nÃo hà / MudanÃas que aconteceram no sÃculo XX, permitiram que avanÃos tecnolÃgicos aumentassem a sobrevida diante de doenÃas anteriormente incurÃveis e processos patolÃgicos irreversÃveis. No entanto, a busca incessante pela cura, alÃm de levar ao aumento da sobrevida, tambÃm gerou a obstinaÃÃo terapÃutica, ou seja, medidas terapÃuticas fÃteis diante de evoluÃÃo inexorÃvel para a morte, impactando em indicadores como Ãndice de satisfaÃÃo do cliente e cuidadores, tempo mÃdio de permanÃncia, elevaÃÃo de custos, bem como em prejuÃzo na distribuiÃÃo equitativa de recursos. No inÃcio dos anos 90, a limitaÃÃo do suporte de vida (LSV) comeÃou a ser estudada e considerada, em paÃses da Europa, Estados Unidos, Canadà e Austrlia, como forma de assistir os pacientes nesses casos, uma vez que as medidas terapÃuticas nÃo mais trariam benefÃcios, mas gerariam prolongamento do sofrimento e do processo de morrer. No Brasil, contudo, os estudos sÃo limitados e os dados referentes ao Nordeste do paÃs sÃo ainda muito escassos. O objetivo do estudo foi caracterizar as condutas mÃdicas que antecederam o Ãbito de pacientes em UTI pediÃtrica e neonatal em um hospital de referÃncia do Nordeste Brasileiro. Foram estudados 86 prontuÃrios de pacientes que morreram nas referidas UTIs no perÃodo de dezembro/09 a novembro/10. Apenas 3,5% dos Ãbitos ocorreram apÃs LSV registrada em prontuÃrio, destes 33,7% tinham doenÃa crÃnica associada, sendo as neoplasias as mais comuns. As causas de Ãbito mais comuns foram sepse (23,5%), falÃncia de mÃltiplos ÃrgÃos (18,8%), insuficiÃncia respiratÃria (12,9%), cardiopatias congÃnitas (8,2%) e as outras causas somaram 36,6%. A maior parte dos pacientes morreu apÃs aumento das medidas de suporte avanÃado de vida, considerando as ultimas 24h antes do Ãbito: drogas vasoativas (59,3% 24h antes e 70,9% no momento do Ãbito); VentilaÃÃo mecÃnica (89,5% 24h antes e 95,2% no momento do Ãbito). Enquanto as medidas de cuidados e conforto nÃo tiveram a mesma expressÃo, tendo um aumento irrelevante: sedaÃÃo (39,5% 24h antes e 43% no momento do Ãbito); analgesia (60% 24h antes e 60,5% no momento do Ãbito). As manobras de ressuscitaÃÃo cardiopulmonar foram registradas em 4,7% 48h antes do Ãbito, 29,1% 24h antes e 69,4% no momento do Ãbito. O uso de adrenalina foi registrado em 55,4% antes do Ãbito. Conclui-se que a LSV ainda nÃo à frequentemente considerada como uma alternativa de assistÃncia de final de vida a pacientes pediÃtricos e neonatais no Estado do CearÃ, onde as condutas mais prevalentes incluem o incremento do suporte avanÃado de vida em detrimento das medidas de conforto e cuidados paliativos. Comparando-se com estudos do Sul e Sudeste do paÃs, evidencia-se uma grande diferenÃa, onde se observam uma maior prevalÃncia de LSV e cuidados paliativos para pacientes em fase terminal, o que denota prÃticas mais humanas e de maior qualidade na assistÃncia. / Changes around the world at the XX century allowed new technologies to improve the possibilities of surviving in so many cases of sickness that were incurable before. Besides the benefits it brought, other consequences have come together specially futility, in other words futile therapeutic measures when the cure is impossible and the death is inevitable. These facts have influence in client satisfaction, lengh of stay and costs elevation. Since 1990 life support limitation (LSL) started to be considered in Europe, United States, Canada and Austrlia to assist patients in terminal conditions to whom curative practices wouldnât bring any benefit. In Brazil there is a limited number of studies and the data from the Northeastern are even less. The aim of this study was to describe the medical practices before death in patients in PICU and NICU at a reference pediatric hospital in Brazilian Northeastern. Data were collected from 86 medical charts. Only 3.5% of LSL was registered. 33.7% of patients had some chronic disease and neoplasic ones were more comons. The main causes of death were: sepsis (23.5%), MDOS (18.8%), respiratory failure (12.9%), congenital heart disease (8.2%) and the other causes 36.6% together. Most of patients died after increment in vasoatives administration, considering the final 24 hours before death (59.3% 24h before, 70.9% at the momento of death). Mechanical ventilation (89.5% 24h before, 95.2% at the moment). In the other hand palliative care and pain control were not so frequent as could be expected: sedative (39.5 24h before, 43% at the moment) analgesic (60% 24h before, 60.5% at the moment). CPR was offered in 4.7% of patients 48h before death, 29.1% 24h before and 69.4% at the moment of death. Adrenaline was used in 55.4% at the moment of death. These data show that LSL is not a frequente alternative to assist terminal patients at PICU and NICU in Brazilian Northeastern, where more prevalent practices are to maintain life support instead of offer palliative care and pain control. At Southern and Southeastern practice include LSL and palliative care more frequently, what suggests better practices of the end-of-life care.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第25157号 / 医博第5043号 / 新制||医||1070(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 石見 拓, 教授 西浦 博, 教授 江木 盛時 / 学位規則第4条第1項該当 / Doctor of Agricultural Science / Kyoto University / DFAM

