A epidemiologia da injúria renal aguda (IRA) nos países desenvolvidos e em desenvolvimento ainda não foi sistematicamente examinada. Estudos epidemiológicos da incidência de IRA nos países em desenvolvimento são escassos e mais raros são estudos populacionais prospectivos na Amazônia brasileira. No capítulo I descreveu-se uma revisão sistemática de estudos sobre a epidemiologia da IRA em pacientes internados em unidades de terapia intensiva (UTI) publicados (2005-2015) nas bases de dados PUBMED, CENTRAL, LILACS e IBECs. Foram examinadas as diferenças na incidência de IRA, a severidade e a mortalidade; seguindo a divisão dos países de acordo com os critérios da Organização das Nações Unidas. Identificaram-se 92 estudos: 59 de países desenvolvidos, 32 de países em desenvolvimento e um estudo com dados de ambos os grupos de países. Dos estudos avaliados, 78 por cento usaram critérios padrão para definição da IRA (RIFLE, AKIN ou KDIGO). Entretanto, encontramos 11 diferentes definições para oligúria e 23 diferentes definições para a creatinina basal. Ambos os grupos relataram ocorrência de IRA na UTI de até 40 por cento . No entanto, a necessidade de diálise, tempo de permanência na UTI e as taxas de mortalidade foram maiores nos países em desenvolvimento, o que pode refletir diferenças nas condições sociais e na infraestrutura hospitalar nesses países. No capítulo II foi realizado um estudo prospectivo em todas as UTIs da cidade de Rio Branco, que atendem a cerca de 75 por cento da população do estado do Acre. Os dados foram coletados durante 18 meses nos anos 2014 e 2016. Pacientes com menos de 18 anos, doença renal crônica dialítica, transplante renal ou internação na UTI < 48 horas foram excluídos. A IRA foi diagnosticada pelo KDIGO e a mortalidade foi avaliada durante a internação na UTI, 30 e 180 dias após a alta da UTI. Dos 1494 pacientes admitidos, 1073 preencheram os critérios de inclusão. A incidência de IRA foi de 52,8 por cento , e a prevalência foi de 67,3. A diálise foi oferecida a 8,2 por cento dos pacientes que fizeram IRA na UTI. Apenas 2,2 por cento das internações foram devidas às doenças tropicais. Os fatores de risco para IRA foram: balanço hídrico positivo maior que 1500 ml / 24h (OR 2,98, p <0,001), pacientes não cirúrgicos (OR 1,69; p = 0,001), aumento de idade (OR 1,16 para aumento de 10 anos; p <0,001) e aumento do escore APACHE II (OR 1,06 para aumento de uma unidade; p <0,001). Em comparação com pacientes que não tiveram IRA, o tempo de permanência na UTI (7 vs 5 dias, p <0,001), assim como as mortalidades na UTI e no hospital (43,4 por cento vs 14 por cento , p <0,001 e 52 por cento vs 18,5 por cento , p <0,001, respectivamente) foram maiores nos pacientes que fizeram IRA na UTI. Foram fatores de risco para mortalidade nos pacientes com IRA na UTI: aumento da idade, sepse, KDIGO estágio 3, uso de ventilação mecânica, de drogas vasoativas e choque. A mortalidade precoce e tardia (até 30 ou 180 dias após a alta na UTI, respectivamente) se associou à presença de IRA. Portanto a IRA é comum em pacientes de UTI nessa região, com poucas internações por doenças tropicais e similares etiologias e fatores de risco com os países desenvolvidos; contudo, com taxas de mortalidade mais altas, o que pode representar as condições econômicas e a dificuldade no acesso aos sistemas de saúde / The epidemiology of Acute Kidney Injury (AKI) in the developed and developing world has not been systematically examined. Epidemiological studies of AKI incidence in developing countries are still scantier and scarcer are prospective population-based studies in Brazilian Amazon, a peculiar region, epidemiologically different from the others. On chapter I we describe a systematic review of published studies (20052015) identified in PUBMED, CENTRAL, LILACS, and IBECs databases using the search terms defining acute kidney injury (AKI) and intensive care unit (ICU). We examined the differences in ICUAKI incidence, severity, associated mortality and describe geographic variations based on the gross national income. We identified 92 studies: 59 from developed countries and 32 from developing countries. One study had data from both group of countries. Of these, 78 per cent used standard criteria (RIFLE, AKIN, KDIGO); however, we found 11 different definitions for oliguria and 23 different definitions for baseline creatinine. Both groups related ICUAKI incidence up to 40 per cent . However, the need for RRT, ICU length of stay and mortality rates were higher in developing countries. Despite the attempt to standardize the criteria for defining AKI, there is still no uniformity in the settings for baseline creatinine, oliguria and timeframe for AKI assessment. Differences in ICU length of stay need for RRT and mortality rates may reflect differences in the entry criteria and the social conditions, access to health care and hospital infrastructure. On chapter II, we did a prospective study on all adult patients admitted in all ICUs of Rio Branco, a western amazon region (600 square kilometers and 800,000 inhabitants). Data were collected for 18 months during the years 2014 and 2016. Patients with age under 18, chronic kidney disease stage 5, kidney transplant or ICU stay < 48 hours were excluded. AKI was diagnosed by KDIGO and mortality was assessed 30 and 180 days after ICU discharge. Of 1494 patients admitted, 1073 fulfilled selection criteria. AKI incidence was 52.8 per cent , and the prevalence was 67.3 per cent . Only 2.2 per cent had tropical diseases. Risk factors for AKI were positive fluid balance over 1500 ml/24h (OR 2.98; p <0,001), nonsurgical patients (OR 1.69; p =0,001), increased age for 10 years interval (OR 1,16; p <0,001) and increased APACHE II score (OR 1,06; p <0,001). ICU length of stay was higher in ICUAKI patients (7 vs 5 days, p <0,001), as well as ICU and hospital mortality (43.4 per cent vs 14 per cent , p <0,001 and 52 per cent vs 18.5 per cent , p <0,001, respectively) compared with no AKI patients. Risk factors for mortality in patients with AKI during ICU stay were: age, presence of sepsis, KDIGO stage 3, use of mechanical ventilation, vasoactive drugs and shock. In conclusion, we observed that AKI is common in ICU patients in the western Brazilian Amazon with few hospitalizations for tropical diseases and similar etiologies, risk factors and outcomes as in developed countries; however, with higher mortality rate that may be due to the local economic conditions and poor access to health care

Breathing is one of the basic life functions and for its proper functioning it is necessary to have the airways free and clear. One way to maintain free and open airways is the tracheostomy. Tracheostomy may be performed either by surgical or puncture method. Nursing care and its quality in patients with tracheostomy are important factors that can significantly affect postoperative complications, their course and overall clinical outcome of treatment of patients. Sufficiently qualified, knowledgeable and experienced nurse applies her knowledge in practice with a holistic view of the patient and his needs. The theoretical part of the thesis introduces us to the anatomy of the respiratory tract, the history of tracheostomy, individual methods of tracheostomy - surgical versus puncture and nursing care for adult patients with tracheostomy for intensive care. Methods: In the empirical part, the data obtained on the basis of a quantitative survey in the form of a questionnaire will be evaluated. The sample of respondents will be nurses working in the intensive care department for more than 1 year with experience in nursing care for tracheostomy. Aim of the work: Analysis of nurses awareness about different tracheostomy methods - surgical versus puncture, role of nurse in these methods, their experience...

