Although vasovagal syncope (VVS) is a common clinical condition the mechanisms behind VVS remain elusive. Upright posture is the major trigger of VVS and lower limb blood pooling affecting cardiac output has been proposed as a major determinant. The overall aim of this thesis was twofold. First, to develop new methodology for calculating limb venous compliance. Second, to study lower limb venous volume load and cardiovascular responses during hypovolemic circulatory stress caused by lower body negative pressure (LBNP) in healthy women and women with VVS, emphasizing compensatory mechanisms to maintain central blood volume. Net fluid filtration was associated with an underestimation ofvenous compliance. This could be accounted for with a correctionmodel. Further, a new venous wall model made it possible to adopt thevenous pressure-volume curve through the entire pressure range andthus provide a valid characterization of venous compliance. Calf blood pooling was similar between the groups and was not associated with tolerance to hypovolemic circulatory stress. Venous compliance was reduced at low venous pressures in VVS and correlated with decreased tolerance to circulatory stress. VVS women displayed attenuated sympathetic vasoconstrictor responses during graded circulatory stress, and mobilization of arm capacitance blood as well as capillary fluid absorption from extra- to intravascular space were reduced. Accordingly, more pronounced reductions in cardiac output were found in VVS. Thus, reduced compensatory mechanisms to maintain cardiac output could contribute to the pathogenesis oforthostatic VVS. In healthy women, rapid pooling in the lower limb was associated with higher tolerance to circulatory stress and more efficient cardiovascular responses, in part due to speed-dependent baroreflex-mediated sympathetic activation. In VVS however, rapid lower limb blood pooling was associated with lower tolerance and deficient cardiovascular responses. No speed-dependent baroreflexmediated sympathetic activation was found in VVS, indicating welldefined differences in cardiovascular regulation already in the initial responses to orthostatic stress.

Researchers have studied memory recall of crisis-oriented or emotional events in non-educational settings. However, within the health care field, there has been a limited study of the the concept of recall of crisis oriented or emotional events in& health care education. Crisis-oriented events such as natural disasters, acts of bioterroism, and industrial accidents, have been reported to impact memory. Patient safety is a primary focus in anesthesia education, appropriate crisis management is imperative to quality anesthesia care. Due to the critical nature of anesthesia delivery, there is a strong, constant need to develop methods that will enhance, support, and improve current anesthesia practices that impact patient safety. Educational methodologies used by both clinical and didactic instructors that will improve teaching effectiveness need to be investigated to ensure that patient safety content is being delivered to nurse anesthesia students in a manner consistent with the American Association of Nurse Anesthetists (AANAs) Council on Accreditation's COAs) standards of care. Utilizing a simulated anesthesia crisis situation, this study compared the differences in cognitive imprinting and application to practice between two content delivery methods, the written case study and patient safety vignettes, in nurse anesthesia students. The control group was given a written case study which is considered a traditional method of content delivery. The treatment groups studied vignettes, which are short, realistic, simulated audio-visual videos that demonstrate content to be relayed. The research hypothesis studied the use of anesthesia crisis oriented vignettes as an educational tool to impact memory recall, thus potentially improving application to clinical practice. Hypotheses for the study were: Hypothesis 1 (Hl): Student anesthetists exposed to audio-visual vignettes will exhibit superior clinical performance during simulated apparatus-related crisis events, evidenced by higher group mean demonstration scores, when compared to a matched group exposed to written case studies. Hypothesis 2 (H2): Student anesthetists exposed to audio-visual vignettes will exhibit superior recall of apparatus related material, evidenced by higher group mean post-test scores, when compared to a matched group exposed to written case studies. Using the paired samples t-test and analysis of variance procedure (ANOVA), statistical findings were evaluated for significance. The different teaching methodologies were represented in the abbreviation of the variables studied. Two different crisis oriented events were presented in vignette format, a malfunctioning unidirectional expiratory valve and a malfunctioning suctioning apparatus. Variables that were studied include: clinical performance during the anesthesia machine checkout process by recreating the stuck expiratory valve and malfunctioning suction apparatus scenarios. Statistically, mixed results were obtained. The impact that the stuck expiratory valve vignette had on student recall and clinical performance was found to be insignificant. The impact resulting from exposure to the non-functioning suction apparatus vignette was found to be significant for both student recall and clinical performance. Other recall and clinical performance measures related to the non- functioning suction apparatus were also found to be significant. Conclusions: In this research study, memory and clinical performance were impacted when the anesthesia provider incorporated the correct anesthesia apparatus checkout process and crisis management skills into their practice. This research demonstrated that under the conditions of this study, teaching methodology impacted some areas of clinical performance. Due to the small sample size and because the clinical performance measurements tools were newly designed for this particular study, findings from this study cannot be generalized to any other group or population. However, the findings from this study merit further investigation into the potential use of vignettes as an educational methodology to impact clinical practice and improve patient safety.

