Delirium är ett akut insättande förvirringstillstånd och vanligt förekommande på intensivvårdsavdelningar. Delirium är allvarligt och livshotande med fluktuerande förlopp. Att drabbas av delirium innebär ett ökat lidande för patienten och dess anhöriga. Det medför ökade vårdtider och en stor kostnad för samhället. Det finns flera olika instrument för att identifiera delirium, CAM-ICU är det enda skattningsinstrumentet som är översatt och validerat till svenska. Kunskap saknas om bakomliggande orsaker till det bristande användandet av skattningsinstrument och om hur intensivvårdssjuksköterskan upplever det att ta hjälp av ett skattningsinstrument för att uppmärksamma delirium. Syfte med studien var att undersöka intensivvårds-sjuksköterskors upplevelse av att arbeta kliniskt med skattningsinstrumentet CAM-ICU. Den vetenskapliga ansatsen var kvalitativ, då datainsamlingen utfördes genom semistrukturerade intervjuer. Kvalitativ innehållsanalys har används för att analysera resultatet. Resultatet redovisas i form av två huvudkategorier samt fem underkategorier. I resultatet framkommer att implementering av skattningsinstrumentet CAM-ICU bidrar till en ökad medvetenhet om delirium som leder till ett förändrat vårdande av intensivvårdspatienten. Informanterna upplevde CAM-ICU som ett användbart skattningsinstrument för delirium, men för att kunna utnyttja instrumentet fullt ut, krävdes tid och erfarenhet. Ett evidensbaserat skattningsinstrument som CAM-ICU bidrar till en ökad patientsäkerhet, förbättrad vårdkvalitet och är en ekonomisk vinst för samhället. Implementering av evidensbaserat arbetssätt är tidskrävande men ger långsiktigt en bättre prognos för patienten, sjukvården och samhället. / Program: Specialistsjuksköterskeutbildning med inriktning mot intensivvård

INTRODUÇÃO: Diferentes parâmetros hemodinâmicos, incluindo os indicadores estáticos de pré-carga cardíaca como o índice de volume diastólico final ventrículo direito (IVDFVD) e parâmetros dinâmicos como a variação de pressão de pulso (VPP) têm sido usados na tomada de decisão para considerar o processo da expansão volêmica em pacientes em estado grave. O objetivo deste estudo foi comparar a reanimação por fluidos guiados tanto por VPP ou IVDFVD após choque hemorrágico induzido experimentalmente. MÉTODO: vinte e seis suínos anestesiados e ventilados mecanicamente foram alocados em três grupos: controle (Grupo I), VPP (Grupo II) e IVDFVD (Grupo III). Foi induzido choque hemorrágico por retirada de sangue até atingir a pressão arterial média de 40mmhg, que foi mantida por 60 minutos. Parâmetros foram medidos no tempo basal (B), no tempo do choque (Choque 0), sessenta minutos depois do choque (Choque 60), imediatamente depois da ressuscitação com hidroxietilamido 6% (130/0. 4) (R0), uma hora (R60) e duas horas (R120) depois ressuscitação. Os pontos de avaliação da reanimação por fluidos foram determinados pelo retorno aos valores basais iniciais de VPP e IVDFVD. A análise estatística dos dados foi baseada em ANOVA para medidas repetidas seguidos pelo teste de Bonferroni (P<0.05%). RESULTADOS: O volume e tempo para ressuscitação foram maiores no grupo III do que no grupo II (Grupo III = 1305±331ml e Grupo II = 965±245ml; p<0.05 e Grupo III = 24.8± 4.7min e Grupo II = 8.8 ± 1.3 min, p<0.01, respectivamente). Todos os parâmetros estáticos e dinâmicos, bem como os biomarcadores de oxigenação tecidual foram afetados pelo choque hemorrágico e quase todos os parâmetros foram totalmente restaurados após a reanimação em ambos os grupos. CONCLUSÃO: Neste estudo em modelo de choque hemorrágico, a reanimação guiada pelo VPP utilizou menor quantidade de fluido e menor quantidade de tempo do que quando guiado por IVDFVD derivado de cateter de artéria pulmonar. / INTRODUCTION: Different hemodynamic parameters, including static indicators of cardiac preload as right ventricular end-diastolic volume index (RVEDVI) and dynamic parameters as pulse pressure variation (PPV) have been used in the decision-making process regarding volume expansion in critically ill patients. The objective of this study was to compare fluid resuscitation guided by either PPV or RVEDVI after experimentally-induced hemorrhagic shock. METHODS: 26 anesthetized and