Base teórica: O avanço no conhecimento e a introdução de tecnologias mais sofisticadas para o cuidado do paciente crítico trouxeram importante incremento na sobrevida deste grande grupo de pacientes. Por outro lado, existe um estrato de pacientes que sobrevivem à condição crítica aguda, porém permanecem dependentes de algum tipo de suporte de manutenção da vida por longos períodos. A doença crítica crônica (DCC) como é conhecida, apesar de descrita desde a década de 80, ainda não possui um critério de definição claro, levando a divergências nos resultados de estudos e prejudicando o avanço em pesquisas que investigam estratégias de tratamento. Objetivo: Avaliar a sobrevida e fatores associados à DCC em uma população de pacientes críticos comparando dois critérios de diagnóstico desta condição. Metodologia: Coorte histórica com avaliação de variáveis clínicas e desfechos durante a internação hospitalar em uma população de doentes críticos de uma única unidade de tratamento intensivo (UTI). Os pacientes foram alocados em três grupos, dois com critérios de DCC definidos por ≥14 ou ≥21 dias de ventilação mecânica (VM) e um terceiro grupo de pacientes críticos agudos (< 14 dias de VM). Recrutamento e alocação foram feitos através de um banco de dados institucional e dos registros hospitalares das internações ocorridas de janeiro de 2007 a dezembro de 2010. Resultados: No período analisado ocorreram 3.023 internações na UTI, 2.783 apresentavam os critérios de inclusão e compuseram a análise final. Em relação ao tempo de VM, 163 pacientes apresentaram ≥14 dias e 89 ≥21 dias. A mortalidade hospitalar e na UTI foi inferior no grupo de pacientes críticos agudos quando comparado com os dois grupos de DCC (≥14 e ≥21 dias de VM) (16.3% versus 55.8% e 58.4% p<0.001; 10.6% versus 47.3% e 53.9% p<0.001 respectivamente). Quando comparados os dois grupos de DCC (≥14 e ≥21 dias de VM), não houve diferença estatisticamente significativa para mortalidade hospitalar e na UTI (57.2% versus 58.4% p=0.5; 39.2% versus 53.9% p=0.18 respectivamente). O pequeno número de pacientes em cada grupo pode ter limitado o poder das análises. Ambos os grupos de DCC tiveram escores de gravidade mais altos, desenvolveram mais complicações na UTI, apresentaram maior tempo de internação hospitalar e mortalidade quando comparados aos críticos agudos. Conclusão: O estudo não mostrou diferença estatisticamente significativa quanto às características e desfechos clínicos entre as duas definições de DCC. Por outro lado, mostrou que os dois grupos de DCC apresentaram desfechos piores quando comparados com os pacientes críticos agudos. Estes resultados justificam o uso do critério de ≥14 dias de VM para a identificação mais precoce dos doentes críticos crônicos. / Theoretical basis: Progress in knowledge and the introduction of more advanced technologies for critical patient care brought about an important increase in the survival of this large group of patients. On the other side, there exists a subset of patients who survive their acute critical illness, but they remain dependent on some kind of life support for long periods. Despite being described since the 1980s, the chronic critical illness (CCI) has still not been clearly defined. This situation led to divergent studies’ results and jeopardized the progress in research focused on treatment strategies for CCI. Objective: To assess the survival and CCI-associated factors in a population of critically ill patients comparing two diagnostic criteria of this condition. Methodology: Historical cohort study assessing clinical variables and outcomes during hospital stay, in a population of critically ill patients of a single intensive care unit (ICU). The patients were divided into three groups, two of these with different criteria of CCI, defined by ≥14 or ≥21 days of mechanical ventilation (MV), and a third group with acutely critically ill patients (less than 14 days of MV). The recruitment and allocation were carried out through an institutional database and medical records of admissions occurred from January 1, 2007 to December 31, 2010. Results: In the study period 3,023 ICU admissions occurred, 2,783 met the inclusion criteria and made part of the final analysis. As far as MV days are concerned, 163 patients had ≥14 days and 89 ≥21 days. Hospital and ICU mortality were lower in the group of acutely critically ill patients compared with the two CCI groups (≥14 days and ≥21 MV days) (16.3% versus 55.8% and 58.4% p<0.001; 10.6% versus 47.3% and 53.9% p<0.001 respectively). The comparative analysis between the two CCI groups (≥14 days and ≥21 MV days, respectively) was not statistically significant for hospital and ICU mortality (57.2% versus 58.4% p=0.5; 39.2% versus 53.9% p=0.18, respectively). The small number of patients in the two groups may have limited the power of analyzes. Both CCI groups had higher severity scores, developed more ICU complications, showed higher hospital length of stay and mortality when compared with the acutely critically ill patients. Conclusion: This study did not show significant difference between the two CCI definitions regarding characteristics and clinical outcomes. However, it showed that both groups had worse outcomes when compared with the acutely critically ill patients. This result justifies the use of the CCI criteria of ≥14 days of MV for earlier identification of this subset of patients.