Patient safety is of particular importance within intensive care units (ICUs), where critically ill, vulnerable patients receive complex multidisciplinary care. Prior research has indicated that improving patient safety and reducing errors within healthcare requires a focus on systems and organisational culture issues. This thesis was concerned with three studies. One focused on assessing the patient safety culture and two on quality improvement initiatives within an intensive care unit (ICU) of a large teaching hospital. The first study involved a survey of ICU consultant, registrar and nursing staff regarding aspects of safety culture. This was conducted using an existing Hospital Survey on Patient Safety Culture. Of the twelve patient safety culture composites assessed, eight had scores lower than 50%, highlighting these as areas for improvement. Overall, while the survey results revealed that teamwork within the ICU was considered a strength, event reporting and patient care handovers and transitions were both considered areas with potential for improvement. The second study focused on the evaluation of a change initiative designed to improve the handover of patient clinical information in the ICU. This study involved a survey and interviews with consultant, registrar and nursing staff before and after the introduction of a Patient Management, Plan and Progress (PMPP) document. Examination of the survey responses involved both quantitative and qualitative analysis; respondent interview transcripts were analysed using thematic analysis. The results of this study revealed resistance to, and criticisms of, the introduction of the PMPP document; the initiative failed and use of the document was discontinued. The second initiative concerned an evaluation of the impact of a hospital-wide document on improving documentation of withdrawal of patient treatment within the ICU. This involved both quantitative and qualitative analysis, with a patient medical record audit of decisions to withdraw patient treatment within the ICU before and after the introduction of an Advance Care Plan (ACP) document. ICU consultant, registrar and nursing staff were interviewed regarding the process of withdrawal of patient treatment within the ICU. Interview transcripts were analysed using a modified grounded theory approach. Results revealed that the attempt to improve the documentation of withdrawal of treatment within the ICU failed, with the ACP document remaining unused in 89% of cases and incomplete in the remaining 11%. Also, documentation of decision-making and of the process within the medical records did not improve. Before-introduction findings revealed that only 26% of medical records met the pre-existing requirements for treatment withdrawal in the ICU, and after-introduction findings revealed that only 19% of medical records audited met the requirements of the ACP document. After-audit findings also revealed significant and inappropriate increases in the involvement of an ICU registrar both as primary and secondary decision-makers. In spite of an increased awareness of ICU staff concerning the importance of improving documentation, the medical record audit revealed less compliance with the standards required for documentation. Possible reasons for the document remaining essentially unused, as revealed from interviews with staff, included: previous criticisms by the coroner when they failed to complete a similar formalised document properly; perceived logistical issues associated with obtaining required staff signatures; disagreement concerning who should be involved in documenting the withdrawal of treatment process; and the existence of an ICU subculture of practice that, in one particular aspect of documentation, was not consistent with established hospital and ICU protocol and documentation requirements. The final chapter of this thesis considered implications of the results of the studies for the planning, development, implementation and evaluation of improvement programs within the ICU setting. The results were considered within the context of organisational change management theory and research, including factors that have been found to be critical in the success or failure of change programs, such as resistance to change, the involvement of key stakeholders in the change process, leadership, communication and organisational culture. It is suggested that management consultants with organisational change expertise in the planning, development, implementation and evaluation of such programs should be involved in future quality improvement initiatives. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1297608 / Thesis (Ph.D.) -- University of Adelaide, School of Psychology, 2007

<p>Syfte med denna enkätstudie var att undersöka hälsorelaterad livskvalitet (HRQOL) tolv månader efter utskrivning från intensivvårdavdelning mellan kvinnor och män och mellan yngre (< 65 år) och äldre (≥65 år). Huvudresultatet visade att det fanns signifikanta skillnader mellan kvinnor och män hur de skattar HRQOL i delskala smärta. Ingen signifikant skillnad fanns mellan yngre och äldre. Även med ett litet antal patienter är skattad HRQOL för hela undersökningsgruppen jämförbar med större studier inom område som mäter HRQOL med SF-36.</p> / <p>The aim of the study was to assess health-related quality of life (HRQOL) twelve months after discharge from the intensive care unit (ICU) as well as to study if there were differences in HRQOL between younger (<65 years) and older (≥65 years) patients. There were significant differences between women and men in how they estimated HRQOL in the domain pain. No significant differences existed between younger and older patients and the HRQOL overall twelve months after discharge from ICU were consistent with previous HRQOL SF-36 research results even with a small sample of patients.</p>