Problem: There is a shortage of military certified registered nurse anesthetists (CRNAs). The exodus from military service to civilian careers could be a result of relative deprivation (the discrepancy that one perceives between what one has and what one could or should have). Relative deprivation is a perception of unfairness dependent on feelings (subjective data) as well as facts (objective data). Purpose: The purpose of this study was to measure relative deprivation in active duty military nurse anesthetists, to explore variables which correlate with relative deprivation, and to validate or refute the theory of relative deprivation in active duty military CRNAs. The study was based on research conducted by Crosby who theorized that wanting (a desire for some object or opportunity) and deserving (a feeling of entitlement to an object or opportunity) were the most relevant preconditions leading to relative deprivation. It was hypothesized that antecedent factors (years as a CRNA, pay, promotion opportunities, and scope of practice/autonomy) and psychological factors (wanting and deserving) correlate with relative deprivation. It was further hypothesized, based on the theory, that psychological factors would have more influence on relative deprivation than antecedent factors.Study design: The descriptive, correlational study was conducted using a self-administered survey sent to 435 active duty Army, Navy and Air Force CRNAs. Surveys were distributed to subjects by mail and could be answered by mail or by secured website designed specifically for the conduct of this study.Results: Response rate was 58% (n = 236). Data was analyzed using descriptive and inferential statistics. Analysis of the data revealed no significant correlation (pConclusions: Further research is indicated to identify tangible factors which can be modified to improve feelings of deprivation as they relate to retention and recruitment of military CRNAs.

Bakgrund:Befolkningen blir allt äldre och kräver en mer komplex vård, vilket gör att framtidens sjukvård måste kunna interagera med andra verksamheter. Intensivvårdssjuksköterskan och sjuksköterskan på akutmottagning har ett nära samarbete vid det akuta omhändertagandet av allvarligt sjuka patienter. Ett multiprofessionellt team i omhändertagandet ger snabbare diagnos ochhandläggning på akutmottagningen, vilket förkortar tiden till rätt vårdinstans. Professionerna i teamet kompletterar varandra, ökar patientsäkerheten och möjliggör personcentrerad vård. Ökad kunskap hos vårdpersonalen kring patientens upplevelse av det akuta omhändertagandet på akutmottagningen är väsentligt för att kunna förbättra vården för patienten i det initiala skedet, men fokus bör även riktas mot sjuksköterskors erfarenheter av akut omhändertagande för att identifiera riskfaktorer som kan påverka patienten negativt. Syfte:Syftet var att beskriva sjuksköterskans erfarenheter av akut omhändertagande av patienter med trauma och patienter med svår sepsis eller septisk chock.Metod: Metoden i studien utgick från en kvalitativ, induktiv ansats där 14 intervjuer genomfördes, varav sju var sjuksköterskor på akutmottagning och sju var intensivvårdssjuksköterskor på intensivvårdsavdelning. Samtliga intervjuer analyserades utifrån en kvalitativ, manifest innehållsanalys. Resultat: Analaysprocessen resulterade i fem olika kategorier: ‘Kommunikation är A och O’, ‘Vikten av att veta sin roll’, ‘Arbete över gränserna’, ‘Att arbeta utifrån en tydlig struktur’ och ‘Vård på olika villkor’. Slutsats: Det finns en otydlig struktur i det akuta omhändertagandet av patienter med svår sepsis eller septisk chock, som var en följd av otydliga roller och bristfällig kommunikation i omhändertagandet. Det framträder fördelar med att införa tydliga riktlinjer i det akuta omhändertagandet av patientgruppen med svår sepsis eller septisk chock, förslagsvis