Background Nutritional treatment in the intensive care unit (ICU) has evolved from meeting nutritional requirements to manipulating patient outcome. Pharmaconutrition, referring to nutrients that are applied for their pharmacological properties, forms part of the standard nutritional care plan. The most abundant amino acid in the body, glutamine, is also the most-researched pharmaconutrient. It is an independent predictor of mortality in ICU patients, at both deficient and very high levels. Glutamine supplementation is recommended in the ICU setting for its proven outcome benefits. However, recent data showed that glutamine supplementation increases mortality risk in certain patient groups. Moreover, it suggested that not all ICU patients are glutamine deficient. Therefore, the main aim of this study was to investigate the plasma glutamine levels of adult ICU patients, on admission to the ICU. In addition, to elucidate the profile of ICU patients that can be expected to present with a glutamine deficiency or excess, with regards to gender, diagnosis and inflammatory markers. Methods In this observational, cross-sectional study, 60 mixed ICU adult patients admitted to two hospitals in the North West province were included in the study group. Blood sampling was conducted within 24 hours following ICU admission, to determine plasma glutamine, interleukin (IL)-6 and C-reactive protein (CRP) levels. Plasma glutamine levels were compared with those of a control group of healthy individuals, matched by age, race, and gender. Gender-related differences in plasma glutamine levels were investigated, as well as differences between patients with various medical conditions. The relationship between plasma glutamine levels and IL-6 or CRP was examined. Additionally, a CRP concentration cut-off point at which glutamine becomes deficient was determined by means of a receiver operating characteristic (ROC) curve. Results and discussion Intensive care unit patients had significantly lower plasma glutamine levels than healthy individuals on day one of ICU admission (p < 0.0001). However, only 38.3% (n = 23) had deficient plasma glutamine levels (< 420 μmol/L), while 6.7% (n = 4) presented with supra-normal levels (> 930 μmol/L). No significant difference could be detected between the plasma glutamine levels of male and female ICU patients (p = 0.116). Likewise, levels between diagnosis categories were also not significantly different (p = 0.325). There was a significant inverse association between plasma glutamine levels and CRP concentrations (r = -0.44, p < 0.05), and a trend towards an inverse association with IL-6 (r = - 0.23, p = 0.08). A CRP cut-off value of 95.5 mg/L was determined, above which plasma glutamine values became deficient; however, more research is needed to confirm this result. Conclusion and recommendations This research therefore showed that ICU patients, when compared with healthy individuals, had lower plasma glutamine levels on day one of admission to the ICU. However, not all were glutamine deficient, as the majority had normal and some presented with supra-normal plasma glutamine levels. An individualised approach should therefore be followed in identifying candidates for glutamine supplementation. The patients‟ condition alone may not be sufficient to predict glutamine status, but an association between plasma glutamine levels and CRP was firmly established, as well as a cut- off CRP-value above which glutamine can be expected to become deficient, which could be of use in this regard. / MSc (Dietetics), North-West University, Potchefstroom Campus, 2015

Background Nutritional treatment in the intensive care unit (ICU) has evolved from meeting nutritional requirements to manipulating patient outcome. Pharmaconutrition, referring to nutrients that are applied for their pharmacological properties, forms part of the standard nutritional care plan. The most abundant amino acid in the body, glutamine, is also the most-researched pharmaconutrient. It is an independent predictor of mortality in ICU patients, at both deficient and very high levels. Glutamine supplementation is recommended in the ICU setting for its proven outcome benefits. However, recent data showed that glutamine supplementation increases mortality risk in certain patient groups. Moreover, it suggested that not all ICU patients are glutamine deficient. Therefore, the main aim of