Abstrakt Bakgrund: Posttraumatiskt stressyndrom (PTSD) innebär en förlängd stressreaktion och beteendeförändring hos en person. Riskfaktorer på IVA för utvecklandet av PTSD är bland andra vårdmiljö, läkemedel, lång vårdtid samt mekanisk ventilation. COVID-19 kan orsaka följdsjukdomar, såväl fysiska- som psykiska, vilket också innebär en risk för dessa patienter att utveckla PTSD.  Motiv: Pandemin har inneburit en extrem belastning på intensivvården. Det är känt att patienter som vårdas på IVA löper risk att utveckla PTSD. Förekomst av symtom på PTSD efter allvarlig COVID-19 infektion är ännu relativt outforskat.  Syfte: Syftet med studien var att kartlägga förekomst av symtom på PTSD efter allvarlig COVID-19 infektion som krävt intensivvård.  Metod: Föreliggande studie har tagit del av data från SWECRIT COVID-19 studien som baseras på kritiskt svårt sjuka patienter med COVID-19 som intensivvårdats i Region Skåne. Kvantitativ ansats med en icke experimentell design var lämpligt, eftersom skattningsinstrumentet PCL-5 användes. Urvalet i studien skedde konsekutivt. Totalt deltog 174 patienter i studien. Variabler som kön, ålder, civilstatus, modersmål och utbildningsnivå studerades. Data analyserades i Jamovi (version 1.6.23).  Resultat: Resultatet visade att 16% av patienterna uppnådde tröskelvärdet ≥33 poäng för symptom på PTSD. Patienter med annat modersmål än svenska visade sig skatta högre för symptom på PTSD, sambandet var signifikant (p=0.003). Kvinnor skattade högre för symtom på PTSD än män, men den procentuella fördelningen bland de som uppfyllde tröskelvärdet var lika mellan könen.  Konklusion: Personcentrerad vård och förebyggande arbete kan ha betydelse för förekomst av symtom på PTSD. Att förhindra eventuella språkbarriärer hos patienter med annat modersmål är av vikt. Fortsatta uppföljningsstudier vid 12- och 36-månader kan visa hur förekomsten av PTSD utvecklas över tid. Kompletterande kvalitativ forskning kan nyansera patienters unika upplevelse av intensivvård för COVID-19. / Abstract  Background: Post-traumatic stress disorder (PTSD) involves a prolonged stress response and behavioral change in a person. Risk factors for the development of PTSD in ICU are care environment, drugs, prolonged care and mechanical ventilation. COVID-19 can cause physical and mental sequelae, which also put these patients at risk for developing PTSD. Motive:  The pandemic has put an extreme strain on intensive care. It is known that patients in ICU are at risk of developing PTSD. The incidence of PTSD symptoms after severe COVID-19 infection is still relatively unexplored. Aim: The aim of the study was to examine the occurrence of symptoms of PTSD after severe COVID-19 infection that required intensive care. Method: The present study has taken part of data from the SWECRIT COVID-19 study, which is based on critically ill patients with COVID-19 who received intensive care in Skåne, Sweden. Quantitative approach with a non-experimental design was appropriate since the instrument PCL-5 was used. The selection of patients was made consecutively. A total of 174 patients participated in the study. Variables such as gender, age, marital status, language and level of education were studied. Data were analyzed in Jamovi (version 1.6.23). Result: The results showed that 16% of the patients reached the threshold ≥33 points for symptoms of PTSD. Patients with other languages than Swedish were found to rate higher for symptoms of PTSD, the association was significant (p = 0.003). Women rated higher for symptoms of PTSD than men, but the distribution of percentage among those who met the threshold was equal between the genders.  Conclusion: Person-centered care and preventive work can be important for the prevalence of symptoms of PTSD. Preventing language barriers are important. Follow-up studies at 12 and 36 months can show how the prevalence of PTSD develops over time. Complementary qualitative research can nuance patients' unique experience of intensive care for COVID-19.

