Submitted by Fabiana Gonçalves Pinto (benf@ndc.uff.br) on 2015-12-11T11:23:28Z No. of bitstreams: 1 Hamanda Garcia da Silva.pdf: 1092873 bytes, checksum: 54c45ec0d110fbe62868a74078f260d5 (MD5) / Made available in DSpace on 2015-12-11T11:23:28Z (GMT). No. of bitstreams: 1 Hamanda Garcia da Silva.pdf: 1092873 bytes, checksum: 54c45ec0d110fbe62868a74078f260d5 (MD5) Previous issue date: 2010 / Mestrado Profissional em Enfermagem Assistencial / A pneumonia hospitalar é a segunda causa mais comum de infecção nosocomial e apresenta elevada letalidade. Nas unidades de terapia intensiva (UTI) ela está associada à ventilação mecânica (VM) que é a infecção mais comum neste ambiente. A pneumonia associada à ventilação mecânica (PAVM) é uma infecção pulmonar que surge 48 a 72 horas após a intubação endotraqueal e instituição da ventilação mecânica invasiva. A equipe multidisciplinar envolvida no cuidado com os pacientes em terapia intensiva possui relação direta com os equipamentos utilizados, nos cuidados com as vias aéreas e procedimentos, o que pode indicar que haja relação da PAVM com o tipo de cuidado que esta equipe multiprofissional oferece, principalmente com relação aos cuidados prestados pela enfermagem, que são em maior número. A manutenção da permeabilidade das vias aéreas tem sido o maior desafio e o principal objetivo na assistência de enfermagem aos pacientes intubados e em ventilação artificial. Inúmeros são os fatores que podem contribuir para que o paciente tenha PAVM, como destaca a literatura, por exemplo: a instalação da ventilação mecânica e sedação prolongada, a forma como é realizada a técnica da aspiração endotraqueal, manutenção da cabeceira do paciente baixa, higiene oral ineficaz. Porém, mesmo não podendo afirmar que a pneumonia decorre da inobservância de medidas preventivas e procedimentos técnicos durante a realização dos cuidados aos pacientes em VM, a falta de diretrizes e educação permanente são fatores que sinalizam riscos para que esses pacientes desenvolvam PAVM, mesmo para aqueles que por outras razões não tiveram pneumonia. Logo, este estudo teve como objetivo testar os efeitos da aplicação de um protocolo com intervenção de enfermagem aos clientes ventilados mecanicamente, em resposta à implantação da sistematização da prevenção de PAVM, através de protocolo assistencial de enfermagem. Trata-se de uma pesquisa de abordagem quantitativa do tipo quase experimental na qual um grupo foi submetido ao controle (Grupo teste), representado pela aplicação de um protocolo de enfermagem elaborado através das melhores práticas estabelecidas, a pacientes ventilados mecanicamente; outro grupo foi constituído de maneira retrospectiva pela análise de resultados, adquiridos em prontuários antigos (grupo controle). Como resultados, foi identificado que o risco dos pacientes contraírem PAVM sem aplicação do protocolo foi de 20% e o risco dos pacientes contraírem PAVM com a aplicação do protocolo foi de 6%. Portanto, a redução absoluta do risco de se contrair PAVM, através da aplicação do protocolo foi de 14%. Concluiu-se que a intervenção do enfermeiro realizada diretamente na assistência ao paciente e na educação da equipe de enfermagem contribui para prevenir que os pacientes ventilados mecanicamente desenvolvessem a pneumonia associada à ventilação mecânica o que demonstra a efetividade da sua utilização, tendo em vista a incidência dessa patologia entre pacientes na terapia intensiva / Pneumonia is the second most common cause of nosocomial infection and has high mortality rates. In intensive care units (ICU) it is associated with mechanical ventilation (MV) is the most common infection in this environment. The ventilator associated pneumonia (VAP) is a lung infection that appears 48-72 hours after endotracheal intubation and invasive mechanical ventilation. The team involved in caring for patients in intensive care has a direct relationship with the equipment used, care of the airways and procedures, which may indicate that there is a relation of VAP with the type of care that provides multidisciplinary team. Particularly in relation to the care provided by nursing, which are larger. Maintaining the patency of the airways has been the greatest challenge and primary goal in nursing care to patients intubated and artificial ventilation. There are many factors that can contribute to the patient has VAP, as highlighted by the literature, for example: the installation of mechanical ventilation and prolonged sedation, the way it is, the technique of endotracheal aspiration, maintenance of the patient's bedside low, hygiene orally ineffective. However, although we can not say that pneumonia results from the failure of preventive measures and technical procedures during the course of care to patients in mechanical ventilation, the lack of guidelines and continuing education are factors that signal risk for these patients develop VAP, even for