do conhecimento pessoal, empírico, estético e ético. Percebeu-se que a família para o idoso é vista na figura da esposa, do marido, dos filhos, sobrinhos e netos. O fato de estarem internados para se submeterem a uma cirurgia os deixa ansiosos e temerosos quanto ao futuro de seus familiares. O cuidado do enfermeiro é visto como uma atividade importante e relevante, porém os mesmos relatam um cuidar de enfermagem centrado nos aspectos biológicos do corpo. Entretanto observa-se também que esses idosos sentem necessidade de outras vertentes do cuidar, que não só a biológica. A partir do momento que entendemos melhor o cotidiano da nossa prática, vista sob o enfoque do cliente (e nesta pesquisa, do idoso) percebemos o quanto detalhes como o olhar, o toque, as palavras e os gestos podem ser importantes para o bem-estar dos mesmos. / The objective of this research lies in Nursing Care Visit during pre-operative evaluation of elderly patients scheduled to heart surgery. According to Regis and Santiago (2008) nursing visits, as a pre-operative routine, greatly contributes in reducing some complications after cardiac surgery. These are sometimes related to fear of the unknown and anxiety caused by lack of information and guidance. Nurses should be prepared to care for the elderly patient who is being prepared to heart surgery since this procedure is increasely being performed. We consider nursing care during pre-operative period of heart surgery an important factor. The nurse that takes care of these patients may ignore some of subjects needs due to the complexity of cardiac surgery and the advances in technology that involves this treatment. This study in part of a Master Degree thesis corresponding to the Academic Master of Science in Health Care at the Universidade Federal Fluminense, in order to: describe the expectations of care from elderly patients facing cardiac surgery based on the analysis of their speech b) discuss the speech of the elderly and the implications for compliance with the standards of knowledge of nurses in the pre-operative period of cardiac surgery. It is a descriptive and exploratory survey, with a critical and reflective perspective and a qualitative approach, using field research. It was held at the National Institute of Cardiology – RJ -Brazil. The subjects were old (>60 years old) patients of both sexes admitted to perform heart surgery. We interviewed 10 seniors, including 6 men and 4 women. Three of them are aged between 60 to 65 years, six aged 66 to 70 years, one aged over 70 years. Three have completed elementary school, two have an incomplete high school education, four have complete high school and one has graduated from university. Four underwent aortic valve replacement (AVR), three coronary artery bypass grafting (CABG), an aortic valve replacement with CABG, one underwent aortic valve replacement with CABG and tricuspid valve annuloplasty and one underwent a mitral valve replacement and tricuspid annuloplasty. The technique used was the analysis of the collective subject discourse according to Lefèvre. The ethical aspects were respected according to the Resolution 196/96 and the research was approved under the number 0268/26.02.2010 from the Research Ethics Committee from the National Institute of Cardiology. The results were presented and discussed based on the five essay questions that emerged after the interviews. It was felt that the family, from elderly point of view, is seen in the figure of the wife, husband, sons, nephews and grandchildren. The fact they are hospitalized to undergo a surgery leaves them anxious and fearful about the future of their families. The nursing care is viewed as an important and relevant activity, but only focused on the biological aspects of the body. Nonetheless it was observed that these individuals feel the need for other aspects of care, not just the biological one. Once we understand better the daily aspects of our practice, viewed from the standpoint of the client (in this research, the elderly) we may realize how small details such as the look, touch, words and gestures may be important to the their well-being.