mechanically ventilated pigs were allocated into control (Group-I), PPV (Group-II) and RVEDVI (Group- III). Hemorrhagic shock was induced by blood withdrawal to target mean arterial pressure of 40mmHg, maintained for 60 minutes. Parameters were measured at baseline, time of shock, sixty minutes after shock, immediately after resuscitation with hydroxyethyl starch 6% (130/0.4), one hour and two hours thereafter. The endpoint of fluid resuscitation was determined as the baseline values of PPV and RVEDVI. Statistical analysis of data was based on ANOVA for repeated measures followed by the Bonferroni test (P<0.05). RESULTS: Volume and time to resuscitation were higher in Group-III than in Group-II (Group-III = 1305±331ml and Group-II = 965±245ml; p<0.05 and Group-IIII = 24.8±4.7min and Group-II = 8.8±1.3 min, p<0.05, respectively). All static and dynamic parameters and biomarkers of tissue oxygenation were affected by hemorrhagic shock and nearly all parameters were restored after resuscitation in both groups. CONCLUSION: In the proposed model of hemorrhagic shock, resuscitation to the established endpoints was achieved within a smaller amount of time and with less volume when guided by PPV than when guided by pulmonary artery catheter-derived RVEDVI.

Submitted by Daniella Santos (daniella.santos@ufma.br) on 2017-06-23T11:28:33Z No. of bitstreams: 1 Rodson Glauber.pdf: 939865 bytes, checksum: a775420adfd317ae3a8530e4411d4502 (MD5) / Made available in DSpace on 2017-06-23T11:28:33Z (GMT). No. of bitstreams: 1 Rodson Glauber.pdf: 939865 bytes, checksum: a775420adfd317ae3a8530e4411d4502 (MD5) Previous issue date: 2017-03-23 / Introduction: taking care of the family within the scope of nursing assures the care planning around this social group and is based on partnership which benefits at the same time professionals, patients and families with significant contributions towards the quality and safety of care, whilst it demands for nursing the recognition that all family members are recognized as attention receivers. Objective: identifying demeanors of nurses about the importance of families in the process of care according to the dimensions of the Scale Families’ Importance in Nursing Care – Nurses Attitudes in the context of intensive therapy. Methodology: transversal and descriptive study with quantitative approach of the population of 43 intensivist nurses from two public health institutions located in São Luís, Maranhão. Data collection was carried out from May to September 2016 supported by the scale Families’ Importance in Nursing Care – Nurses Attitudes (IFCE-AE). The IFCE-AE scale is auto fill Likert type composed of 26 items with four answer options (completely disagree, disagree, agree, and completely agree). The score of each item varies from 1 to 4 and of the complete scale IFCE-AE from 26 to 104 points. The attitudes of nurses face the importance of family care relations were categorized into three independent dimensions as defined by IFCE-AE: Family: dialogue partner and coping resource, family: resource in nursing care and family burden. The collected data were inserted in database using Microsoft Access ® Program and subsequently analyzed by the software STATA ® 12.1 and the results presented according to the attitudes of each dimension of IFCE-AE through the scores average. Results: according to the IFCE-AE scale nurses showed attitudes of family care, considering the total average score was 75.1 points. When categorized by dimension the average of the family dialogue partner and coping resource was 34.4 points; in the Family resource dimension of nursing care, the score was 30.0 points and in the Family Burden the average was 10.06 points. These results suggest that the nurses of the study recognize the importance of family care. Regarding the Family dialogue partner dimension and coping resource concerning to attitudes showed that 72.1% agreed to discuss with family members during the first contact, about the care process, it saves time in future work; 83.7% always sought to know who were the family members of the patient; the main attitudes on Family dimension: nursing care resources; 97.68% of nurses accept/stated that it is important to know who were the family members of