those for other reasons did not have pneumonia. Soon this study was to test the effects of a nursing intervention protocol with customers on mechanical ventilation in response to implementation of systematic prevention of VAP, using a protocol of nursing care. This is a quantitative research approach of the type in which a quasi-experimental group was subjected to the control (test group), represented by the implementation of a nursing protocol developed through best practices established for patients on mechanical ventilation and the other group consisted retrospectively by the analysis of results obtained in ancient records (control group). As a result, we identified that the risk of patients contracting VAP without application of the protocol was 20% and the risk of patients contracting VAP with the implementation of the protocol was 6%. Therefore, the absolute risk reduction of contracting VAP by implementing the protocol was 14%. Conclude that the intervention of the nurse performed directly in patient care and education of the nursing staff contributes to prevent mechanically ventilated patients develop pneumonia associated with mechanical ventilation which demonstrates the effectiveness of their use in view of the incidence of this disease among patients in intensive care

Introduktion: På en intensivvårdsavdelning vårdas patienter med livshotande tillstånd med hopp om förbättring i en högteknologisk miljö. Trots detta avlider det cirka 10% av intensivvårdspatienter årligen i Sverige. De livsuppehållande behandlingar som ges är ofta invasiva och smärtsamma. Insikten om att den livsuppehållande behandlingen inte alltid gynnar patienten, har ökat bland vårdpersonalen på intensivvårdsavdelningar. Detta leder även till att beslut om att avbryta den kurativa behandlingen och övergå till palliativ vård har ökat. Detta medför att intensivvårdssjuksköterskan kommer ofta i kontakt med vård av palliativa patienter i sin profession.  Syfte: Syftet var att undersöka intensivvårdssjuksköterskans upplevelse av vårdtillfällen inom intensivvård när kurativ behandling inte påbörjas, eller avslutas och övergår till palliativ vård. Metod: En kvalitativ metod med deskriptiv design användes för att genomföra studien. Datainsamlingen genomfördes genom semistrukturerade öppna intervjuer. Kvalitativ innehållsanalys användes för att analysera datan. Resultat: Analysen resulterade i ett tema en vilja att lindra lidande för både patient och närstående och fyra kategorier: IVA-sjuksköterskans upplevelse av att vårda döende patienter, IVA sjuksköterskans delaktighet i beslut, IVA-sjuksköterskans upplevelse av att involvera närstående i beslutsfattandet, samt IVA-sjuksköterskans upplevelse av frustration över beslutsprocess. Konklusion: Intensivvårdssjuksköterskor upplevde inte det som känslomässigt påfrestande att vårda palliativa patienter men upplevde istället att processen fram till att beslutet att övergå från kurativ behandling till palliativ vård var frustrerande. Kommunikation angavs som en nyckelfaktor under hela beslutsprocessen. Detta gällde både kommunikationen inom vårdlaget och kommunikationen med närstående. / Introduction: Patients with a life-threatening illness are admitted to the ICU with hope of recovery. ICU patients receive advanced life-saving treatment in a high technological environment. About 10% of ICU patients die regardless of the invasive and sometimes painful treatment received. Health care professionals have however gained insight that the life-saving treatment patients receive can sometimes be futile. This has even lead to an increase of ending curative treatment in ICU patients hence starting end-of-life care. This means that the ICU nurses often experience giving end-of-life care to ICU patients in their profession. Aim: The aim was to study ICU nurses’ experiences of withholding or withdrawing curative treatment and the transition to end-of-life care. Method: A qualitative method with a descriptive design was used to conduct the study. Data were collected using semi-structured, open interviews, and analyzed using qualitative content analysis. Results: The analysis of data resulted in a theme: an intention to alleviate the patient’s and relatives’ suffering, and four categories: ICU nurses’ experiences of caring for the dying ICU patient, ICU nurses’ experiences of being involved in the decision-making process, ICU nurses’ experiences of involving the relatives in the decision-making process, and ICU nurses’ feelings of frustration over the decision-making process. Conclusion: The ICU nurses did not experience emotional distress due to providing end-of-life care to ICU patients. However, the process of transition from curative treatment to end-of-life care was frustrating for ICU nurses. Communication, both within the health-care team and between the ICU nurses and the relatives, was a key factor during the entire decision-making process.