<p>The combination of a severe systemic illness, corticosteroids, and neuromuscular blocking agents in patients on the mechanical ventilator often results in a condition known as Acute Quadriplegic Myopathy (AQM). While severe weakness of all spinal nerve innervated muscles is known to be a significant clinical characteristic of the disease, this symptom is typically not recognized until the disease has progressed to an advanced stage. End result effects have been classified, which include the loss of the thick filament, or myosin heavy chain, an in-excitable muscle membrane, and an up-regulation of protein degradation; however, there is little known about the acute stage of AQM. This project has focused on understanding the underlying mechanisms of AQM, specifically in regard to protein synthesis, both at the mRNA and nuclear transcription levels. To study the early stages of the disease two animal models have been developed: rat and pig. Further, we have examined AQM muscle tissue, to investigate the similarities of our animal models to patients, as well as to study the recovery process. Particular interest was directed on the myofibrillar proteins myosin (MyHC) and actin, as they are the primary proteins involved in muscle contraction, as well as the myosin associated proteins, myosin binding protein C and H. </p><p>At the mRNA level, MyHC and actin are both down-regulated in response to AQM. The myosin binding proteins are affected differently, with H protein increasing during severe atrophy and C protein either being slightly down-regulated or unchanged. Nuclear transcription factors were also affected, with such factors as MuRF1 and MAFbx up-regulated. </p><p>Thus far results have shown that protein synthesis is altered in AQM and largely contributes to both the development and recovery of the disease. The pathways of protein synthesis may prove to be an ideal target for the prevention of AQM and/or symptom alleviation.</p>

The combination of a severe systemic illness, corticosteroids, and neuromuscular blocking agents in patients on the mechanical ventilator often results in a condition known as Acute Quadriplegic Myopathy (AQM). While severe weakness of all spinal nerve innervated muscles is known to be a significant clinical characteristic of the disease, this symptom is typically not recognized until the disease has progressed to an advanced stage. End result effects have been classified, which include the loss of the thick filament, or myosin heavy chain, an in-excitable muscle membrane, and an up-regulation of protein degradation; however, there is little known about the acute stage of AQM. This project has focused on understanding the underlying mechanisms of AQM, specifically in regard to protein synthesis, both at the mRNA and nuclear transcription levels. To study the early stages of the disease two animal models have been developed: rat and pig. Further, we have examined AQM muscle tissue, to investigate the similarities of our animal models to patients, as well as to study the recovery process. Particular interest was directed on the myofibrillar proteins myosin (MyHC) and actin, as they are the primary proteins involved in muscle contraction, as well as the myosin associated proteins, myosin binding protein C and H. At the mRNA level, MyHC and actin are both down-regulated in response to AQM. The myosin binding proteins are affected differently, with H protein increasing during severe atrophy and C protein either being slightly down-regulated or unchanged. Nuclear transcription factors were also affected, with such factors as MuRF1 and MAFbx up-regulated. Thus far results have shown that protein synthesis is altered in AQM and largely contributes to both the development and recovery of the disease. The pathways of protein synthesis may prove to be an ideal target for the prevention of AQM and/or symptom alleviation.

Syfte med denna enkätstudie var att undersöka hälsorelaterad livskvalitet (HRQOL) tolv månader efter utskrivning från intensivvårdavdelning mellan kvinnor och män och mellan yngre (&lt; 65 år) och äldre (≥65 år). Huvudresultatet visade att det fanns signifikanta skillnader mellan kvinnor och män hur de skattar HRQOL i delskala smärta. Ingen signifikant skillnad fanns mellan yngre och äldre. Även med ett litet antal patienter är skattad HRQOL för hela undersökningsgruppen jämförbar med större studier inom område som mäter HRQOL med SF-36. / The aim of the study was to assess health-related quality of life (HRQOL) twelve months after discharge from the intensive care unit (ICU) as well as to study if there were differences in HRQOL between younger (&lt;65 years) and older (≥65 years) patients. There were significant differences between women and men in how they estimated HRQOL in the domain pain. No significant differences existed between younger and older patients and the HRQOL overall twelve months after discharge from ICU were consistent with previous HRQOL SF-36 research results even with a small sample of patients.