Bakgrund: Tidigare forskning visar att det finns flera faktorer som bidrar till preoperativ oro, vilket är ett tillstånd som kan orsaka flera negativa konsekvensen både i direkt anslutning till operation som långt senare efter operation. Ett av målen vid ett preoperativt möte mellan anestesisjuksköterskan och patienten är att anestesisjuksköterskan ska minska patientens stress. Därmed är det av värde att göra en översikt avseende aktuell forskning kring omvårdnadsåtgärder som kan vidtas av anestesisjuksköterskor för att lindra preoperativ oro. Syfte: Studiens syfte var att beskriva vilka omvårdnadsåtgärder som kan att vidtas av anestesisjuksköterskor för att lindra preoperativ oro hos patienten. Metod: Metod var integrerad litteraturöversikt bestående av 20 vetenskapliga artiklar, varav 14 kvantitativa och sex kvalitativa. Vid litteratursökning användes databaserna CINAHL och PubMed. Resultat: Analysen resulterade i fyra kategorier som beskriver omvårdnadsåtgärder som anestesisjuksköterskor kan vidta för att lindra preoperativ oro: Individanpassa den preoperativa informationen, Skapa en bekväm miljö, Bemöta individanpassat och empatiskt och Ha en lugnande närvaro och kommunikation. Slutsats: Analysen resulterade i fyra distinkta kategorier gällande omvårdnadsåtgärder mot preoperativ oro. Utifrån komfortteorin är det möjligt att anföra att om anestesisjuksköterskor kombinerar omvårdnadsåtgärder från de fyra kategorierna för att lindra patienters preoperativa oro har patienter större möjlighet att nå total komfort. Framtida forskning behövs avseende effekten av omvårdnadsåtgärder som utförs av just anestesisjuksköterskor samt effekten av patientens egna strategier för att lindra preoperativ oro. / Background: Previous research has identified several factors contributing to patients experiencing preoperative anxiety, which is a condition that can cause several negative consequences both directly in connection with the surgery, as well as long after the surgical procedure. One of the aims during a preoperative meeting between the nurse anesthetist and the patient is for the nurse anesthetist to ease the patient’s stress. Thus, it is of value to conduct and overview of current research regarding nursing interventions that can be conducted by nurse anesthetists to alleviate preoperative anxiety. Aim: The aim of the study was to describe what nursing interventions that nurse anesthetists can conduct to alleviate a patient’s preoperative anxiety. Method: Integrative literature review consisting of 20 scientific articles, of which 14 were quantitative and six qualitative. The literature search was conducted in the databases CINAHL and PubMed. Result: The analysis resulted in four categories describing nursing interventions that nurse anesthetists can conduct to alleviate a patient’s preoperative anxiety: Individualize the preoperative information, Create a comfortable environment, Treat individually and empathically and Have a soothing presence and communication. Conclusion: The integrative literature review with data from the 20 scientific articles resulted in four categories describing nursing interventions to alleviate preoperative anxiety. It is possible to say, based on the theory of comfort, that the patient has a greater chance to reach total comfort if nurse anesthetists combine multiple nursing interventions from the four categories to alleviate the patient’s preoperative anxiety. Future research is suggested to focus on the effect of nursing interventions performed by nurse anesthetists and the effect of the patient’s own strategies to alleviate preoperative anxiety.

A cirurgia de cabeça e pescoço é uma importante abordagem terapêutica no tratamento do câncer de cabeça e pescoço, no entanto, além as seqüelas mais comuns decorrentes do processo cirúrgico, as complicações pulmonares são também causas importantes de morbidade e mortalidade no período pós-operatório, estando a ocorrência destas complicações associadas à existência de fatores de risco pré-operatórios. Este estudo teve por objetivo investigar a eficácia de uma proposta de protocolo de intervenções de fisioterapia respiratória pré-operatória, na prevenção de complicações pulmonares em pacientes submetidos à cirurgia por câncer de boca, laringe ou faringe. A amostra foi composta por 43 pacientes que foram avaliados prospectivamente no período pré-operatório e alocados em dois grupos estratificados de acordo com a localização do tumor. Os grupos foram compostos por 37 pacientes com diagnóstico de câncer em região de boca/orofaringe, e 6 pacientes com diagnóstico