La surveillance des infections acquises en réanimation (IAR) représente un outil majeur dans la stratégie de lutte contre les infections nosocomiales. Nous avons enrichi la base de données de surveillance REA-RAISIN avec des données médico-administratives du PMSI afin de disposer d’informations sur l’hospitalisation complète et d’analyser des facteurs de risques supplémentaires. L’étude descriptive détaillée des 11 années de notre cohorte a permis de montrer des variations temporelles et les groupes les plus à risque. L’estimation de l’impact de ces IAR sur la mortalité et la durée de séjour nécessite des techniques statistiques multiples afin de prendre en compte les biais dont la durée d’apparition de l’IAR et le risque compétitif. Cet impact dépend du type d’IAR. La mortalité est très impactée par les bactériémies, peu par les pneumopathies et pas par les infections urinaires. L’augmentation de la durée de séjour est la plus importante pour les pneumopathies, suivie des infections urinaires et est modérée pour les bactériémies. L’étude du portage de S. aureus méticillino-résistant est parue insuffisante pour détecter des épidémies. / Monitoring the infection acquired in intensive care units (ICU-AI) is a strategic tool for the control of hospital-associated infections. We enhanced the national surveillance database REA-RAISIN with the local diagnosis-related group database. This allows us to have data on the whole hospitalization and assess additional risk factors. The assessment of the impact of these ICU-AI on mortality and length of stay needs appropriate and multiple statistical analysis to take in account various potential bias, including time-dependent bias and competitive risk. This impact is a function of the kind of IAR. Mortality is most affected by bacteremia, more lightly by pneumonia and stay equivalent for patients with or without urinary tract infections. On the other hand, excess of length of stay was the most important for patients with pneumonia and urinary tract infections but moderate for those with bacteremia.Finally, studying the carriage of methicillin-resistant S. aureus appeared insufficient to detect outbreaks and does not measure the risk associated with SASM carriage.

The principal aim of the thesis titled "Physiotherapy at Chronic Intensive Care Unit" (CICU) is to describe and analyze the not much known area of physiotherapy at the CICU and the various methods of its utilization. The thesis is structured in order to deal with the system at CICU, the typology of patients, physiotherapeutic methods and the ventilator modes. The patient should be taken care of by the multidisciplinary team which should cooperate in order to achieve a common goal - consecutive weaning followed by the liberating from the ventilator's support. The chapters about ergotherapy and psychological effects complete the overview of the topic. Practical part of the thesis consists of the survey file which represent the patient-family-doctor-physiotherapist point of view. Powered by TCPDF (www.tcpdf.org)

Les infections néonatales tardives (INT, survenant après 3 jours de vie) sont fréquentes et sont associées à une mortalité et une morbidité importantes chez les nouveau-nés prématurés. Dans ce contexte, il a été récemment décrit un clone de Staphylococcus capitis, appelé NRCS-A, impliqué spécifiquement dans ces INT dans différents services de réanimation néonatale (RN) à travers la France, et présentant un profil multirésistant atypique chez cette espèce, incluant notamment une sensibilité diminuée à la vancomycine, qui est pourtant l'antibiotique de première ligne en cas de suspicion d'INT. Dans le cadre de ce travail, nous avons démontré la distribution endémique du clone NRCS-A dans au moins 17 pays à travers le monde, spécifiquement dans les services de RN. De plus des données épidémiologiques issues des services de RN français ont identifié une prévalence élevée du clone dans certains services, illustrant sa capacité à s'implanter puis à persister dans ces services. Une caractérisation génétique du clone NRCS-A a été réalisée afin de mettre en évidence d'éventuels facteurs génétiques pouvant favoriser son implantation dans les services de RN. Cette analyse a démontré le rôle des éléments génétiques mobiles dans l'émergence du phénotype multirésistant du clone NRCS-A. En revanche aucun gène de virulence spécifique du clone n'a pu être mis en évidence. L'analyse des gènes spécifiques du clone a toutefois permis d'identifier le gène nsr codant pour la résistance à la nisine, bactériocine active sur de nombreuses bactéries à Gram positif et sécrétée par les bactéries de la flore commensale digestive. Ce gène pourrait donc conférer un avantage sélectif au clone NRCS-A pour s'implanter dans le microbiote des nouveau-nés prématurés. La persistance du clone dans les services de RN évoque la présence de réservoirs inertes ou humains au sein de ces services. Grâce à la mise