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Plus de la moitié des enfants survivant à une maladie critique sont anémiques à leur sortie des soins intensifs pédiatriques (SIP). Cette proportion est inquiétante puisqu’il existe une association entre l’anémie et un développement neurocognitif anormal chez le jeune enfant. Les causes d’anémie aux soins intensifs sont multiples. Le volume de sang prélevé à visée diagnostique est un facteur de risque probable mais aussi un facteur de risque qui est potentiellement modifiable. Ce mémoire explore la contribution des prélèvements sanguins à la prévalence d’anémie chez les enfants atteints d’une maladie critique. L’objectif global est d’une part d’évaluer les pratiques cliniques actuelles de prélèvements sanguins et d’autre part d’évaluer les stratégies étudiées dans la littérature pouvant nous permettre de réduire de manière sécuritaire les quantités de sang retirées à ces enfants. On présente deux articles : une étude de cohorte prospective observationnelle des pratiques de prélèvements sanguins dans notre service de soins intensifs pédiatriques ainsi qu’un scoping review de la littérature des interventions visant à réduire les pertes sanguines à visée diagnostique. La 1ère étude souligne le problème d’anémie iatrogène aux soins intensifs pédiatriques. Cette étude démontre que le volume de sang prélevé pour des raisons diagnostiques est significatif et égal à environ 5% du volume de sang circulant total. Nous démontrons également qu’il y a une association entre les prélèvements sanguins et un risque élevé d’anémie à la sortie des soins intensifs. La 2ème étude résume la littérature actuelle des stratégies efficaces destinées à réduire le sang prélevé en volume et fréquence, réduire l’anémie et également les besoins en transfusion. Les systèmes de prélèvement à circuit clos, les tubes de petit volume, et les tests sanguins réalisés au chevet pour répondre à une question clinique, sont tous des interventions prometteuses. La modification des habitudes de prescription de l’équipe médicale semble également essentielle. Ce mémoire nous permettra de mieux comprendre le problème de l’anémie iatrogène chez les enfants admis aux soins intensifs. Il est important de continuer à améliorer notre pratique actuelle et de minimiser le volume de sang prélevé et/ou gaspillé. / More than 50% of pediatric intensive care unit (PICU) survivors are anemic at PICU discharge. This proportion is worrisome because of the known negative association between anemia and neurocognitive development of young children. The etiology of critical care anemia is multifactorial. Diagnostic blood sampling is an iatrogenic contributor to this problem, but it is also a potentially modifiable factor. The overall objective of our project is to explore current clinical practice for diagnostic blood sampling in PICU and to look for solutions to improve patient care. In this thesis, we present two articles: a prospective observational cohort study, conducted in our PICU, and a scoping review of the existing literature on interventions to minimize diagnostic blood loss. The 1st study highlights the existing problem of iatrogenic anemia in PICU. Our study demonstrates that the volume of blood sampled for diagnostic purposes is significant. Nearly 5% of total circulating blood volume is removed from a critical ill child during a PICU stay. This study detected an association between blood sampling volume and a higher risk of anemia at PICU discharge. The 2nd study summarizes current evidence on efficacious strategies to minimize blood sampling volume and frequency, anemia, and transfusion. Closed blood sampling devices, small volume blood collection tubes, point-of-care testing, and medical education, are all promising interventions. This thesis, which includes both articles, helps us to better understand the problem of iatrogenic anemia in critically ill children admitted to the intensive care unit. It is important to continue to improve daily practice and to minimize blood volume sampled and/or wasted.