genom checklistor eller någon form av medicinskt larm i likhet med traumalarm, och där ett multiprofessionellt team samverkar kring patienten. / Background: The population is aging and requires more complex healthcare. This means that in the future, interaction with other healthcare departments is essential. Such interaction would lead to increased demand on the ability to cooperate among healthcare personnel. The intensivecare nurse and the nurse in the emergency department have a close cooperation when managing the acute severely ill patient. A multiprofessional team gives a faster diagnosis and management in the emergency department, which shortens the time to the final instance of care. The members of the team complement each other, increasing patient safety and enabling person-centered care. Increased knowledge with the nursing staff on the acute management in emergency department is essential to be able to enhance the care for the patient in the initial stage, but focus should also be at the nurse’s experience of the acute management to identify risk factors that could pose a negative influence on the patient.Aim: The aim of this study was to describe nurses’ experience of acute management of patients with trauma and patients with severe sepsis or septic shock.Method: The method used was a qualitative, inductive approach where 14 interviews were conducted, seven with nurses from the emergency department and seven intensive care nurses from the intensive care department. The interviews were analysed using a qualitative, manifest content analysis.Result:The analyzation process resulted in five different categories: ‘Communication is A&O’, ‘The importance of knowing one’s role’, ‘Work over the borders’, ‘Working from a clear structure’ and ‘Care on different terms’. Conclusion: There is an unclear structure in the emergency care of patients with severe sepsis or septic shock, which was a result of unclear roles and inadequate communication in the care. It appears to be advantageous to introduce clear guidelines in the emergency care of the patient group with severe sepsis or septic shock, suggestively by checklists or some medical alert like a trauma alarm, and where a multi-professional team interacts around the patient.

Bakgrund: Posttraumatiskt stressyndrom (PTSD) är ett tillstånd som kännetecknas av ångest och oro relaterat till situationer som påminner om en traumatisk händelse. Intensivvårdsrelaterad PTSD har fått ökad uppmärksamhet de senaste åren. Genom ett preventivt arbete och tidiga insatser minskar risken för att patienter utvecklar PTSD. För att detta ska ske krävs god kunskap av problemet hos intensivvårdspersonal. Hur deras erfarenheter ser ut är tidigare outforskat. Syfte: Syftet var att beskriva intensivvårdssjuksköterskors och anestesiologers erfarenheter av intensivvårdsrelaterad PTSD hos intensivvårdspatienter. Metod: En kvalitativ intervjustudie gjordes. Semistrukturerade och individuella intervjuer genomfördes med nio intensivvårdssjuksköterskor och fyra anestesiologer. Data analyserades med en kvalitativ innehållsanalys. Resultat: Analysen resulterade i tre kategorier: En känsla att vi kan göra mer, Att normalisera livet och Fortsatt stöd efter tiden på IVA. Resultatet visade att delirium upplevdes vara en ledande riskfaktor till PTSD. Relationer och kommunikation upplevdes som viktiga i det profylaktiska arbetet mot PTSD. Post-IVAmottagningar och dagböcker tros kunna bidra till bättre uppföljning och kan fungera preventivt mot PTSD. Slutsats: Resultatet visar att det finns en liten erfarenhet om PTSD efter intensivvård, ändå förekom ett omedvetet preventivt arbete. En organisatorisk satsning behövs för att öka medvetenhet hos intensivvårdspersonalen. Det behövs mer kvalitativ och kvantitativ forskning om bland annat riskfaktorer och uppföljning gällande intensivvårdsrelaterad PTSD.