au point d'une technique d'identification de S. capitis par gélose chromogénique sélective, nous avons pu démontrer la diffusion et la persistance de S. capitis dans un service de RN, sans toutefois identifier un réservoir unique responsable de cette colonisation. Nous avons également observé une inefficacité partielle des mesures de décontamination. Il n'existe en revanche pas de portage chronique chez le personnel soignant, ni de colonisation vaginale chez les femmes enceintes. Par ailleurs, nous avons pu mettre en évidence par repiquages successifs in vitro une capacité particulière du clone NRCS-A à acquérir de façon rapide et stable une résistance à la vancomycine sous pression de sélection par cet antibiotique. Cette capacité constitue un avantage sélectif majeur pour ce clone et pourrait avoir favorisé son implantation et sa persistance dans les services de RN où la pression de sélection par la vancomycine est élevée. Pour compléter ces résultats, une étude de cohorte prospective menée en RN a permis de démontrer que l'administration de vancomycine constituait un facteur de risque indépendant de survenue d'INT à S. capitis. Au-delà de la problématique spécifique des INT à S. capitis en RN, nos travaux illustrent plus largement un des enjeux majeurs de santé publique qui est l'impact écologique potentiel de l'utilisation des antibiothérapies probabilistes à large spectre sur l'émergence et la sélection de bactéries multirésistantes impliquées secondairement dans des infections nosocomiales. Ces travaux ouvrent de nouveaux axes de recherche concernant d'une part la meilleure compréhension de la physiopathologie des INT à S. capitis, et d'autre part plus largement les modalités de prévention des INT en RN et d'amélioration du diagnostic précoce des INT / Pas de résumé en anglais

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The field of early detection and intervention of hearing loss in neonates and infants has been marked by a growing international body of research investigating hearing screening programmes, protocols and outcomes of early detection for hearing loss. In South Africa, screening for neonates and infants in general and particularly for hearing loss is not common practice and is not meeting the needs of the South African population, with very few infants identified with hearing loss early in life. The Year 2002 Hearing Screening Position Statement recommends an intermediate step toward universal screening in the form of Targeted Newborn Hearing Screening (TNHS) as an option for developing countries with limited resources. The Neonatal Intensive Care Unit (NICU) provides a starting point for TNHS because it encompasses a number of risk factors for hearing loss. A combined descriptive and exploratory research methodology was followed to provide a comprehensive perspective on longitudinal hearing screening for NICU neonates and infants at a provincial hospital in South Africa. The quantitative methods included a structured interview to compile risk factor information. Immittance measurements used included acoustic reflex measurements, 226 Hz and 1000 Hz tympanometry. Automated Otoacoustic Emission (AOAE) as well as Automated Auditory Brainstem Response (AABR) screening was conducted. Routine follow-up visits at three month intervals were booked if a subject passed the screen and a follow-up screening for further testing was booked if a subject referred the screening. A total of 49 neonates and infants as well as mothers were enrolled in the first year and followed up for the second year of data collection period. The results indicated that the NICU had potential as platform for TNHS in South Africa. The high incidence of risk factors reported is more when compared with developed countries and highlights the importance of hearing screening in the at risk population for a developing country. The results confirmed reports that 226 Hz probe tone tympanometry produces erroneous responses in young infants. A high correspondence between high frequency tympanometry and AOAE results was found and underlines the need for differential diagnosis to accurately detect middle ear effusion and/or sensorineural hearing loss in neonates and infants. The unilateral AOAE refer rate (7%) was within range of the reported values for initial screening at discharge from the NICU. AABR results indicated a relatively high unilateral refer result (24%) and may be attributed to irritability and restlessness. The highest referral rates in the current study were recorded during the second and third visit and may be attributed to the presence of middle-ear pathology in older infants. The perceptions of mothers emphasized the lack of awareness regarding hearing and hearing loss in South Africa. Lack of knowledge may be a contributing actor to poor compliance with screening follow-up. Despite prevailing challenges, such as a low follow-up return rate, lack of awareness regarding the benefits of early detection of hearing loss, the effect of middle ear effusion on screening results, the cost of hearing screening and different priorities of the national healthcare system, such as Human Immunodeficiency Virus, demonstrated the NICU promise as platform for TNHS in South Africa. TNHS programmes may serve as starting point to direct universal neonatal hearing screening programmes in South Africa. / Dissertation (MCommunication Pathology)--University of Pretoria, 2008. / Speech-Language Pathology and Audiology / MComm Path / unrestricted