Sepsis drabbar årligen 19,4 miljoner människor. Fler och fler människor överlever behandlingen, även om mortaliteten fortfarande är hög. Många av överlevarna drabbas av komplikationer i efterförloppet som påverkar deras framtida livskvalitet. Livskvalitet är ett mångdimensionellt uttryck som har ett flertal olika definitioner. Syftet med examensarbetet var att granska befintlig forskning om hur patienter som har överlevt sepsis upplever sin livskvalitet efter att ha vårdats på en intensivvårdsavdelning. Examensarbetet genomfördes med en integrativ systematisk litteraturstudie som metod. Två huvudteman identifierades, Vem har jag blivit? och Tillgång till världen, med tre subteman vardera, förändrad bild av sig själv, relationsförändringar och känslor efter sepsis samt fysiska följder, kognitiva följer och psykiska följder. Generellt sågs ingen skillnad i livskvalitet mellan en patient med sepsis som hade vårdats på en intensivvårdsavdelning jämfört med en patient som hade vårdats på en intensivvårdsavdelning för andra diagnoser. Patienterna behöver få information om hur kroppen har förändrats och hur de själva kan påverka sin situation. De behöver också få information om var de ska vända sig när de behöver hjälp och stöd efter utskrivning. De behöver få stöd av kompetent personal som är insatta i de komplikationer som intensivvården för med sig. Vidare forskning behövs inte bara för att optimera patienternas överlevnad utan även för att optimera för en god livskvalitet efter intensivvården. / Sepsis affects approximately 19,4 million people each year. An increasing number of people survive the treatment, even though the mortality rate is still high. Many of the survivors are suffering from sequelae that is affecting their quality of life. Quality of life is a multidimensional concept with several definitions. The aim of the study was to examine existing research regarding the patients’ perceptions of their quality of life after a sepsis that required intensive care. The method used was an integrative review. Two main themes were identified, Who have I become? and Access to the world, each with three sub themes, changed view of yourself, changes in relationships and feelings after sepsis and also physical impact, cognitive impact and mental impact. There were no significant differences in quality of life between patients that had been hospitalized and admitted to intensive care for sepsis compared to patients with other diagnoses. Patients need information about how their body has changed and how they can affect their own situation but they also need information about where to turn when they need more help after discharge. They need health care professionals that understand what has happened to their bodies during intensive care and the kind of sequelae that often affects these patients. More research is needed to make sure that patients not only survive, but have a good quality of life after intensive care.

Antecedentes: La investigación de resultados o outcomes research, es el estudio de la efectividad de las diferentes intervenciones sanitarias. En el contexto constantemente cambiante de las ciencias de la salud, se hace necesario evaluar si una estrategia, un abordaje o una medida sanitaria demuestra su efectividad, entendida esta como el modo en que una intervención alcanza sus objetivos cuando se aplica en las condiciones habituales de trabajo ya que cuando se aplica en condiciones reales, suele tener una efectividad inferior a sus condiciones ideales de eficacia. Por todo ello, se hace necesario evaluar de una manera sistemática y rigurosa su efectividad. Objetivos: Los tres objetivos de esta tesis doctoral son: 1) Evaluar la efectividad de un programa de prevención y control de infecciones por COVID-19 en los profesionales sanitarios del servicio de urgencias de un hospital de tercer nivel; 2) Estimar la prevalencia de anticuerpos IgG frente a SARS-CoV-2 en profesionales sanitarios de un departamento de salud; y por último 3) Evaluar la efectividad del uso sistemático de filtros antimicrobianos en los grifos de agua de las unidades de cuidados críticos para la prevención de las infecciones asociadas a los cuidados de la salud por Pseudomonas aeruginosa. Metodología: Tesis por compendio de publicaciones. Se compone de tres publicaciones en revistas indexadas en el JCR. La metodología difiere en función del estudio, para el primer objetivo un estudio observacional en profesionales del servicio de urgencias para estudiar el impacto de la recomendación de uso de mascarilla y el de la declaración de estado de alarma mediante el programa de evaluación de riesgo biológico. Para evaluar el impacto del uso de mascarilla y el impacto del estado de alarma se comparó la incidencia acumulada en los periodos