the patient; 100% agreed that a good relationship with the members of the family would give them job satisfaction; 81.39% cite the presence of family members was important to them as a nurse; In the Family burden dimension 65.12% of observed nurses disagreed that the presence of family members makes their work difficult. Conclusion: According to nurses attitudes, it was observed that the characteristics that determine care guided by horizontal, vertical and complementary relationships are marked by the opening of new and diverse opinions as well as by the reception of them and involve the ability to value the experiences of family members, flexibility, tolerance and reflective thought. / Introdução: cuidar da família no âmbito da enfermagem assegura o planejamento do cuidado em torno desse grupo social e fundamenta-se na parceria que beneficia ao mesmo tempo profissionais, pacientes e famílias com contribuições significativas para a qualidade e a segurança do cuidado, ao mesmo tempo em que demanda para a enfermagem o reconhecimento de que todos os membros da família sejam reconhecidos como receptores de atenção. Objetivo: identificar atitudes de enfermeiros sobre a importância das famílias no processo de cuidados segundo as dimensões da Escala A Importância das Famílias nos Cuidados de Enfermagem – Atitudes dos Enfermeiros (IFCE-AE) no contexto da terapia intensiva. Metodologia: estudo transversal, descritivo com abordagem quantitativa com a população de 43 enfermeiros intensivistas de duas instituições públicas de saúde localizadas em São Luís - Maranhão. A coleta de dados foi realizada no período de maio a setembro de 2016 apoiada pela escala Families’ Importance in Nursing Care – Nurses Attitudes (IFCE-AE). A escala IFCE-AE é de autopreenchimento do tipo Likert composta por 26 itens com quatro opções de resposta (discordo completamente, discordo, concordo e concordo completamente). O escore de cada item varia de 1 a 4 e da escala total IFCE-AE de 26 a 104 pontos. As atitudes dos enfermeiros frente a importância da família nas relações de cuidados foram categorizadas em três dimensões independentes como definida pela IFCE-AE: Família: parceiro dialogante e recurso de coping, família: recurso nos cuidados de enfermagem e a família fardo. Os dados coletados foram inseridos em base de dados utilizando o Programa Microsoft Access® e posteriormente analisados pelo software STATA® 12.1 e os resultados apresentados segundo as atitudes de cada dimensão da IFCE-AE por meio da média dos escores. Resultados: segundo a Escala IFCE-AE os enfermeiros apresentaram atitudes de cuidado à família, considerando que a média total do escore foi de 75,1 pontos. Quando categorizados por dimensão a média da dimensão Família parceiro dialogante e recurso de coping foi de 34,4 pontos; na dimensão Família recurso nos cuidados de enfermagem a média foi de 30,0 pontos e na dimensão Família Fardo a média foi 10,06 pontos. Estes resultados sugerem que os enfermeiros do estudo reconhecem a importância da família no cuidado. Quanto as atitudes do enfermeiro na valorização da família na Dimensão Família parceiro dialogante e recurso de coping 72,1% concordaram que discutir sobre o processo de cuidados com os membros da família no primeiro contato poupa tempo em seu trabalho futuro e 83,7% procuravam sempre saber quem eram os membros da família do paciente. As principais atitudes na dimensão Família recurso nos cuidados de enfermagem 97,68% dos enfermeiros afirmaram que é importante saber quem eram os membros da família do paciente; 100% concordaram que uma boa relação com os membros da família lhes davam satisfação no trabalho; 81,39 % citam que a presença de membros da família era importante para eles como enfermeira (o); na Dimensão Família fardo 65,12% dos enfermeiros discordaram que a presença de membros da família dificultava o seu trabalho. Conclusão: De acordo com as atitudes dos enfermeiros as características que determinam cuidados pautados em relações horizontais, verticais e complementares são marcadas pela abertura de novas e diversas opiniões assim como para o acolhimento das mesmas e envolve a capacidade de valorizar as experiências dos familiares, flexibilidade, tolerância e pensamento reflexivo.