de câncer em região de laringe/hipofaringe. Para a aplicação do protocolo proposto, os pacientes foram randomizados em grupo A, onde o paciente recebeu a intervenção da fisioterapia no período pré-operatório 3 a 5 dias antes de ser submetido à cirurgia, incentivo quanto a cessação do fumo e do consumo de álcool e orientação verbal e por escrito, de execução da fisioterapia respiratória e da utilização do inspirômetro de incentivo; ou grupo B, onde o paciente recebeu incentivo quanto a cessação do fumo e do álcool, e orientação verbal e por escrito, de execução da fisioterapia respiratória. Após a randomização, foi realizada a avaliação fisioterapêutica pré-operatória que constou de anamnese completa do paciente e avaliação das condições física e respiratória. No período pós-operatório, os 43 pacientes receberam o atendimento padrão da instituição, e a coleta de informações referentes as complicações pulmonares foram monitoradas até 30 dias pós a cirurgia. Após 30 dias do procedimento cirúrgico foi realizada re-avaliação das condições física e respiratória dos pacientes. A maioria dos pacientes eram do sexo masculino com idade superior a 60 anos (média 61,4 anos), e apresentavam 2 ou mais comorbidades associadas (48,84%). Não foi observada associação entre a fisioterapia respiratória no pré-operatório com a prevenção de complicações pulmonares no pós-operatório (p=0,650). No entanto, verificou-se que os baixos valores obtidos na Pressão Expiratória Máxima no período pré-operatório (mediana 60cmH2O) demonstrou ser um fator de risco para complicações pulmonares no pós-operatório (p=0,006). Protocolos direcionados para a melhora da PE máxima devem ser testados em novos estudos / Surgery for head and neck is an important therapeutic approach in the treatment of head and neck cancer, however, beyond the most common sequel resulting from surgical procedure, pulmonary complications are important causes of morbidity and mortality in the postoperative period, and the occurrence of these complications closely related to the existence of risk factors pre-operatively. This study aimed to investigate the efficacy of a protocol of interventions preoperative respiratory therapy in the prevention of pulmonary complications in patients undergoing surgery for cancer of the mouth, larynx or pharynx. The sample comprised 43 patients who were prospectively evaluated the preoperative and assigned to two groups stratified according to tumor location. The groups were composed of 37 patients diagnosed with cancer in the region of mouth / oropharynx, and six patients diagnosed with cancer in the region of the larynx / hypopharynx. To implement the proposed protocol, patients were randomized into group A, where the patient received the intervention of physiotherapy in the preoperative period 3-5 days before undergoing surgery, as encouraging smoking cessation and alcohol consumption and verbal and written execution of respiratory therapy and the use of an incentive spirometer; group B, where the patient received incentive for smoking cessation and alcohol, and verbal and written execution of respiratory therapy. After randomization, we performed a preoperative physical therapy evaluation that consisted of complete history and evaluation of the patient\'s physical and respiratory conditions. In the postoperative period, 43 patients received standard care of the institution and the collection of information regarding pulmonary complications were monitored until 30 days after surgery. After 30 days of surgery was performed re-appraisal of the physical and respiratory patients. Most patients were males aged over 60 years (mean 61.4 years), and had two or more comorbidities (48,84%). No association was observed between the respiratory therapy preoperatively with the prevention of pulmonary complications postoperatively (p = 0.650). However, it was found that the low values obtained at maximal expiratory pressure in the preoperative period (median 60cmH2O) proved to be a risk factor for pulmonary complications postoperatively (p = 0.006). Protocols directed to improve in PE maximal should be tested in new studies