pre y post exposición y para cuantificar la magnitud de asociación y el impacto se calcularon el riesgo relativo, el riesgo atribuible y la fracción de prevención. Para el segundo objetivo un estudio observacional de tipo transversal para determinar la presencia de anticuerpos frente a SARS-CoV-2 en los profesionales sanitarios del departamento. Para estudiar la magnitud de asociación con las diferentes variables se calculó la odds ratio. Por último para el tercero de los objetivos se realizó un ensayo comunitario de intervención, no aleatorizado, cruzado y abierto en unidades de cuidados intensivos médicos y quirúrgicos determinando la tasa de incidencia de infección por Pseudomonas aeruginosa por 1000 días de estancia. Se determinó la razón de tasas entre ambos grupos. Resultados: Los principales hallazgos que se desprenden de esta tesis han sido: Entre los profesionales sanitarios del servicio de urgencias hospitalarias y los del resto del departamento de salud no hubo diferencias significativas en la prevalencia de infecciones por SARS-CoV-2 ni entre los motivos de contacto (Artículo 1). La prevalencia global de presencia de anticuerpos IgG frente a SARS-CoV-2 fue del 6,6% (Artículo 2). La incidencia de infecciones por Pseudomonas aeruginosa fue de 5,5 casos por 1000 días de hospitalización en las unidades que usaban de manera sistemática los filtros mientras que fue de 5,4 casos por 1000 días de hospitalización en aquellas que no los utilizaban de forma sistemática (Artículo 3). Conclusiones: Las principales conclusiones han sido: El programa de prevención de control de infecciones orientado al servicio de urgencias hospitalarias que determina el reconocimiento y aislamiento temprano de los pacientes con sospecha de COVID-19, la puesta en marcha de medidas de higiene respiratoria y el uso de las precauciones ampliadas de forma precoz, reduce las exposiciones sin protección de los profesionales sanitarios de urgencias y es efectivo para la prevención de la infección por SARS-CoV-2 en estos (Artículo 1). El impacto de la COVID-19 en los profesionales sanitarios del departamento de salud está igualado al de la población general de las grandes ciudades, lo que orienta sobre la efectividad del programa de prevención y control de infecciones dirigido a los profesionales sanitarios de este departamento de salud. Que los riesgos a los que están expuestos los profesionales sanitarios se igualen a los del resto de la población dependen de las recomendaciones que se establezcan en los programas y del grado de cumplimiento de estas (Artículo 2). El uso sistemático de filtros antimicrobianos en los grifos de agua de las unidades de cuidados críticos no es efectivo para la prevención de las infecciones asociadas a los cuidados de la salud por Pseudomonas aeruginosa (Artículo 3).

Patients in the intensive and critical care unit frequently undergo diagnostic radiology procedures such as computed tomography (CT) and X-ray imaging. As these patients often require respiratory assistance and are vulnerable to infection, it is important to understand the potential acute effects of these procedures on the lungs and immune system. The aim of this study was to determine the acute effects of a single clinically relevant low-dose X-ray exposure in order to establish baseline responses in markers of lung injury and immune function in a rodent model. Male Sprague-Dawley rats (200-250 g) were irradiated with 0, 2, 20 or 200 mGy whole-body X-rays in an XRAD 320 irradiator. Markers of lung injury and immune activation in the lungs and spleen were evaluated 0.5, 4, and 24 h post-irradiation to examine the acute stages of the physiological and immunological response. Intratrachaeal lipopolysaccharide (LPS) exposure was used as a positive control model of acute lung injury. Lung injury endpoints included respiratory mechanics, pulmonary oedema, arterial blood oxygenation, histological analysis, and cellular and proteinaceous infiltrate via bronchoalveolar lavage. Immunological measures in the spleen focused on splenocyte proliferation, using the MTS assay and differential cell counts before and after stimulation with LPS or concanavalin A (Con A), as compared to unstimulated cultures. Splenocyte proliferation in response to Con A, but not LPS, was significantly decreased after 200 mGy in vivo X-irradiation (repeated measures two-way ANOVA with LSD post-hoc, p=0.024). There was a non-significant trend towards increased lung tissue resistance after 200 mGy, with no significant effect on pulmonary oedema, cellular or proteinaceous infiltrate, nor other aspects of respiratory mechanics (two-way ANOVA with LSD post-hoc, p>0.05). A clear understanding of these immunological and physiological effects informs the responsible use of