Advanced practice nurses fill a vital need in the U.S. by increasing access to needed healthcare. Certified Registered Nurse Anesthetists (CRNAs) are one type of advanced practice nurse with a long history of safe and effective peri-anesthetic care. Nurse anesthetists have a rich tradition of providing anesthetic care for rural and underserved communities, and are a primary provider of anesthesia for active and retired military personnel. CRNAs comprise over one-half of the actively practicing U.S. anesthesia workforce currently, and are able to function in any anesthetic care model. Nurse anesthesia educational programs (NAEPs) are the single source for new graduate nurse anesthetists in the U.S. Demographic, geographic and epidemiological factors have combined to produce a predicted increase in the demand for peri-operative anesthesia care among a complex, aging and increasing patient population. The uninterrupted or increased supply of CRNAs to the anesthesia workforce is important. The goal of this study was the production of a comprehensive analysis of potential resource constraints upon the NAEPs in the U.S. This was accomplished through a focused, prospective and correlational research design, grounded conceptually in Resource Dependence Theory. A novel survey tool was developed for the assessment of critical resource constraints, completed by U.S. NAEP administrators and faculty. This research was exploratory in nature and is the basis for continued work in critical resource planning tools for U.S. NAEPs.

It is widely acknowledged that elevated levels of noise are commonplace in the healthcare environment, particularly in high acuity areas such as the operating room (OR). Excessive ambient noise may pose a threat to patient safety by adversely impacting provider performance and interfering with communication among perioperative care team members. With respect to the certified registered nurse anesthetist (CRNA), increased ambient OR noise may engender distractibility, diminish situation awareness and cause untoward health effects, thereby increasing the possibility for the occurrence of error and patient injury. This research project analytically examines the perceived impact of ambient noise in the operating room by CRNAs. Findings from this study reveal that CRNAs perceive elevated noise to be regularly present in the OR, specifically during the critical emergence phase of the anesthetic. However, CRNAs feel that increased noise only occasionally limits their ability to perform procedures, concentrate and communicate with the perioperative team. OR noise rarely interferes with memory retrieval. CRNAs perceive that noise is sometimes a threat to patient safety but infrequently engenders adverse patient outcomes. CRNAs do not perceive noise in the OR to be detrimental to their health but strongly agree that excessive noise can and should be controlled. Increased ambient OR noise is a veritable reality that may pose a potential threat to patient safety. Further research to identify elevations in noise during critical phases of the anesthetic and delineation of significant contributors to its genesis is warranted.

Orientador: Regina Paolucci El Dib / Resumo: Introduction: A high-quality electronic search is essential in ensuring accuracy and comprehensivness in identifying potentially relevant records in conducting a systematic review. To assist researchers in identifying terms when formulating a sensitive search strategy, librarians and educators instruct researchers to consult and include preferred and non-preferred terms of the controlled database. However, by using all available terms in the thesaurus (i.e. subject headings), strategies can be lengthy and very laborious. Objective: To identify the most efficient method for searching in both Medline through PubMed and EMBASE, covering search terms with different spellings, direct and indirect orders, and association (or lack thereof) with MeSH and EMTREE terms. Method: In our cross-sectional study of search strategies, we selected and analysed 37 search strategies specifically developed for the anesthesiology field. These search strategies were adapted in order to cover all potentially relevant search terms in terms of different spellings and direct and indirect orders, most efficiently. Results: When adapted to include different spellings and direct and indirect orders, adapted versions of the selected search strategies retrieved the same number of search results in the Medline (mean of 61,3%) and higher number in EMBASE (mean of 63,9%) of the analyzed sample. The number of results retrieved by the searches analysed was not identical using the association or not of MeSH and E... (Resumo completo, clicar acesso eletrônico abaixo) / Doutor