Le cholangiocarcinome (CC) est une tumeur maligne au pronostic péjoratif dont le traitement repose sur la résection chirurgicale. Il représente 3 % de l’ensemble des cancers digestifs et il est la deuxième tumeur primitive du foie, en fréquence, derrière le carcinome hépatocellulaire. L’âge moyen est de 70 ans avec une prédominance masculine. On distingue actuellement les cholangiocarcinomes intra et extra-hépatiques. La survie est inférieure à 5% à 5 ans tous stades confondues. 60 à 70 % sont des tumeurs de la convergence des canaux biliaires appelées également tumeurs de Klatskin.Le but de ce travail était de répondre aux interrogations persistantes concernant le cholangiocarcinome péri-hilaire (CCPH) en appliquant différentes méthodes statistiques sur différentes bases de données et revue de la littérature.Les trois axes principaux de ce travail s’articulent selon la temporalité de prise en charge, du diagnostic aux suites post-opératoires en passant par la mise en condition préopératoire.Le premier axe repose sur une base de données locale (registre de cancer digestif du Calvados). Les résultats montrent que le CCPH constitue seulement un tiers des cholangiocarcinomes dans la population générale, que son taux d’incidence est stable avec néanmoins une diminution d’incidence, bien que non-significative, chez les femmes ayant un CCPH et que le sexe féminin est un facteur pronostic négatif pour la survie à 5 ans. Le deuxième axe concernait la prise en charge préopératoire des patients, notamment l’optimisation préopératoire du foie restant par le drainage biliaire. Ce travail repose sur deux méta-analyses. Il a permis de mettre en évidence la supériorité de la voie radiologique sur la voie endoscopique concernant les complications liées à la procédure mais en revanche, l’absence de différence significative sur la morbi-mortalité post-résection hépatique, la survie à 5 ans, la survie sans récidive et le taux de dissémination liée à la procédure quand les procédures sont étudiées en intention de traiter. Nos résultats suggèrent qu’un mauvais choix de voie d’abord pour réaliser le drainage biliaire conduit à des échecs répétés qui influencent la récidive tumorale et donc la survie. Le troisième axe s’intéressait aux facteurs pronostiques de morbi-mortalité immédiates post-résection hépatique à partir d’une base de données Européenne (base de l’association Française de chirurgie). Les résultats montrent que la surface corporelle ≥ 1.82 m², l’hyperbilirubinémie > 50 µmol/l et la résection hépatique droite sont des facteurs prédictifs indépendants influençant la mortalité post-opératoire à 30 jours. / Cholangiocarcinoma (CC) is a malignant tumor with a poor prognosis. Its treatment is based on surgical resection. It accounts for 3% of all digestive cancers and is the second primary tumor of the liver, in frequency, after hepatocellular carcinoma. The average age is 70 years old with male predominance. At present intra and extrahepatic cholangiocarcinomas are distinguished. Survival rate is less than 5% at 5 years in all stages. 60 to 70% are tumors of the biliary convergence also called Klatskin tumors.The aim of this work was to answer persistent questions about peri-hilar cholangiocarcinoma (PHCC) by applying different statistical methods on different databases and review of the literature.The three main axes of this work are articulated according to the temporality of management, from the diagnosis to the postoperative follow-up, going through the preoperative setting.The first axis is based on a local database (registry of digestive cancer of Calvados). The results show that PHCC accounts for only one third of cholangiocarcinomas in the general population, that its incidence rate is stable with a decrease in incidence, although not significant, in women having PHCC and that female gender is a negative prognostic factor for 5-year survival. The second axis concerned the preoperative management of patients, including preoperative optimization of the remaining liver by biliary drainage. This work is based on two Meta-analyzes. It made it possible to highlight the superiority of the radiological way in the endoscopic way concerning the complications related to the procedure but on the other hand, the absence of significant difference on the morbi-mortality post hepatic resection, the survival at 5 years, the recurrence free survival and the rate of dissemination related to the procedure when the procedures are studied in intent to treat. Our results suggest that a poor choice of pathway for achieving biliary drainage leads to repeated failures that influence tumor recurrence and thus survival. The third axis was concerned with the prognostic factors of immediate morbidity and mortality after hepatic resection from a European database (base of the French association of surgery). The results show that body surface area ≥ 1.82 m², hyperbilirubinemia > 50 μmol / l and right hepatic resection are independent predictors influencing post-operative mortality at 30 days.