medical diagnostic procedures in modern medicine. Establishment of this model for the elucidation of acute immune effects of low-dose radiation will facilitate future work evaluating these parameters in disease models, mimicking patients in intensive care. / Thesis / Master of Science (MSc) / Diagnostic procedures such as computed tomography (CT) and X-ray imaging are a common part of intensive and critical care medicine. Some physicians are concerned that this exposure to diagnostic radiation may negatively affect the health of their patients, who are prone to infection and who often need a machine to breathe for them. In order for doctors to make informed decisions, the possible effects of these levels of radiation must be understood. To improve this understanding, this study looked at the short-term effects of X-ray doses on key organs affected by critical illness, the lungs, and the spleen, which is an important organ of the immune system that helps fight infection. Using an animal model, doses of X-rays in the range of diagnostic radiation (0-200 mGy) were examined and no significant effect on lung health was found. However, the highest dose of X-rays tested, which is greater than that expected for a single CT scan, did have an effect on cells from the spleen. Spleen cells are designed to multiply when they detect various types of infection, so that there are more immune cells to fight that infection. The cells from animals that were given the highest dose of X-rays didn’t multiply as much in response to infective stimulus as those from animals that received lower doses, or no X-rays at all. Overall, it seems that diagnostic radiation doesn’t have an effect in the lungs, but very high diagnostic doses could slightly affect a patient’s ability to fight infection. It is important to remember that patients in critical care are very sick, so doctors have good reason to use diagnostic tools available to them. Missing a diagnosis has major and immediate consequences, which must be balanced against the potential small risks of using radiation to make that diagnosis.

Bakgrund: Ett personcentrerat förhållningssätt innebär en holistisk syn på patienten där det etableras ett partnerskap mellan patient och sjuksköterska. Ett personcentrerat förhållningssätt upplevs svårt att implementera i det dagliga arbetet inom vården. Akutsjukvårdsmiljöer präglas av att medicinska åtgärder i första hand måste prioriteras och det finns kort om tid i kritiska situationer. Det kan uppstå en konflikt mellan personcentrerad vård och de medicinska insatserna. Syfte: Syftet var att belysa sjuksköterskans upplevelse av ett personcentrerat förhållningssätt i akutsjukvårdsmiljöer. Metod: En allmän litteraturstudie där tio artiklar granskades och bearbetades med hjälp av innehållsanalys. Resultat: Sjuksköterskan upplever att det finns hinder och främjande faktorer för ett personcentrerat förhållningssätt inom akutsjukvårdsmiljöer. Hindrande faktorer är relaterade till: tidsbrist och hög arbetsbelastning, brist på organisatoriskt stöd, begränsade rutiner, sjuksköterskans brist på intresse och emotionell stress. Främjande faktorer är relaterade till: patientrelation, kommunikation, kunskap och kompetens, samverkan i team, organisationens stöd och arbetsglädje. Konklusion: Sjuksköterskorna upplever att ett personcentrerat förhållningssätt inom akutsjukvårdsmiljöer skulle kunna förbättra vårdkvalitén och öka arbetsglädjen. / Background: A person-centred approach means a holistic view of the patient where a partnership is established between the patient and the nurse. Personcentred care is perceived as difficult to implement in the daily work in health care. Emergency care environments are characterized by the fact that medical interventions must be prioritized in the first place and there is little time available in critical situations. A conflict between person-centred care and medical interventions might occur. Aim: The aim was to illustrate the nurse’s experience of a person-centred approach in emergency care environments. Method: A general literature study in which ten articles were reviewed and processed using content analysis. Results: The nurse experienced barriers and promoting factors a person-centred approach in emergency care environments Hindering factors are related to lack of time and high workload, lack of organizational support, limiting routines, the nurse’s lack of interest and emotional stress. Promoting factors are related to patient relationship, communication, knowledge and competence, collaboration in teams, organizational support and job satisfaction. Conclusion: The nurses experience that a person-centred approach in emergency care environments could improve the quality of care and increase job satisfaction.