Patients who require mechanical ventilation (MV) are at risk for developing ventilator associated pneumonia (VAP). Nurses’ adherence to sedation vacations (SVs) has a direct impact on the development of VAP, because SVs have been shown to reduce patients’ average duration of MV and length of stay (LOS) in the intensive care unit (ICU). The purposes of this study guided by Donabedian’s (1966) model were to quantify nurses’ level of adherence to SVs, in relation to the health outcomes of critically ill patients, and identify the barriers and facilitators to performing SVs. A correlational design was used. The design included three components: abstraction of patient data from the electronic medical record (EMR) (n=79 with VAP and n=79 without VAP), administration of surveys to ICU nurses (N =34), and vignettes related to SVs. Analyses included descriptive statistics, t-tests, correlations, and analyses of covariance. Most nurses held a Bachelors degree (70.6%), had < 9 years of ICU experience (52.9%), worked in a medical ICU (47.1%), and reported high confidence in managing SVs (M =8.88, SD =1.25). The majority of patients (N =158) were Black (58.2%), males (56.3%), and on average middle-aged (M =61.5, SD =14.91), with a long ICU LOS (M =15.5, SD =11.84), extended duration of MV (M =9.5, SD =8.47), and high acuity (APACHE III) (M =70.2, SD =25.42). The nurses’ education, advanced certification, and ICU experience were not associated with the appropriate implementation of SVs in the vignettes. On average nurses’ had low scores on the vignettes (M =6.97, SD =2.21; possible range =0-14). The adherence rate of nurses’ implementation of SVs, determined using EMR data, was also low (M =24%; SD =23%). There were higher rates of SV adherence in patients without VAP (p (p < .01), and a duration of MV < 6 days (p =.04). These findings indicate that even with established protocols, nurses may not consistently implement the evidenced-based interventions that have been shown to prevent nosocomial infections. Future research is needed to improve nursing practice and the quality of care in this patient population.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

Tyrimo tikslas - ištirti intensyvios terapijos ligonių slaugymo įtaką jų gydymo baigčiai ligoninėje. Tyrimo uždaviniai. Įvertinti intensyvios terapijos skyriaus ligonių gydymo rezultatus (mirštamumą, gydymo ligoninėje laiką, pakartotinių guldymų į intensyvios terapijos skyrių, kitų komplikacijų dažnumą). Nustatyti, kokią įtaką turi intensyvios terapijos ligonių slaugos intensyvumas jų gydymo baigčiai ligoninėje. Palyginti intensyvios terapijos skyriaus ligonių gydymo baigtį ligoninėje, priklausomai nuo jų slaugos intensyvumo intensyvios terapijos skyriuje. Tyrimo objektas. Ligonių slauga intensyvios terapijos skyriuje. Tyrimo metodai. Buvo atliktas retrospektyvinis tyrimas, pasirinkta dokumentų turinio statistinė duomenų analizė, į tyrimą buvo įtraukti 261 tiriamųjų ligonių, kurie nuo 2008-07-01 iki 2008-11-01 gydėsi 15 lovų I Reanimacijos - intensyvios terapijos skyriuje VUL Santariškių klinikose, ir kurie, perkėlus iš I RITS, tęsė gydymą Santariškių klinikose bendrosiose palatose. Ligoniai, gydyti I RITS trumpiau kaip 8 valandas, t. y. tie, kurių būklė aktyviai stebėta trumpą laiką arba kurie dėl ypač sunkios būklės greitai mirė, taip pat ligoniai kurie buvo iš I RITS iškelti į kitus stacionarus, į tyrimą nebuvo įtraukti. Slaugos procesas RITS buvo apskaičiuotas individualiai vienam pacientui, taikant validizuotą, iš anglų kalbos išverstą, Terapinių Intervencijų Apskaičiavimo Skalę – 28 (Therapeutic Inervention Scoring Sistem -28 (TISS-28)). Tyrimo duomenys buvo apdoroti ir... [toliau žr. visą tekstą] / Research objective – to analyze the influence of intensive care patients nursing on their hospital outcomes. Research tasks: To evaluate the results of treatment of intensive care unit patients (mortality, duration of stay in a hospital, frequency of repeated admissions to department of intensive care and other complications). To determine the influence of intensity of care delivered to intensive care patients to their hospital outcome. To compare hospital outcomes of intensive care unit patients according to intensity of care delivered to them in department of intensive care. Object of research: Nursing of patients in unit of intensive care. Method of research: There was a retrospective research accomplished and statistic analysis of document content chosen. The research included 261 surveyed patients who were treated in fifteen-bed Ist Department of Reanimation and Intensive Therapy of Vilnius University Hospital Santariškių klinikos and who continued treatment in general-purpose wards of Santariškių klinikos after transferring from Ist ICU. Patients who stayed in Ist ICU for less than 8 hours, i.e. those whose state was actively observed for a short period or those who died because of their particularly critical state and those who were transferred from Ist ICU to other hospitals, were excluded from the research. Nursing process in ICU was evaluated for each patient individually using Therapeutic Intervention Scoring System -28 (TISS-28). Main results of research:... [to full text]