Nos quadros de sepse ocorre o aumento da permeabilidade vascular, translocação e perda de albumina para o espaço extravascular, resultando assim em hipoalbuminemia e redução da pressão coloidosmótica plasmática. Desta forma o objetivo deste estudo foi avaliar a relação da pressão coloidosmótica com a evolução clínica de 41 cadelas com sepse grave ou choque séptico decorrente de piometra que foram submetidas a ovariosalpingohisterectomia. Para tanto, os valores da pressão arterial sistólica, do débito urinário, do lactato, do déficit de base venoso e da pressão coloidosmótica foram avaliados a cada três horas ao longo do período de internação. O momento da mensuração da pressão coloidosmótica foi distinto entre os grupos, sendo grupo I (critério clínico) (n= 21) avaliado após o fim do tratamento e no grupo II (critério quantitativo) (n= 20), as amostras foram avaliadas imediatamente após a colheita. As variáveis clínicas utilizadas como guia a administração de coloide no grupo I não apresentaram correlação com os valores de pressão coloidosmótica baixo. A administração de coloide não apresentou impacto sobre os valores de albumina e pressão coloidosmótica, bem como não interferiu na perfusão tecidual. A pressão coloidosmótica apresentou uma correlação não significativa e inversamente proporcional com o SOFA. Desta forma, a partir dos resultados obtidos é possível concluir que os valores da pressão coloidosmótica não apresentaram correlação com os valores das variáveis de perfusão tecidual; o coloide não contribuiu para a melhora da perfusão tecidual e da manutenção da pressão coloidosmótica após a administração de grandes volumes de solução cristaloide. / Sepsis induces increased vascular permeability, translocation and albumin loss to extracellular space, resulting in hypoalbuminemia and lower plasma colloid osmotic pressure. This study correlate colloid osmotic pressure with the clinical progress of 41 female dogs presenting severe sepsis or sepsis shock due to pyometra, submitted to ovario-salpingo-hysterectomy. The parameters evaluated were: systolic arterial pressure, urinary debt, blood lactate, venous base excess and colloid osmotic pressure. Samples were collected every three hours during the inpatient period. Laboratorial analysis of colloid osmotic pressure was performed in different timings: group I (clinic criteria, n=21), samples analyzed only after the end of the treatment; and group II (quantitative criteria, n=20): samples analyzed immediately after collection. The parameters were a guide to evaluate the necessity of colloid administration. We found no correlation between the parameters evaluate and the values of colloid osmotic pressure. The administration of colloid presented a non-significant and inversely proportional correlation with SOFA. We concluded that colloid osmotic pressure is not directly correlated with tissue perfusion and colloid administration does not improve tissue perfusion or colloid osmotic pressure, even after the administration of substantial volumes of crystalloid solution.

BACKGROUND: Nurses working in intensive care units (ICUs) frequently care for patients and their families at the end-of-life (EOL). Providing high quality EOL care is important for both patients and families, yet ICU nurses face many obstacles that hinder EOL care. Researchers have identified various ICU nurse-perceived obstacles, but no studies have been found addressing the progress that has been made over the last 17 years.OBJECTIVE: To determine the most common and current obstacles in EOL care as perceived by ICU nurses and then to evaluate whether or not meaningful changes have occurred since data were first gathered in 1998.METHODS: A quantitative-qualitative mixed methods design was used. A random, geographically dispersed sample of 2,000 members of the American Association of Critical-Care Nurses was surveyed.RESULTS: Five obstacle items increased in mean score and rank as compared to 1999 data including: (1) family not understanding what the phrase "life-saving measures" really means; (2) providing life-saving measures at families' requests despite patient's advance directive listing no such care; (3) family not accepting patient's poor prognosis; (4) family members fighting about use of life support; and, (5) not enough time to provide EOL care because the nurse is consumed with life-saving measures attempting to save the patient's life. Five obstacle items decreased in mean score and rank compared to 1999 data including (1) physicians differing in opinion about care of the patient; (2) family and friends who continually call the nurse rather than calling the designated family member; (3) physicians who are evasive and avoid families; (4) nurses having to deal with angry families; and, (5) nurses not knowing their patient's wishes regarding continuing with tests and treatments.CONCLUSIONS: Obstacles in EOL care, as perceived by critical care nurses, still exist. Family-related obstacles have increased over time and may not be easily overcome as each family, dealing with a dying family member in an ICU, likely has never experienced a similar situation. Based on the current top five obstacles, recommendations for possible areas of focus may include (1) improved nursing assessment regarding the health literacy of families followed with directed, appropriate, and specific EOL information, (2) improved care coordination between physicians and other health care providers to facilitate sharing care plans, (3) advanced directives that are followed as written by patients, (4) designated family contact communicating with family and friends regarding patient information, and, finally, (5) earlier, transparent discussions of patient prognoses as disease processes advance and patient conditions deteriorate.