this study was to investigate the plasma glutamine levels of adult ICU patients, on admission to the ICU. In addition, to elucidate the profile of ICU patients that can be expected to present with a glutamine deficiency or excess, with regards to gender, diagnosis and inflammatory markers. Methods In this observational, cross-sectional study, 60 mixed ICU adult patients admitted to two hospitals in the North West province were included in the study group. Blood sampling was conducted within 24 hours following ICU admission, to determine plasma glutamine, interleukin (IL)-6 and C-reactive protein (CRP) levels. Plasma glutamine levels were compared with those of a control group of healthy individuals, matched by age, race, and gender. Gender-related differences in plasma glutamine levels were investigated, as well as differences between patients with various medical conditions. The relationship between plasma glutamine levels and IL-6 or CRP was examined. Additionally, a CRP concentration cut-off point at which glutamine becomes deficient was determined by means of a receiver operating characteristic (ROC) curve. Results and discussion Intensive care unit patients had significantly lower plasma glutamine levels than healthy individuals on day one of ICU admission (p < 0.0001). However, only 38.3% (n = 23) had deficient plasma glutamine levels (< 420 μmol/L), while 6.7% (n = 4) presented with supra-normal levels (> 930 μmol/L). No significant difference could be detected between the plasma glutamine levels of male and female ICU patients (p = 0.116). Likewise, levels between diagnosis categories were also not significantly different (p = 0.325). There was a significant inverse association between plasma glutamine levels and CRP concentrations (r = -0.44, p < 0.05), and a trend towards an inverse association with IL-6 (r = - 0.23, p = 0.08). A CRP cut-off value of 95.5 mg/L was determined, above which plasma glutamine values became deficient; however, more research is needed to confirm this result. Conclusion and recommendations This research therefore showed that ICU patients, when compared with healthy individuals, had lower plasma glutamine levels on day one of admission to the ICU. However, not all were glutamine deficient, as the majority had normal and some presented with supra-normal plasma glutamine levels. An individualised approach should therefore be followed in identifying candidates for glutamine supplementation. The patients‟ condition alone may not be sufficient to predict glutamine status, but an association between plasma glutamine levels and CRP was firmly established, as well as a cut- off CRP-value above which glutamine can be expected to become deficient, which could be of use in this regard. / MSc (Dietetics), North-West University, Potchefstroom Campus, 2015

The overall aim of the present thesis was to study aspects of patient safety in critically ill patients with special focus on airway management, respiratory complications and nursing procedures. Study I describes a method called pharyngeal oxygen administration during intubation in an experimental acute lung injury model. The study showed that pharyngeal oxygenation prevented or considerably increased the time to life-threatening hypoxemia at shunt fractions by at least up to 25% and that this technique could be implemented in airway algorithms for the intubation of hypoxemic patients. In study II, we investigated short-term disconnection of the expiratory circuit from the ventilator during filter exchange in critically ill patients. We demonstrated that when using pressure modes in the ventilator, there was no indication of any significant deterioration in the patient's lung function. A bench test suggests that this result is explained by auto-triggering with high inspiratory flows during the filter exchange, maintaining the airway pressure. Study III was a clinical observational study of critically ill patients in which adverse events were studied in connection with routine nursing procedures. We found that adverse events were common, not well documented, and potentially harmful, indicating that it is important to weigh the risks and benefits of routine nursing when caring for unstable, critically ill patients. In study IV, we conducted a retrospective database study in patients with pelvis fractures treated in the intensive care unit. We found that the incidence of respiratory failure was high, that the procedure involved in surgical stabilization affected the respiratory status in patients with lung contusion, and that the mortality was low and probably not influenced by the respiratory condition. In conclusion, the results obtained in the present thesis have increase our knowledge in important areas in the most severely ill patients and have underlined the need for improvements in the field of patient safety.