Bakgrund: Postoperativt delirium (POD) är en allvarlig komplikation till hjärtkirurgi och anestesi. Det är ett akut konfusionstillstånd som orsakar lidande för patienter och anhöriga. Det associeras med många negativa konsekvenser som förlängd sjukhusvistelse, ökad dödlighet och nedsatt kognitiv och funktionell återhämtning. POD kan påverka livskvaliteten senare i livet och det är av betydelse att tillståndet förebyggs, diagnosticeras och behandlas tidigt. Syfte: Syftet var att identifiera peroperativa riskfaktorer som kan påverka utvecklingen av POD hos patienter som genomgår hjärtkirurgi. Metod: En litteraturstudie med systematisk sökning med 14 inkluderade studier som redovisats i en narrativ sammanställning efter Bettany-Saltikov och McSherry (2016) analysmetod. Resultat: Analysen resulterade i sex teman: Patienters bakgrund och sjukhistoria, Patienters hemodynamik, Patienters behov av läkemedel, Patienter i mekanisk ventilation, Patienter i hjärt-lungmaskin och Patienters operationstid som kan påverka utveckling av POD vid hjärtkirurgi. Slutsats: Utvecklingen av POD är dålig förstådd trots många studier och det beror på att det är multifaktorellt. Föreliggande studie bekräftar detta då inga generella slutsatser kan dras utifrån studiens resultat. Det verkar vara av betydelse att upprätthålla en välbalanserad peroperativ anestesi i synnerhet då det handlar om äldre och multisjuka. Patienter upplever lidande vid POD och är i behov av trygghet, värdighet och säkerhet med helhetlig omvårdnad för patienter och anhöriga. Ytterligare forskning behövs i syfte att utarbeta riktlinjer för att förebygga POD och nå konsensus kring riskfaktorer för POD. / Background: Postoperative delirium (POD) is a serious complication of cardiac surgery and anesthesia. It is an acute confusion condition that causes suffering for patients and relatives. It is associated with many negative consequences such as prolonged hospitalization, increased mortality and reduced cognitive and functional recovery. POD can affect the quality of life later in life and it is imperative that this condition is prevented, diagnosed and treated at an early stage. Preoperative risk factors are well studied, but preoperative risk factors for POD that anesthetic nurses could influence are less known. Purpose: The purpose of this systematic literature study was to identify preoperative risk factors that may affect the development of POD in patients undergoing cardiac surgery. Method: A literature study with systematic search including 14 studies reported in a narrative compilation following Bettany-Saltikov and McSherry (2016) method of analysis. Results: The analysis resulted in six themes: Patients background and medical history, Patients hemodynamics, Patients need for drugs, Patients duration on mechanical ventilation, Patients duration in cardiac pulmonary bypass (CPB) and Patients operation time that can influence the development of POD during cardiac surgery. Conclusion: The development of POD is poorly understood despite many studies and this is because it is multifactorial. The present study confirms this as no general conclusions can be drawn from the study's results. It seems to be important to maintain a well-balanced peroperative anesthesia, especially when it comes to the elderly and comorbidities. Patients experience suffering from POD and need support, dignity and security with comprehensive care for patients and their relatives. Further research is needed in order to develop guidelines to prevent POD and reach a consensus on risk factors for POD.

Introduktion: Vården som operationssjuksköterskan bedriver ska ske i enlighet med etiska riktlinjer och lagar. Kognitiv funktionsnedsättning innebär intellektuell nedsättning där bristande kommunikationsförmåga och förståelse kan föreligga. Studier har visat att etiska dilemman kan uppstå vid omvårdnad av kognitivt funktionsnedsatt patient. Syfte: Syftet med studien var att beskriva operationssjuksköterskors erfarenheter och upplevelser av etiska dilemman vid pre- och intraoperativ vård av patienter med kognitiv funktionsnedsättning. Metod: Konventionell, kvalitativ innehållsanalys (Hsieh &amp; Shannon, 2005) med induktiv ansats och semistrukturerade intervjuer (n=10) användes. Strategiskt- och bekvämlighetsurval användes. Resultat: Resultatet gav tre kategorier med totalt sju subkategorier. Operationssjuksköterskorna upplevde svårigheter med att definiera etiska dilemman. Det definierades som situationer där en vårdhandling önskas utföras men patienten inte vill deltaga på grund av begränsad förståelse. Etiska dilemman kunde vara vård under tvång eller avgöra huruvida anhöriga bör närvara. Konklusion: Etiska dilemman var svårt att definiera för operationssjuksköterskor. De upplevde att rädsla hos patienten kan leda till att etiska dilemman uppstår. Operationssjuksköterskorna beskrev åtgärder och arbetssätt för att motverka etiska dilemman, vilket kan användas till förbättringsarbete och vidare forskning. Det är av vikt att ta sig tid och arbeta för att främja autonomin och personcentrera vården och undvika rädsla, därmed motverka etiska dilemman. / Introduction: As a theatre nurse, nursing care should be performed in relation to ethical guidelines and laws. Cognitive impairment implies intellectual impairment where difficulties in communication and understanding may be present. Studies have shown that ethical dilemmas can arise when nursing patients with cognitive impairment. Aim: The aim of this study was to describe the theatre nurses’ experiences of ethical dilemmas in pre- and intraoperative nursing of patients with cognitive impairment. Method: A conventional, qualitative content analysis (Hsieh &amp; Shannon, 2005) with an inductive approach and semi-structured interviews (n=10) was used. Purposive and convenience sampling methods were used. Results: The results showed three categories with a total of seven subcategories. The theatre nurses experienced difficulties in defining ethical dilemmas. It was defined as situations in which a caring intervention wishes to be conducted, yet the patient refuses to participate due to limited understanding. Forced care or determine whether a patient’s relative should participate could be ethical dilemmas. Conclusion: Ethical dilemmas were difficult for the theatre nurses to define. They experienced that patients’ fear may result in ethical dilemmas. The theatre nurses described working methods to avoid ethical dilemmas, which might be used for improvements within the clinic as well as in further research. It is important to dedicate time to work towards person-centered care and to avoid fear, and accordingly counteract ethical dilemmas.