The purpose of this qualitative pilot study is to explore the patient perspectives about what it is like to receive a bed bath. Examining studies of bath basins versus alternative methods has shown a decrease in the spread of nosocominal infections. However, there is not sufficient evidence evaluating the patient perspectives of assistive bed bathing and interactions with nurses and nursing support staff. This information can provide healthcare providers, especially nurses, with a better understanding of patient perspectives and values. It also supports the national healthcare approach towards patient-centered care.

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Sepsis is a severe life-threatening critical illness that damages multiple physiological systems. After hospital discharge, more than 70% of severe sepsis survivors report profound weakness which significantly impacts quality of life. Such weakness gives rise to new limitations of daily living, which ultimately leads to loss of independence in many patients. Despite wide recognition of this serious issue by clinicians and researchers alike, the mechanisms contributing to chronic skeletal muscle dysfunction after sepsis are not well understood. Lack of progress in this field is largely due to the absence of an appropriate animal model; current models are either too mild to induce muscle weakness or too severe and cause death within a few days. As such, this dissertation work first focused on establishing a clinically-relevant animal model of sepsis which yields surviving mice with chronic skeletal muscle weakness (Aim 1). This aim involved refining the cecal slurry injection model of polymicrobial sepsis in young adult animals, as well as optimizing the timing, duration, and dose of multiple therapeutic agents. The resulting resuscitation protocol was adapted for use in late-middle-aged animals, and muscle strength was evaluated using an ex vivo system which confirmed significant muscle weakness in sepsis survivors, long after sepsis was resolved. Next, using this novel model, we sought to characterize sepsis-induced long-term muscle dysfunction at the molecular level (Aim 2). The first set of experiments under this aim was designed to identify the primary global mechanism(s) (i.e. atrophy, polyneuropathy, and/or myopathy) responsible for muscle weakness in sepsis survivors. Analysis of the force-frequency curves and specific force measurements led to the conclusion that myopathy is the primary cause. Electron micrograph observation, functional assays, and protein analysis then showed that sepsis survivors’ skeletal muscles are characterized by profound mitochondrial abnormalities and oxidative damage. Collectively, these studies demonstrate that long-term muscle weakness is apparent in sepsis-surviving animals, and the functional decline is associated with unresolved mitochondrial damage and dysfunction. This work suggests that medical treatments beyond targeting muscle wasting alone could allow sepsis survivors to regain function and return to productive lives.

The purpose of this dissertation was to explore the physical and psychological responses to the combination of major trauma (Injury Severity Score [ISS] > 15) and variable periods of immobility. Specific aims were to: 1) develop a conceptual model that illustrates physiological and psychological alterations that occur after injury and subsequent immobility, and their association with skeletal muscle responses and recovery; 2) evaluate daily measures of skeletal muscle strength (bicep and quadricep) using dynamometry and skeletal muscle (rectus femoris and biceps brachii) muscle thickness measured with ultrasound in patients after major trauma; and 3) assess the predictive ability of anxiety and depressive symptoms after traumatic injury on delayed ambulation (> 48 hours) following hospital admission. Specific Aim 1 was addressed by development of a conceptual model to describe the association between injury responses, immobility and skeletal muscle after trauma based on a comprehensive review of the state of the science. This model guided the research reported in Aims 2 and 3. The second specific aim was addressed with the conduct of an observational study in which we evaluated daily skeletal muscle strength with dynamometry and muscle thickness with ultrasound to evaluate the impact of trauma and immobility on skeletal muscle in patients after major trauma (n = 19). Participants with delayed ambulation after trauma (more than 48 hours immobility) demonstrated significantly less muscle strength compared with those who had early ambulation (bicep: delayed ambulation 12.9 ± 3.8, early ambulation 17.7 ± 4.7, p = 0.004; quadriceps: delayed ambulation 9.9 ± 3.1, early ambulation 17.1 ± 4.6, p = 0.001). Muscle thickness was unchanged over time in those with delayed ambulation; however, in those who ambulated early, muscle thickness significantly increased by 0.17 cm (p = 0.008) from baseline to day 5. The third specific aim was addressed with data collected during the same observational study of patients after trauma (n = 19). Participants provided measures of anxiety and depressive symptoms at baseline. Anxiety was not a predictor of delayed ambulation; however, depressive symptoms increased the likelihood of delayed ambulation by 67% (Odds Ratio [OR]: 1.67, 95% CI: 1.02 – 2.72, p = 0.041). Early ambulation was associated with significantly greater muscle strength and thickness as determined by dynamometry and muscle ultrasound, and depressive symptoms significantly increased the likelihood of delayed ambulation. Systematic evaluation of the association between trauma injury, immobility, skeletal muscle function and structure, and psychological state will provide an opportunity for the appropriate evaluation after injury and development of effective, tailored interventions to improve short- and long-term physiological and psychological recovery.