PURPOSE: The purpose of this feasibility study was to explore the use of a nurse-centered intervention, the Critical Caring Program, with family members of critically ill adults. The intervention was a series of therapeutic conversations with a family member, beginning in the ICU and following patient discharge from the ICU. FRAMEWORK: The Family Adjustment and Adaptation Response Model (Patterson, 1988) provided the conceptual framework; the intervention was adapted from the Calgary Family Assessment and Intervention Model. DESIGN: A randomized, controlled design with two groups (usual care and intervention) was used to assess the feasibility of the intervention. A convenience sample of 19 adult family members were recruited from an 18-bed ICU from October 2021–January 2022. RESULTS: 151 family members were screened for participation; 40 who were eligible and 19 were enrolled. Overall retention was 58% for the intervention group; 62% for the usual care group. Outcomes revealed no statistically significant differences between groups or changes within groups. The nurses viewed the training and conversations as positive but identified incorporating the visits into routine practice as challenging. CONCLUSION: The Calgary Family Intervention Model is a useful model for addressing families’ need for communication and support. Additional research is needed on incorporating therapeutic conversations into critical care nursing practice.

Bakgrund: Den palliativa vården ska se till hela familjens behov av stöd. Lagen är tydlig vad gäller barns rättigheter när en förälder är sjuk, men syskon som grupp blir ofta förbisedda. Syskon som mist en närstående har ökad risk för ångest och depression, men löper även högre risk för missbruk, och detta kan relateras till hur syskonen upplevde situationen när deras bror eller syster var sjuk. Barn och unga är en särskilt sårbar grupp som behöver extra omsorg i och med en högre risk för komplicerad och långvarig sorg, och sjukvården har ett ansvar i att stötta dessa individer. Genom ökad kunskap om syskons erfarenheter av att leva med en svårt sjuk bror eller syster kan vi konstruera adekvat stöd baserat på deras behov. Syfte: Att beskriva syskons erfarenheter av att leva med en svårt sjuk bror eller syster. Metod: En litteraturöversikt baserad på 13 originalartiklar, insamlade från två databaser, publicerade mellan 2013–2023. En tematisk analys gjordes utifrån Braun och Clarkes analysmodell. Resultat: Tre huvudteman framkom vid sammanställning av resultat: Att hantera sig själv och sina känslor beskriver syskonens utsatthet och känsla av isolering - en känsla av att hamna i skuggan av sin bror eller systers sjukdom, där en stark önskan om att bli sedd, men en ovilja att ta plats framkom, och stöd från omgivningen var uppskattat. Känslan av förståelse beskriver att information och inkludering uppskattas - att de oftast vet om när saker går osagda och att de själva tvingas läsa mellan raderna kring vad de ser och vad som sägs. Det nya normala beskriver förändring i situation och vardag - där familjen blev allt viktigare, men att rollerna inom familjen förändrades, och det ständigt fanns en närvaro av oro kring den sjuka brodern eller systern. Slutsats: Sjuksköterskor och annan vårdpersonal bör känna till och beakta syskons