Att smärtlindra sederade intensivvårdspatienter vid procedurer är något som intensivvårdssjuksköterskor utför dagligen på sina arbetsplatser. Att behandla smärta är viktigt för patientens välmående samtidigt som att bedöma smärta hos en sederad patient upplevs svårare än att bedöma smärta hos en vaken patient. Syfte: Studiens syfte är att beskriva intensivvårdssjuksköterskors erfarenheter av att smärtlindra sederade intensivvårdspatienter vid procedurrelaterad smärta. Metod: En kvalitativ intervjustudie med ett induktivt förhållningssätt. Nio legitimerade sjuksköterskor med specialistutbildning inom intenssivsjukvård intervjuades till studien. Intervjuerna analyserades med kvalitativ innehållsanalys. Urval: Inklusionskriterierna var legitimerad sjuksköterska med specialistutbildning inom intensivsjukvård och en arbetslivserfarenhet av minst tre år vid en intensivvårdsavdelning samt en vilja att berätta sina erfarenheter. Resultat: Analysprocessen gav fyra kategorier: Utmaningen att bedöma smärta, Att förebygga smärta inför procedurer,  Att smärtlindra den sederade patienten vid procedurer, Samarbete och kommunikation. Slutsats: Intensivvårdssjuksköterskor använder sig av observation av patienten och sina tidigare erfarenheter för att tolka och bedöma smärta hos patienten. Studien betonar även vikten av att samarbeta i teamet runt patienten för att förebygga smärta vid olika procedurer. / <p>Presentation skett via Zoom 9/6</p>

En intensivvårdsavdelning är en miljö med mycket teknologi där fokus ofta ligger på livräddande behandling av mycket svårt sjuka patienter. Intensivvårdssjuksköterskan har inte endast ansvar om den medicinska behandling som ordineras utan förväntas även vara den som inleder och ser till att patienten mobiliseras. Tidigare forskning visar att tidig mobilisering många gånger prioriteras bort. Syftet med denna magisteruppsats var att undersöka Intensivvårdssjuksköterskans upplevelse av barriärer och möjligheter för tidig mobilisering av en patient inom intensivvården. Metoden som valts är en integrativ litteraturöversikt. Efter analys framkom totalt åtta faktorer som påverkar tidig mobilisering. Fyra faktorer relaterade till barriärer till tidig mobilisering: kunskapsbrist, resurs- och tidsbrist, kultur/teamarbete och patientrelaterade omständigheter samt fyra faktorer som beskrev möjligheter för tidig mobilisering: utbildning, multidisciplinärt samarbete, riktlinjer och motiverande faktorer. För möjliggörande av tidig mobilisering behövs mer utbildning för personalen, högre personaltäthet samt samarbete mellan olika yrkeskategorier. Forskning pekar på att tidig mobilisering är gynnsamt för patienten på många olika sätt. Att ge intensivvårdssjuksköterskan den kunskap som behövs för att mobilisering skall kunna genomföras på ett säkert sätt för både patienter och personal kan leda till mindre motstånd till tidig mobilisering, vilket skulle kunna bidra till att tidig mobilisering utförs i större utsträckning. / An intensive care unit is an environment with a lot of technology, the focus is often on life-saving treatment of very seriously ill patients. As an intensive care nurse, you are not only responsible for the medical treatment that is prescribed, but also to be the one who initiates and ensures that the patient is mobilised. Previous research shows that early mobilisation is often de-prioritised. The purpose of this master's thesis was to investigate the nurse's experience of barriers and opportunities for early mobilisation of an adult intensive care patient. The method chosen is a systematic literature review. After the analysis, a total of eight factors that influence early mobilisation emerged. Four factors for barriers to early mobilisation: lack of knowledge, lack of resources and time, culture/teamwork and patient-related circumstances and four factors for opportunities for early mobilisation: education, multidisciplinary collaboration, guidelines and motivating factors. In order to enable early mobilisation, it isnecessary to have more training for staff, higher staff density and collaboration between different professional categories. The research indicates that early mobilisation is beneficial for the patient in many ways. Giving the intensive care nurse the knowledge needed for mobilisation to be carried out safely for both patients and staff can lead to less resistance to early mobilisation, which could contribute to early mobilisation being carried out to a greater extent.