Mechanical ventilation (MV) therapy has been utilised in the intensive care unit (ICU) for 50 years to treat patients with respiratory illness by supporting the work of breathing, providing oxygen and removing carbon dioxide. MV therapy is utilised by 30-50% of ICU patients, and is a major driver of increased length of stay, increased cost and increased mortality. For patients suffering from acute respiratory distress syndrome (ARDS), the optimal MV settings are highly debated. ARDS patients suffer from a lack of recruited alveoli, and the application of positive end expiratory pressure (PEEP) is often used to maintain recruitment to maximise gas exchange and minimise lung damage. However, determining what level of PEEP is best for the patient is difficult. In particular, it involves a complex trade off between patient safety and ventilation efficacy. Currently, no clinical protocols exist to determine a patient-specific “best” PEEP. Model-based approaches provide an alternative patient-specific method to help clinical diagnosis and therapy selection. In particular, model-based methods can utilise a mix of both engineering and medical principles to create patient-specific models. The models are used for optimising ventilation settings and providing greater physiological insight into lung status than is currently available. Two model-based approaches are presented here. First, a quasi-static, minimal model of lung mechanics is presented based solely on fundamental lung physiology and mechanics. Secondly, a model of dynamic functional residual capacity (dFRC) is developed and presented based on model-based status of lung stress and strain. These models are validated with retrospective clinical data to evaluate the potential of such model-based approaches. Finally, the models are further validated with real time clinical data over a broader spectrum of pressure-volume ranges than prior studies to evaluate the clinical viability of model-based approaches to optimise MV therapy. When validated with real-time clinical trials data, the outputs of the recruitment model provide a range of optimal patient-specific values of PEEP based on different clinically and physiologically derived criteria. The recruitment model is also shown to have the ability to track the disease state of ARDS over time. The dFRC model introduces the PEEP stress parameter, β, which represents a unique population constant. The dFRC model suggests that clinically reasonable estimates of dFRC can be achieved by using this novel value of β, rather than the current, potentially hazardous, methods of deflating the lung to atmospheric pressure. Finally, a third model, combining the principles of recruitment and gas exchange is introduced. The combined model has the ability to estimate cardiac output (CO) changes with respect to PEEP changes during MV therapy. In addition, the model relates the coupled areas of circulation and pulmonary management, as well as linking these MV decision support models to oxygenation based clinical endpoints. A proof of concept is shown for this model by combining two different retrospective datasets and highlighting its ability to capture clinically expected drops in CO as PEEP increases. The model allows valuable cardiovascular circulation data to be predicted and also provides an alternative method and clinical end point by which PEEP could be optimised. The model requires further clinical validation before clinical use, but shows significant promise. The models developed and tested in this research enable rapid parameter identification from minimal, readily available clinical data, and thus provide a novel way of guiding therapy. The models can potentially provide clinicians with information to select an optimal patient-specific level of PEEP using only standard ventilation data, such as pressure-volume curves. In addition, the development of a dFRC stress model provides a unique population constant, β. Overall, the modelling approaches developed and validated in this research provide several novel methods of guiding therapy setting mechanical ventilation parameters and tracking and assess a patient’s lung condition. This research thus creates and provides novel validated methods for improving MV therapy with minimal cost or added invasiveness.