Bakgrund: Självmord är ett globalt hälsoproblem. Enligt WHO tar årligen 800 000 människor i världen sitt liv och suicidförsöken är långt flera. Syfte: Att beskriva intensivvårdssjuksköterskans upplevelser av att, på intensivvårdsavdelningen, vårda patienter som har utfört ett suicidförsök. Metod: Beskrivande design med kvalitativ ansats användes. Tio intensivvårdssjuksköterskor inkluderades. Datainsamlingen skedde genom semistrukturerade intervjuer och analyserades utifrån kvalitativ innehållsanalys. Resultat: Fem kategorier framkom; Att möta patienter som utfört suicidförsök är komplext, Att möta närstående till patienter som utfört suicidförsök, Att psykiatrin har betydelse för patienter som utfört suicidförsök, Att vårda patienter som utfört suicidförsök väcker flera olika känslor samt Att uppleva begränsningar och möjligheter vid omvårdnaden av patienter som utfört suicidförsök. Intensivvårdssjuksköterskorna beskrev att det var utmanande att vårda, kommunicera och bemöta patienter som utfört ett suicidförsök. Dessa patienter beskrevs som en återkommande patientgrupp som ofta hade en tidigare kontakt med psykiatrin. Närstående reagerade olika vid suicidförsök och behövde stöd enligt intensivvårdssjuksköterskornas beskrivningar. De upplevde lång väntan på psykiatrikonsulten vilket bidrog till fördröjd planering av patientens fortsatta vård. Intensivvårdssjuksköterskorna beskrev självmord som tragiskt och att det väckte olika känslor hos dem. Intensivvårdssjuksköterskorna beskrev vidare att de upplevde skillnader av suicidförsökets allvarlighetsgrad, utifrån metoden patienten använt, samt att fördomar förekom mot denna patientkategori bland deras kollegor. Intensivvårdssjuksköterskorna upplevde att de saknade kunskap om psykisk ohälsa samt önskade ett bättre samarbete med psykiatrin. Slutsats: Intensivvårdssjuksköterskorna beskrev upplevelsen av komplexiteten att vårda, kommunicera och bemöta denna patientgrupp, då de saknar kunskap samt att samarbetet med psykiatrin kan utvecklas. / Background: Suicide is a global health problem, according to WHO 800 000 people worldwide commit suicide every year and the suicide attempts are far more. Aim: To describe intensive care nurses’ (ICU nurse) experiences of taking care of patients, at an intensive care unit, who has committed a suicide attempt. Method: A descriptive design with a qualitative approach was used. Semi structured interviews with ten ICU nurses were conducted and analyzed using qualitative content analysis. Results: Five categories were found; To meet patients who has committed a suicide attempt is complicated, To meet relatives of patients who has committed a suicide attempt, To patients who has committed a suicide attempt, psychiatry has meaning, To care for patients who has committed a suicide attempt brings up a lot of emotions, and To experience limitations and possibilities when taking care of patients who has committed a suicide attempt. ICU nurses described the complexity of nursing, communicating and treating patients who have committed a suicide attempt. These patients were described as a recurrent group, who often had an earlier experience of psychiatric care. They described a variety of reactions from relatives and the relatives need for support. ICU nurses experienced a long wait for the psychiatric consultation which contributed to slowing down the planning of the patients’ continued care. ICU nurses referred to suicide as tragic and that it brings up a lot of emotions among them. They also described that they experienced differences in severity of the suicide attempt depending on the use of suicide method and that prejudices existed among colleagues. ICU nurses described they lacked knowledge about mental illness and wished for better cooperation with psychiatric care. Conclusion: ICU nurses described the complexity of nursing, communicating and treating this group of patients due to lack of knowledge and that cooperation with psychiatric care could be improved.

Parkinson’s disease (PD) is one of the most common neurodegenerative disorders and it is caused by a loss of dopamine (DA) producing neurons in the basal ganglia in the brain. The PD patient suffers from motor symptoms such as tremor, bradykinesia and rigidity and treatment with levodopa (LD), the precursor of DA, has positive effects on these symptoms. Several factors affect the availability of orally given LD. Gastric emptying (GE) is one factor and it has been shown to be delayed in PD patients resulting in impaired levodopa uptake. Different enzymes metabolize LD on its way from the gut to the brain resulting in less LD available in the brain and more side effects from the metabolites. By adding dopa decarboxylase inhibitors (carbidopa or benserazide) or