känsloliv och önskningar för att på bästa sätt kunna stötta och hjälpa syskonet genom den svåra tiden. För att nå upp till barnkonventionen, som numera är lag, gäller detta även för sjukvårdspersonal inom vuxenvården, då barn som har palliativa vårdbehov många gånger vårdas inom vuxenkliniker. / Background: Palliative care must take care of the entire family's need for support. The law is clear regarding children's rights when a parent is ill, but siblings as a group are often overlooked. Siblings who have lost a loved one have an increased risk of anxiety and depression, but are also at higher risk of substance abuse, and this can be related to how the sibling experienced the situation when their brother or sister was ill. Children and young people are a particularly vulnerable group that needs extra care due to a higher risk of complicated and prolonged grief, and the healthcare system has a responsibility to support these individuals. Through increased knowledge of siblings' experiences of living with a seriously ill brother or sister, we can construct adequate support for these children based on their needs.  Aim: To describe the siblings' experiences of living with a seriously ill brother or sister. Method: A literature review based on 13 original articles, collected from two databases, published between 2013-2023. A thematic analysis was made based on Braun and Clarke's analysis model. Results: Three main themes emerged when compiling results: Dealing with oneself and one's feelings - describes the sibling's vulnerability and sense of isolation, a feeling of being overshadowed by their brother or sister's illness, where a strong desire to be seen, but an unwillingness to take place emerged, and support from the environment was appreciated. The feeling of understanding - describes that information and inclusion are appreciated, that they usually know when things are left unsaid and that they themselves are forced to read between the lines regarding what they see and what is said. The new normal - describes a change in situation and everyday life, where the family became increasingly important, but the roles within the family changed, and there was a constant presence of concern around the sick brother or sister. Conclusion: Nurses and other healthcare personnel should know and consider the sibling's emotional life and wishes in order to best support and help the sibling through the difficult time. In order to meet the Convention on the Rights of the Child, which is now law, this also applies to healthcare staff in adult care, as children who have palliative care needs are often cared for in adult clinics.

Bakgrund: Den palliativa vården ska se till hela familjens behov av stöd. Lagen är tydlig vad gäller barns rättigheter när en förälder är sjuk, men syskon som grupp blir ofta förbisedda. Syskon som mist en närstående har ökad risk för ångest och depression, men löper även högre risk för missbruk, och detta kan relateras till hur syskonen upplevde situationen när deras bror eller syster var sjuk. Barn och unga är en särskilt sårbar grupp som behöver extra omsorg i och med en högre risk för komplicerad och långvarig sorg, och sjukvården har ett ansvar i att stötta dessa individer. Genom ökad kunskap om syskons erfarenheter av att leva med en svårt sjuk bror eller syster kan vi konstruera adekvat stöd baserat på deras behov. Syfte: Att beskriva syskons erfarenheter av att leva med en svårt sjuk bror eller syster. Metod: En litteraturöversikt baserad på 13 originalartiklar, insamlade från två databaser, publicerade mellan 2013–2023. En tematisk analys gjordes utifrån Braun och Clarkes analysmodell. Resultat: Tre huvudteman framkom vid sammanställning av resultat: Att hantera sig själv och sina känslor beskriver syskonens utsatthet och känsla av isolering - en känsla av att hamna i skuggan av sin bror eller systers sjukdom, där en stark önskan om att bli sedd, men en ovilja att ta plats framkom, och stöd från omgivningen var uppskattat. Känslan av förståelse beskriver att information och inkludering uppskattas - att de oftast vet om när saker går osagda och att de själva tvingas läsa mellan raderna kring vad de ser och vad som sägs. Det nya normala beskriver förändring i situation och vardag - där familjen blev allt viktigare, men att rollerna inom familjen förändrades, och det ständigt fanns en närvaro av oro kring den sjuka brodern eller systern. Slutsats: Sjuksköterskor och annan vårdpersonal bör känna till och beakta syskons känsloliv och önskningar för att på bästa sätt kunna stötta och hjälpa syskonet genom den svåra tiden. För att nå upp till barnkonventionen, som numera är lag, gäller detta även för sjukvårdspersonal inom vuxenvården, då barn som har palliativa vårdbehov många gånger vårdas inom vuxenkliniker. / Background: Palliative care must take care of the entire family's need for support. The law is clear regarding children's rights when a parent is ill, but siblings as a group are often overlooked. Siblings who have lost a loved one have an increased risk of anxiety and depression, but are also at higher risk of substance abuse, and this can be related to how the sibling experienced the situation when their brother or sister was ill. Children and young people are a particularly vulnerable group that needs extra care due to a higher risk of complicated and prolonged grief, and the healthcare system has a responsibility to support these individuals. Through increased knowledge of siblings' experiences of living with a seriously ill brother or sister, we can construct adequate support for these children based on their needs. Aim: To describe the siblings' experiences of living with a seriously ill brother or sister. Method: A literature review based on 13 original articles, collected from two databases, published between 2013-2023. A thematic analysis was made based on Braun and Clarke's analysis model. Results:Three main themes emerged when compiling results: Dealing with oneself and one's feelings - describes the sibling's vulnerability and sense of isolation, a feeling of being overshadowed by their brother or sister's illness, where a strong desire to be seen, but an unwillingness to take place emerged, and support from the environment was appreciated. The feeling of understanding - describes that information and inclusion are appreciated, that they usually know when things are left unsaid and that they themselves are forced to read between the lines regarding what they see and what is said. The new normal - describes a change in situation and everyday life, where the family became increasingly important, but the roles within the family changed, and there was a constant presence of concern around the sick brother or sister. Conclusion: Nurses and other healthcare personnel should know and consider the sibling's emotional life and wishes in order to best support and help the sibling through the difficult time. In order to meet the Convention on the Rights of the Child, which is now law, this also applies to healthcare staff in adult care, as children who have palliative care needs are often cared for in adult clinics.