The needs of patients who are nursed on the ICU are becoming more widely recognised and services are beginning to reflect this. However there is little research into how patients who have suffered from a severe and progressive muscular paralysis called Guillain-Barré Syndrome (GBS) experience the disease and subsequent hospitalisation. The purpose of this study was to explore how these patients experience the different aspects of the illness, including an extended period of paralysis and treatment on an ICU. This is intended to expand upon the limited research in this area and identify how the findings can inform clinical practice and future studies. Method: A systematic literature search identified research in relation to the experiences of individuals who had GBS which was utilised to form the basis of the understanding for this study. Very little systematic research has looked at individuals‟ experiences of Guillain-Barré Syndrome whilst ill and their subsequent recovery. A mixed methods study was carried out with the aim of adding to this research. Interpretative Phenomenological Analysis was selected as the method of analysis for Study 1, which involved interviews with seven participants who had experienced GBS severe enough to need treatment on an ICU. This then enabled quantitative questionnaires to be disseminated which asked about individuals‟ levels of anxiety, depression and Post Traumatic Stress symptomatology both retrospectively and following recovery in Study 2. Results: Study1 found that participants experienced GBS as either a slow and frustrating, or as a rapid and scary onset. The main themes that were developed included: the paralysis being viewed as multiple losses, frustration, difficulties associated with communication loss, vulnerability and frightening hallucinations. Study 2 utilised non-parametric analyses of the data and found that participants experienced high levels of anxiety and depression at the onset of GBS and that some continued to experience anxiety, depression and post traumatic symptoms after recovery from GBS. Generally the profile suggests predominantly anxiety problems during the acute onset phase and then predominantly depression at the time of follow-up. Aspects of post traumatic stress were positively correlated with duration of mechanical ventilation which in turn was related to duration of paralysis. This challenged the hypothesis that GBS patients habituate to the experience of paralysis. Conclusion: For some individuals, GBS was experienced as a frightening event, but one that they could draw positive things from. However, for others, GBS was experienced as a traumatic event and some of these people continued to exhibit signs of psychological distress even after recovery. It remains important for staff to feel able to speak about distressing situations with their patients and to signpost them to other psychological services if appropriate.

Class of 2012 Abstract / Specific Aims: The objective of this study is to evaluate and compare clinical outcomes and economic impact involved with the use of beractant (B) compared to poractant (P) for the treatment of respiratory distress syndrome (RDS) in premature neonates admitted to a neonatal intensive care unit. Methods: Patients were included if they were less than 35 weeks gestational age at birth, survived at least 48 hours, and admitted to the neonatal intensive care unit and treated with P or B for RDS. The primary outcome of this study is the change in the fraction of inspired oxygen (FiO2) over the first 48 hours after surfactant administration. Secondary outcomes were the change in oxygen saturation, time spent on mechanical ventilation and continuous positive airway pressure (CPAP), complication occurrence and mortality of the neonates. Main Results: There were a total of 40 neonates whose charts were reviewed (n= 13 and n=27 in the P and B groups respectively). The mean gestational age of the neonates were 29.2+/-2.9 and 28.8+/-2.9 weeks in the P and B groups respectively. The FiO2 was found to not be lower between the P and B groups (35.5+/-22.2 and 42.4+/-24.2, respectively; p=0.379), as well as the O2 saturation (94.6+/-4.6 and 92.3+/-6.1; p=0.194). Significance was also not found for the other clinical or economic outcomes assessed in this study. Conclusions: There was not a significant difference between poractant and beractant in FiO2, O2 saturation, or in the other clinical outcomes evaluated in this study.