Ischemic stroke is the leading cause of disability world-wide and affects over 800,000 people per year in the United States. The majority of these strokes are ischemic due to a blockage of blood flow to the brain. Damage to the brain occurs at the onset of stroke, neuronal cell death is irreversible and therefore, quick treatment to remove blockage is critical factor in the recovery from stroke. Mechanical thrombectomy as a treatment for ischemic stroke provides an ideal opportunity to collect blood distal and proximal to the cerebral thrombus to examine neurochemical changes occurring during stroke. The purpose of this dissertation was to explore the trajectory of neurochemical changes that occur in response to ischemic stroke during the first 72 hours and the physiological response from stroke patients to improve stroke outcomes. The specific aims were to: 1) to determine whether venous blood gases predict infarct volume and/or mortality in acute ischemic stroke in young male rats; 2) determine whether venous blood gases predict infarct and edema volume, and/or mortality in acute ischemic stroke in aged male and female rats; 3) compare the presence and relative concentrations of acid/base and electrolytes in static blood distal to thrombus and in peripheral blood drawn from adults who received thrombectomy for ischemic stroke and identify associations to postreperfusion functional outcomes. Specific Aim One was addressed by evaluation of young (three-month old) Sprague-Dawley rats that underwent permanent or transient middle cerebral artery occlusion (MCAO). Pre- and post-MCAO venous samples from permanent and transient models provided pH, carbon dioxide, oxygen, bicarbonate, glucose, hematocrit, hematocrit, and electrolyte values of ionized calcium, potassium and sodium. The analyses indicated that mean differences in the blood gas and electrolytes between pre- to post-MCAO and pH and iCa2+ were predictors of infarct volume in the permanent MCAO model. The second aim was addressed by evaluation of aged (18 month old) male and female rats pre-MCAO, post-MCAO, and at 72 hours of permanent MCAO venous blood gas samples (pH, carbon dioxide, oxygen, bicarbonate, glucose, hematocrit, hematocrit, and electrolyte concentrations of ionized calcium, potassium and sodium). Changes in pH (from pre-MCAO to post-MACO and post-MCAO to 72 hours) and changes in Na+ and iCa2+ (from post-MCAO to 72 hours) were predictors of infarct volume and edema volume, respectively in both sexes. Cox regression revealed there was a 3.25 times increased risk for mortality based on changes (cut-off range within -2.00 to - 7.00) in bicarbonate levels (pre- to post-MCAO). The third aim was addressed by evaluation of acid/base balance (pH, carbon dioxide, oxygen, bicarbonate, ionized calcium, potassium and sodium) of ischemic stroke patients who underwent mechanical thrombectomy. Our results suggests sex differences matter in ischemic stroke populations. Significant differences occur within proximal blood between the sexes. Additionally, females had approximately 2.5 hour increased time between stroke symptom onset to thrombectomy completion time (described as infarct time). Changes in bicarbonate and base deficit were predictors of infarct time, but only in our female population.