Selenoproteine spielen eine wichtige Rolle in der antioxidativen Abwehr und bei Immunreaktionen. Der Selen(Se)metabolismus wird von Hepatozyten gesteuert, die das Se-Transportprotein Selenoprotein P (SEPP) synthetisieren und sezernieren. SEPP nimmt bei kritischen Erkrankungen, z. B. Sepsis ab und führt zu niedrigen Se-Spiegeln. Sepsis triggert die übermäßige Produktion von proinflammatorischen Zytokinen. Aminoglykosid-Antibiotika (AG), die oft bei schwerer Sepsis eingesetzt werden, induzieren Fehlinterpretationen der mRNA inklusive des Stoppcodons UGA welches für die Selenoprotein-Biosynthese notwendig ist. Es wurden daher die molekularen Wechselwirkungen zwischen den Zytokinen IL-6, IL-1b und TNFa, AG und dem Se-Status mit der Biosynthese in Leberzelllinien untersucht. IL-6 führte zu einer starken Reduktion der SEPP-mRNA und einer dosisabhängigen Reduktion von SEPP. Parallel dazu reduzierte IL-6 das Transkriptlevel, die Proteinexpression und die Enzymaktivität der Typ-I-Dejodase (DIO1). Auf die Expression der antioxidativ-wirkenden Glutathionperoxidasen (GPX) wirkte IL-6 isozymspezifisch; während die Transkriptkonzentrationen von GPX2 anstiegen und die von GPX4 abnahmen, blieb GPX1 unbeeinflusst. Die IL-6-abhängigen Effekte bestätigten sich auch in Reportergenassays von SEPP-, DIO1-, GPX2- und GPX4-Promotorkonstrukten. Um die Wirkungen von AG auf die Selenoprotein-Translation besser zu verstehen, wurden die SECIS-Elemente von GPX1-, GPX4- und SEPP-Transkripten in ein Reportersystem kloniert und auf eine Regulation durch AG und Se analysiert. Die Ergebnisse zeigen, dass der korrekte Se-Einbau vom Se-Status, von der AG-Konzentration und dem spezifischen SECIS-Element abhängig ist. Auf transkriptionaler und translationaler Ebene führten AG zu stark erhöhten SEPP-Spiegeln, während die Expression und Enzymaktivität von GPX und DIO1 nur in geringerem Ausmaß beeinflusst wurden. Eine Analyse der Se-Beladung zeigte, dass der Se-Gehalt von SEPP stark durch AG reduziert und vom Se-Status abhängig war. / Selenoproteins play important roles in antioxidant defence and immunoregulation. Selenium (Se) metabolism is controlled by hepatocytes synthesizing and secreting the Se-transporter selenoprotein P (SEPP) declining in critical illness, e.g., sepsis. Sepsis triggers excessive production of pro-inflammatory cytokines. Aminoglycoside (AG) antibiotics applied in sepsis in induce mRNA misinterpretation including the stop codon UGA required during selenoproteins biosynthesis. The molecular interplay between the cytokines IL-6, IL-1b and TNFa, AG and Se-status on selenoprotein expression was investigated in hepatic-derived cell lines. IL-6 strongly reduced the level of SEPP mRNA and secreted SEPP in a dose-dependent manner. Likewise, expression of selenoenzyme type 1 deiodinase (DIO1) declined at the transcript, protein and enzyme activity level. The effects of IL-6 on the expression of antioxidative-acting glutathione peroxidases (GPX) were isozyme-specific; while transcript level of GPX2 increased and those of GPX4 decreased, GPX1 remained unaffected. IL-6-dependent effects were reflected in reporter gene experiments of selenoprotein promoter constructs. Characterising the effects of AG on selenoprotein translation, the SECIS-elements of GPX1, GPX4 and SEPP transcripts were cloned into a reporter system and analysed for their response to AG and Se. The results indicate that the correct co-translational Se-insertion depends on the Se-status, AG concentration and the specific SECIS-element. At both transcriptional and translational levels, SEPP levels were strongly increased in response to AG, whereas the expression and enzyme activity of GPX and DIO1 were affected to a lower degree. Analysis Se-status indicate that the Se-content of SEPP was strongly reduced by AG and depends on Se-status.