COMT-inhibitors (e.g. entacapone) the bioavailability of LD increases significantly and more LD can pass the blood-brain-barrier and be converted to DA in the brain. It has been considered of importance to avoid high levodopa peaks in the brain because this seems to induce changes in postsynaptic dopaminergic neurons causing disabling motor complications in PD patients. More continuously given LD, e.g. duodenal or intravenous (IV) infusions, has been shown to improve these motor complications. Deep brain stimulation of the subthalamic nucleus (STN DBS) has also been proven to improve motor complications and to make it possible to reduce the LD dosage in PD patients. In this doctoral thesis the main purpose is to study the pharmacokinetics of LD in patients with PD and motor complications; in blood and subcutaneous tissue and study the effect of GE and PD stage on LD uptake and the effect of continuously given LD (CDS) on LD uptake and GE; in blood and cerebrospinal fluid (CSF) when adding the peripheral enzyme inhibitors entacapone and carbidopa to LD infusion IV; in brain during STN DBSand during oral or IV LD treatment. To conclude, LD uptake is more favorable in PD patients with less severe disease and GE is delayed in PD patients. No obvious relation between LD uptake and GE or between GE and PD stage is seen and CDS decreases the LD levels. Entacapone increases the maximal concentration of LD in blood and CSF. This is more evident with additional carbidopa and important to consider in avoiding high LD peaks in brain during PD treatment. LD in brain increases during both oral and IV LD treatment and the DA levels follows LD well indicating that PD patients still have capacity to metabolize LD to DA despite probable pronounced nigral degeneration. STN DBS seems to increase putaminal DA levels and together with IV LD treatment also increases LD in brain possibly explaining why it is possible to decrease LD medication after STN DBS surgery. / Parkinsons sjukdom (PS) är en av de vanligaste s.k. neurodegenerativasjukdomarna och orsakas av förlust av dopamin(DA)producerande nervceller i hjärnan. Detta orsakar motoriska symptom såsom skakningar, stelhet och förlångsammade rörelser. Levodopa (LD) är ett ämne, som kan omvandlas till DA i hjärnan och ge symptomlindring och det är oftast förstahandsval vid behandling av patienter med PS. Flera faktorer påverkar tillgängligheten av LD, bl.a. den hastighet som magsäcken tömmer sig med och denna verkar förlångsammad hos personer med PS vilket ger sämre tillgänglighet av LD i blodet och därmed i hjärnan. LD bryts även ner i hög grad av olika enzym ute i kroppen vilket leder till mindre mängd LD som hamnar i hjärnan och till fler nedbrytningsprodukter som orsakar biverkningar. Tillägg av enzymhämmare leder till ökad mängd LD som kan nå hjärnan och omvandlas till DA. Det anses viktigt att undvika höga toppar av LD i hjärnan då dessa verkar bidra till utvecklandet av besvärliga motoriska komplikationer hos patienter med PS. Om LD ges mer kontinuerligt, exempelvis som en kontinuerlig infusion in i tarmen eller i blodet, så minskar dessa motoriska komplikationer. Inopererande av stimulatorer i vissa delar av hjärnan (DBS) har också visat sig minska dessa motoriska komplikationer och även resultera i att man kan minska LD-dosen. Huvudsyftet med den här avhandlingen är att studera LD hos patienter med PS; i blod och fettvävnad då LD ges i tablettform och se om det finns något samband med LD-upptag och hastigheten på magsäckstömningen (MT) och om kontinuerligt given LD påverkar LD-upptaget eller MT; i blod och i ryggmärgsvätska då enzymhämmarna entakapon och karbidopa tillsätts LD; i hjärna vid behandling med DBS och då LD ges både som tablett och som infusion i blodet. Sammanfattningsvis kan vi se att LD-upptaget är mer gynnsamt hos patienter med PS i tidigare skede av sjukdomens komplikationsfas. MT är förlångsammad hos patienter med PS och det är inget tydligt samband mellan LD-upptag och MT eller mellan MT och sjukdomsgrad. Kontinuerligt given LD minskar LDnivåerna. Enzymhämmaren entakapon ökar den maximala koncentrationen av LD i blod och ryggmärgsvätska och effekten är mer tydlig vid tillägg av karbidopa vilket är viktigt att ta i beaktande vid behandling av PS för att undvika höga toppar av LD i hjärnan. LD ökar i hjärnan då man behandlar med LD i tablettform och som infusion i blodet och DA-nivåerna i hjärnan följer LD väl vilket visar på att patienter med PS fortfarande kan omvandla LD till DA trots trolig uttalad brist av de DA-producerande nervcellerna i hjärnan. DBS verkar öka DA i vissa områden i hjärnan och tillsammans med LD-infusion i blodet verkar det även öka LD i hjärnan och det kan förklara varför man kan sänka LDdosen efter DBS-operation.