The purpose of this study was to conduct an integrated review of the literature examining the use of non-pharmacologic pain management strategies in premature neonates and to explore the relationship between health outcomes and time to discharge from the neonatal intensive care unit (NICU). Non-pharmacologic pain management strategies include human touch, facilitated tucking, non-nutritive sucking, and kangaroo care. A systematic review of the literature was conducted from multiple online databases. Peer reviewed, English-language articles containing the keywords ‘pain management’, ‘neonatal intensive care unit’, and ‘non-pharmacologic’ were included for synthesis. Exclusion criteria included articles with a focus on infants not admitted to the NICU and infants with a gestational age greater than 37 weeks. Results revealed positive outcomes when alternative pain-relieving methods, rather than drug therapy, were used in the NICU. A majority of articles suggest facilitated tucking is very successful in lowering a preterm infant’s pain. However, facilitated tucking alone was significantly less effective in relieving procedural pain compared to facilitated tucking in combination with oral sucrose administration. Kangaroo care and gentle human touch also proved to reduce physiologic and behavioral signs of pain in neonates. The literature reveled an overall positive outcome when non-pharmacologic pain interventions are used in the NICU, with some behavioral interventions showing better efficacy than others at relieving neonatal pain. None of the reviewed articles explored the relationship between reduced length of stay and parameters assessing health outcomes based on pain control in neonates. The literature indicated nurses play a significant role in the use of pain-relieving methods in neonatal populations. Implications for future research that focuses on successful behavioral based pain management strategies that assists in refining neonatal pain relief would be of great benefit to improving health outcomes related to infant survival after discharge from the NICU.

Introduction: Acute respiratory distress syndrome (ARDS), seen in critically ill patients, is a disease process that affects the lungs and directly impacts a patient’s oxygenation. Despite treatment, patients often die of ARDS secondary to systemic complications. Prone positioning has been introduced as a treatment to improve the outcomes of ARDS patients. This thesis summarized and critiqued recent literature on the outcomes of prone positioning in ARDS patients. Methodology: An initial literature search was conducted using CINAHL Plus with Text, Medline, Cochrane Database of Systematic Reviews, and US National Library of Medicine National Institutes of Health. Multiple search terms were used. Inclusion criteria consisted of peer reviewed research articles, academic journal articles, and evidence-based research or practices published within the last ten years. All studies included adult subjects and were published in the English language. Studies that did not address patient outcomes such as mortality, length of stay, or hemodynamic oxygenation were excluded from the review. Results: The review of literature contains one meta-analysis and two studies. Data indicated that prone positioning was statistically significant in reducing mortality when performed in sessions of 12 hours or longer (p=0.05). Hemodynamic oxygenation improved significantly after at least 48 hours of implementing prone positioning. There was no trend in the length of stay or duration in mechanical ventilation whether supine or prone positioning was used. Complications such as endotracheal tube dislodgement, incidence of ventilator-associated pneumonia, and pressure ulcers were reported in both supine and prone position with an increased risk of pressure ulcers and endotracheal tube obstruction in the prone position groups. Conclusions: Findings support a benefit in patient outcomes in patients placed in prone position with ARDS. Mortality was reduced when prone sessions lasted longer than 12 hours possibly due to the improvement in patient oxygenation 48 hours after initiation of prone positioning intervention. Further research is needed to solidify these findings and establish guidelines and optimal procedural methods to maximize patient outcomes and lower the incidence of patient complications.