INTRODUÇÃO: A síndrome da imunodeficiência adquirida (AIDS) é atualmente uma pandemia, e as doenças pulmonares são a principal causa de morbidade e mortalidade dos pacientes com AIDS. Nesse sentido, as infecções respiratórias são frequente causa de hipoxemia e morte. Os pacientes com AIDS e insuficiência respiratória hipoxêmica frequentemente necessitam de ventilação mecânica invasiva, a qual é independentemente associada com mortalidade. A ventilação não invasiva com pressão positiva refere-se à oferta de assistência ventilatória mecânica sem a necessidade de invasão artificial das vias aéreas, sendo reconhecida por melhorar a oxigenação e a dispneia dos pacientes com insuficiência respiratória hipoxêmica, principalmente se aplicada de forma sequencial e progressiva, e esta pode reduzir a necessidade de ventilação mecânica invasiva nestes pacientes. Tendo em vista as incertezas quanto à resposta da oxigenação a PEEP nos pacientes com AIDS com insuficiência respiratória aguda hipoxêmica e usando o racional da pressurização progressiva das vias aéreas e seu potencial benefício na oxigenação sanguínea, nós fizemos a hipótese de que o incremento sequencial dos níveis de PEEP até 15 cmH2O pode melhorar a oxigenação sanguínea sem afetar o conforto e a hemodinâmica do paciente. O objetivo principal deste estudo foi investigar os efeitos de diferentes sequências de níveis de PEEP aplicado de forma não invasiva sobre as trocas gasosas, a sensação de dispneia e os padrões hemodinâmicos em pacientes com AIDS e insuficiência respiratória aguda hipoxêmica. O objetivo secundário foi avaliar o tempo livre de ventilação mecânica invasiva em 28 dias e a mortalidade hospitalar em 60 dias. MÉTODOS: Foram estudados 30 pacientes adultos com HIV/AIDS e insuficiência respiratória aguda hipoxêmica. Todos os pacientes receberam uma sequência randomizada de PEEP não invasivo (os valores usados foram 5, 10 ou 15 cmH2O) por vinte minutos. A PEEP foi fornecida através de máscara facial com pressão suporte (PSV) de 5 cmH2O e uma FiO2 = 1. Um período de washout de 20 minutos com respiração espontânea foi permitido entre cada PEEP. Variáveis clínicas e uma gasometria arterial foram registradas após cada etapa de PEEP. RESULTADOS: Analisando os 30 pacientes, a oxigenação melhorou linearmente com a elevação da PEEP, contudo, estudando os pacientes conforme a PEEP inicial randomizada, a oxigenação foi similar independentemente da primeira PEEP randomizada (5, 10 ou 15 cmH2O), e somente o subgrupo com PEEP inicial = 5 cmH2O melhorou mais a oxigenação quando PEEPs maiores foram usadas. A PaCO2 também aumentou junto com a elevação da PEEP, especialmente com uma PEEP = 15 cmH2O. O uso de PSV = 5 cmH2O foi associado com significante e consistente melhora da sensação subjetiva de dispnéia e da frequência respiratória com PEEP de 0 a 15 cmH2O. CONCLUSÕES: Os pacientes com SIDA e insuficiência respiratória hipoxêmica melhoram a oxigenação com a elevação progressiva e sequencial da PEEP até 15 cmH2O, contudo a elevação da PaCO2 limita a PEEP até 10 cmH2O. Uma PSV = 5 cmH2O promove uma melhora da sensação subjetiva da dispnéia independentemente do uso de PEEP / INTRODUTION: The acquired immunodeficiency syndrome (AIDS) is a pandemic, and lung diseases are the leading cause of morbidity and mortality and are often associated with respiratory infections, hypoxemia and death. The noninvasive ventilation with positive pressure refers to the provision of mechanical ventilatory assistance without the need for artificial airway invasion, being recognized for improving oxygenation and dyspnea in patients with hipoxemic respiratory failure. Patients with AIDS and hypoxemic respiratory failure often require invasive mechanical ventilation, which is independently associated with mortality. Given the uncertainties about response in oxygenation with PEEP in patients with AIDS with acute hypoxemic respiratory failure and using the rational for progressive pressurization of the airway and its potential benefits on blood oxygenation, we made the hypothesis that increased levels of sequential PEEP up to 15 cmH2O may improve blood oxygenation without affecting the comfort and hemodynamics of the patient. The main objective of this study was to investigate the effects of different sequences of PEEP levels on gas exchange, the sensation of dyspnea and hemodynamics in patients with AIDS and acute