Purpose. To systematically develop and field test an intervention to engage families and healthcare teams in the decision-making process about life support for critically ill patients in the Intensive Care Unit (ICU). Setting. Adult medical-surgical ICU at a Canadian academic teaching hospital. Methods. The International Patient Decision Aid Standards (IPDAS) criteria and the Interprofessional Shared Decision Making (SDM) model guided the study of families facing decisions about life support for their relative in ICU that involved:1) systematic review; 2) qualitative descriptive study; 3) mixed methods field test of a novel patient decision aid (DA). Systematic review findings. Of 3162 citations, four trials evaluated interventions to improve communication between health professionals and patients/families. One intervention met eight of nine criteria for SDM but did not evaluate its effect on the benefit to communication. Qualitative study findings. Six family members and nine health professionals identified two options (life support or comfort care) and values associated with these options. Values included maintaining quality of life, surviving critical illness, minimizing pain and suffering, not being attached to machines, giving the family enough time to adapt emotionally to the patient’s health situation, and the judicious use of healthcare resources. Families were unlikely to become engaged without healthcare professionals making the decision explicit and minimizing other barriers across the decision-making process. Field test findings. Family members and health professionals for eight patients indicated that the DA was feasible to use, acceptable to users, had the potential to do what was intended, and did not seem to present adverse consequences to users. An enhanced delivery strategy is needed for future evaluation of its effect on facilitating patient/family involvement in decisions. Conclusions. Limited involvement of families in the process of decision-making about life support in the ICU reinforced the need for effective interventions to facilitate SDM. These studies validated the operationalization of the IPDAS criteria, as part of a systematic process for developing and field testing DAs. However, IPDAS criteria stop short of elements necessary to consider when implementing the DA in the processes of care.

Malgré les avancées en matière de prévention, Pseudomonas aeruginosa reste un pathogène fréquent et délétère en réanimation. Des facteurs de risque d’acquisition de ce micro-organisme ont déjà pu être identifiés, mais jamais dans un contexte multicentrique et rarement en ajustant sur des caractéristiques du service. Si l’analyse de la littérature était jusqu’alors en faveur d’une forte origine individuelle, la part du contexte d’hospitalisation et des caractéristiques de la réanimation paraît de moins en moins négligeable. Notre travail a permis non seulement de faire un état des lieux concernant les connaissances actuelles sur Pseudomonas aeruginosa en réanimation mais également d’identifier des profils type de patients et services de réanimation plus à risque vis à vis de ce micro-organisme. L’intérêt majeur est non seulement de pouvoir ainsi orienter les cliniciens face à une conjonction d’éléments mais surtout, là où les facteurs patients restent souvent peu modifiables, d’identifier des éléments contextuels d’acquisition sur lesquels il serait possible d’agir afin de réduire le risque infectieux. / Despite major advance in techniques and reinforcement of infection control measures, Pseudomonas aeruginosa remains frequent in intensive care unit (ICU) and is responsible for severe hospital-acquired infections. Several patient and pathogen-specific risk factors have been associated with acquisition of P. aeruginosa in ICUs Nevertheless those risk factors were identified in monocentric studies which rarely took in account the context of cares. If individual risk factors for P. aeruginosa acquisition have appeared to be predominant since then, the role of contextual variables seems to have been underestimated. This thesis provides insight into the epidemiology of P. aeruginosa in ICU, identifies individual and contextual risk factors for P. aeruginosa infection and P. aeruginosa acquisition and emphasizes the interest of contextual variables which gives new perspectives to P. aeruginosa prevention.