Bakgrund: Oro och ångest är ett vanligt förekommande problem hos patienter som inväntar operation. Sjuksköterskan har till uppgift att uppmärksamma och identifiera patientens individuella behov preoperativt men ansvarar även för att stötta, lugna och trösta patienten utifrån hans eller hennes behov. Oro och ångest kan yttra sig fysiskt såväl som psykiskt och dessa oroskänslor orsakar ett lidande för patienten samtidigt som det ökar risken för ett sämre postoperativt förlopp. Syfte: Att belysa patienters värderingar av omvårdnadsåtgärder som kan lindra preoperativ oro och ångest som är relevanta för den grundutbildade sjuksköterskan att använda sig av. Metod: För att besvara valt syfte gjordes en litteraturstudie med kvantitativ ansats. Sökningarna genomfördes i PubMed och CINAHL. Resultatet baserades på tio kvantitativa vetenskapliga artiklar som belyste preoperativ oro och ångest inför ett elektivt kirurgiskt ingrepp. Resultat: Studierna i resultatet belyste ett antal olika patientperspektiv och värderingar på de omvårdnadsåtgärder som visat sig lindra preoperativ oro och ångest. Resultatet mynnade ut i tre huvudkategorier där olika värderingar belystes; patienters tillgång till information, användandet av musik och relationsfördjupning mellan vårdgivare och patient för att stärka patientens egenmakt pre- och postoperativt. I resultatet beskrivs även vilka åtgärder som inte haft någon effekt alternativt orsakat patienten oroskänslor preoperativt. Slutsats: Utökad information utformad på patientens villkor, användandet av musik preoperativt och att arbeta enligt Peplau’s relationsfördjupande modell är kliniskt tillämpbara verktyg som kan gynna patienten och lindra preoperativ oro och ångest. / Background: Preoperative anxiety is a common issue among patients undergoing surgery. The nurse has a responsibility to be attentive and identify the patient's individual needs before surgery. It is important that the patient is supported, reassured and comforted by the nurse based on his or her needs. Anxiety and worry can manifest themselves physically as well as mentally and these feelings cause suffering for the patient as well as an increased risk of a negative postoperative outcome. Purpose: The aim was to investigate the impact of different nursing measures on a patient’s preoperative anxiety and explain how patient values these measures. The measures are intended to be relevant and applicable to nurses. Method: The study was designed as a quantitative literature review. The search was conducted through the databases PubMed and CINAHL. The result is based on ten quantitative articles that include discussion of preoperative anxiety for patients undergoing an elective surgical procedure. Result: The nursing measures that were shown to reduce preoperative anxiety can be split into three categories; a patient’s access to information, the use of music, and a relationship development between the caregiver and patient in order to empower the patient both pre- and postoperatively. The measures were also examined to show which interventions didn’t have an effect or worse – caused the patient distress. Conclusion: Increased access to information on the patient’s terms, the use of pre-operative music, and working with Peplau’s relationship model are nursing measures which can be applied within the working environment in order to benefit patients in reducing preoperative worry and anxiety.