The critical care unit (CCU) is a unit where different health care professionals work together to care for the patient efficiently. A lot of studies in the past have shown that good communication and transfer of information from one health care professional to the other is an essential aspect in the transfer of a patients care. Most of these studies are concentrated on the reporter or informant. Lapses in communication and information transfer could result in unnecessary suffering both for the patient and for the health care worker. There are very few studies on how well the recipient of the information or report understands or comprehends the information passed. The aim of this study was to illuminate the critical care nurses (CCN) experiences of receiving report of patients transferred from other units. A qualitative design was chosen and five CCNs in a particular CCU were interviewed. The analysis was done using the content analysis method. The analysis resulted in four main categories which are: The patient’s situation-a determinant factor, the work environment, communication deficit creates uncertainty and structure enhances report and ten subcategories. The findings showed that CCNs' experience a feeling of uncertainty as a result of lapses in communication and their work environment and its attendant distractions has a great influence on the quality of the report they receive. To ensure a good quality of care that promotes patient’s safety and job satisfaction, it would be necessary to address the factors that hinder effective communication during handover in nurses' education programs and clinical practices.

Background: Care of premature infants is challenging for health care professionals. When the preterm infant is separated from its mother the parent-child interaction is impeded. In the last few decades, there has been increasing interest in the effectiveness of massage as an intervention to counter the negative physiological, clinical and behavioral consequences of prematurity and the neonatal intensive care unit environment. Aims: To establish the effectiveness of moderate pressure massage from evidence in the literature and to then explore the cultural, organisational and contextual factors that may act as facilitators and/or barriers for its future implementation in Lebanon. Methods: This thesis utilizes a two-step approach. Two literature reviews were undertaken to establish recent evidence on moderate pressure massage. A qualitative exploratory investigation was adopted as no articles were found that elucidated the contextual barriers and facilitators for massage implementation in the neonatal intensive care unit. The normalization process theory was used as a sensitizing framework to understand implementation issues and address the observed difficulties in implementing new interventions in clinical settings. This study was also concerned with context and culture as moderate pressure massage is not practiced in the Lebanese neonatal intensive care units. A purposive sample of Lebanese health care professionals and parents were recruited from three university hospitals with data generated through focus group discussions and observational notes. Framework analysis was used for the analysis and interpretation of the findings. The study drew on the principles and practice of ethnographic approaches. Findings: The findings from the two literature reviews only revealed randomized control trials that observed mostly the short-term physiological and psychological effects of moderate pressure massage. There were no studies that examined the organizational and contextual issues that need to be understood before any trial could be designed in the neonatal intensive care unit setting. The evidence from this review suggested there is a need to explore the views of health care professionals and parents on the practice of massage in the neonatal intensive care units to provide insight into the subsequent design of an intervention study that would be culturally sensitive, appropriate, and acceptable in practice. The findings from the qualitative study then revealed that despite the participants’ interest in implementing massage intervention, parents’ participation in the neonatal intensive care unit is almost absent except for breastfeeding. Participants in both groups, parents and health care professionals, highlighted the parents’ fear and anxiety. In general, nurses are in charge and parents are passive observers. Transportation difficulties, unavailability of helpful staff, and fear were reported as major barriers to parent-implemented infant moderate pressure massage; health care professionals highlighted staff attitude and resistance, workload and time constraints. Communication, gradual implementation, encouragement and support were identified by parents as potential facilitators. In comparison, having extra staff and a protocol for teaching nurses, training parents and openness to innovation were the main potential facilitators of implementation identified by health care professionals. Conclusion: This study helped to reveal the potential challenges of applying such a complex intervention as moderate pressure massage by the parents in the neonatal intensive care unit. Adopting infant massage in the Lebanese neonatal intensive care unit without preparation of health care professionals and parents would be premature. Good communication between parents and health care providers is a key element to facilitate early bonding and parent-infant interaction. Missing the opportunity to involve parents in neonatal intensive care unit care puts the family in a difficult situation to adapt to the new challenges after discharge. The findings of this study will advance current knowledge in understanding the factors that determine applicability, acceptability and feasibility of massage implementation in the neonatal intensive care unit setting. It will also assist and inform the design of future randomized control trials. The noramalization process theory was a valuable lens to guide the process of inquiry and to make sense of the emergent findings from this exploratory qualitative study.