Dans le secteur de la santé et particulièrement en unité des soins intensifs, diverses situations cliniques sont rencontrées et l'interprétation d'une grande quantité de données, y compris celles fournies par les équipements tels que moniteurs et ventilateurs, est exigée pour une prise de décision appropriée. La disparité entre cette quantité importante d'information et la capacité humaine limitée crée une variabilité inutile à la décision clinique. Pour faire face au problème, les experts médicaux ont défini des stratégies en vue de promouvoir une pratique fondée sur les données probantes. Cette méthode est devenue un standard pour la pratique clinique et a montré beaucoup d'avantages en menant à la définition de directives spécifiques ou des protocoles précis à appliquer dans certaines situations. Cependant, l'utilisation de directives/protocoles, particulièrement dans les soins intensifs, exige une participation continue des professionnels au chevet du malade et est ainsi difficile à appliquer en pratique clinique. La définition d'assistants informatisés est une solution technologique intéressante à explorer pour faciliter l'introduction des protocoles dans la routine clinique. En ventilation mécanique, on assiste à une prise de conscience croissante sur le potentiel de l'informatisation et son applicabilité au-delà de la recherche et plus concrètement dans le soutien du clinicien dans sa prise de décision quotidienne. Ceci à travers la prise en charge des tâches répétitives et la proposition de suggestions. Ce domaine constitue un environnement idéal pour de telles applications surtout que les ventilateurs de réanimation son aujourd'hui des équipements électroniques sophistiqués qui peuvent embarquer des protocoles informatisés. L'objectif de cette thèse était d'explorer les aspects de développement, déploiement et d'efficacité des « contrôleurs intelligents » en ventilation mécanique afin d'accélérer leur création et leur adoption. Pour examiner les phases de développement et de déploiement, nous nous sommes concentrés sur l'utilisation et l'extension du SmartCare®, une plateforme logicielle qui facilite l'automatisation des procédures thérapeutiques en ventilation mécanique à partir de la modélisation des connaissances expertes jusqu'à leur exécution en temps réel dans un équipement médical. A travers une approche ascendante, en se basant particulièrement sur notre expérience pratique dans le design de contrôleurs intelligents et après l'examen de divers contrôleurs existants, l'objectif était de définir un catalogue de pièces maitresses pour la représentation des protocoles en ventilation mécanique. L'utilisation d'une ontologie du domaine assure une formalisation saine de ces pièces.Sur base de cette approche, nous avons développé un contrôleur pour l'oxygénation testé au chevet du malade. Nous rapportons ses performances comparées à la pratique standard / In healthcare, especially in critical care, various clinical situations are encountered and a huge amount of data, including those provided by equipment such as monitors and ventilators, are required for an appropriate decision-making. The mismatch between this vast amount of information and the human capability creates unnecessary variability in clinical decision. To cope with this problem, medical experts have defined specific strategy called evidence based medicine. This method has become the standard of practice and showed many benefits by leading to the definition of specific guidelines or precise protocols to follow in specific situations. However, the use of guidelines/protocols, especially in critical care, requires the continuous involvement of professionals at the patient's bedside strongly limiting their application in practice. The introduction of computerized assistants for implementing such guidelines/protocols may be an interesting technological solution. In mechanical ventilation where various protocols are available there is a growing acceptance that such computerization might be useful beyond research, in assisting clinicians in their daily decision making by taking over some routine tasks or providing suggestions. Moreover, this domain constitutes an ideal environment because mechanical ventilators are presently powerful electronic equipments in which computerized protocols can be efficiently embedded. The objective of this thesis was to explore several aspects of the development, deployment, and effectiveness of computerized protocols or smart controllers in mechanical ventilation in order to accelerate their creation and adoption. For this purpose, we focused on the use and the extension of SmartCare®, a computer framework for the automation of respiratory therapy starting from clinical knowledge modelling to execution in real time of specific routines embedded into medical products [1]. Through a reengineering approach, from practical experience in smart controller design and investigation of existing controllers, the objective was to define a catalogue of building blocks to facilitate the creation of new controllers. The modeling of such blocks using dedicated domain ontology ensures a sound formalization. To prove the effectiveness of such a generic approach, we built a smart controller for oxygenation tested on the patient's bedside. We reported its performance compared to standard therapy