hypoxemic respiratory failure. The secondary objective was to assess the time free of invasive mechanical ventilation in 28 days and hospital mortality within 60 days. METHODS: We studied 30 adults patients with HIV/AIDS and acute hypoxemic respiratory failure. All patients received a randomized sequence of noninvasive PEEP (the values used were 5,10 or 15 cmH2O) for twenty minutes. PEEP was delivered via face mask with pressure support (PSV) of 5 cmH2O and FiO2 = 1. A washout period of 20 minutes with spontaneous breathing was allowed between each PEEP trial. Clinical variables and arterial blood gases were recorded after each PEEP step. RESULTS: Analyzing the 30 patients, oxygenation improved linearly with increasing PEEP, however studying the patients randomized according to the initial PEEP, oxygenation was similar regardless of the first randomized PEEP (5,10 or 15 cmH2O), and only the subgroup with initial PEEP = 5 cmH2O further improve the oxygenation when high PEEP were used. The PaCO2 also rose beside the PEEP elevation, especially with a PEEP = 15 cmH2O. The use of PSV = 5 cmH2O was associated with significant and consistent improvement of subjective sensation of dyspnea and respiratory rate with a PEEP from 0 to 15 cmH2O. CONCLUSION: AIDS-patients with hypoxemic respiratory failure improve oxygenation with a progressive sequential elevation of PEEP up to 15 cmH2O, however the elevation of PaCO2 limit the PEEP up to 10 cmH2O. A PSV = 5 cmH2O promotes an improvement of subjective sensation of dyspnea independently from the use of PEEP

Beneš J.: HEMODYNAMIKA V ČASNÉ FÁZI KRITICKÝCH STAVŮ A PERIOPERAČNÍ MEDICÍNĚ - Využití méně invazivních monitorovacích prostředků k cílené hemodynamické péči ABSTRACT Hemodynamic instability occurs very often in critically ill patients and during the perioperative period. Insufficiency in the preload, contractility and afterload contribute in major part to this phenomenon. Hemodynamic monitoring allows clinicians to recognize and to intervene early the underlying cause. Due to new technologies development in recent years it is possible to provide continuous monitoring of hemodynamic parameters with diminished invasivity. Hemodynamic optimization and goal directed therapy show treatment benefit in some groups of critically ill patients and mainly during the perioperative period. Aim of hemodynamic optimizations is to attain the best obtainable hemodynamic conditions with use of fluid loading and inotropic support. In many studies in recent years goal-directed therapy was associated with morbidity and mortality reduction. According to the results of our clinical research hemodynamic optimization using stroke volume variation and minimally invasive device based on the pressure wave analysis is feasible and show the same results as other works with more invasive devices. Key words Hemodynamic monitoring,...

INTRODUÇÃO: A síndrome da imunodeficiência adquirida (AIDS) é atualmente uma pandemia, e as doenças pulmonares são a principal causa de morbidade e mortalidade dos pacientes com AIDS. Nesse sentido, as infecções respiratórias são frequente causa de hipoxemia e morte. Os pacientes com AIDS e insuficiência respiratória hipoxêmica frequentemente necessitam de ventilação mecânica invasiva, a qual é independentemente associada com mortalidade. A ventilação não invasiva com pressão positiva refere-se à oferta de assistência ventilatória mecânica sem a necessidade de invasão artificial das vias aéreas, sendo reconhecida por melhorar a oxigenação e a dispneia dos pacientes com insuficiência respiratória hipoxêmica, principalmente se aplicada de forma sequencial e progressiva, e esta pode reduzir a necessidade de ventilação mecânica invasiva nestes pacientes. Tendo em vista as incertezas quanto à resposta da oxigenação a PEEP nos pacientes com AIDS com insuficiência respiratória aguda hipoxêmica e usando o racional da pressurização progressiva das vias aéreas e seu potencial benefício na oxigenação sanguínea, nós fizemos a hipótese de que o incremento sequencial dos níveis de PEEP até 15 cmH2O pode melhorar a oxigenação sanguínea sem afetar o conforto e a hemodinâmica do paciente. O objetivo principal deste estudo foi investigar os efeitos de diferentes sequências de níveis de PEEP aplicado de forma não invasiva sobre as trocas gasosas, a sensação de dispneia e os padrões hemodinâmicos em pacientes com AIDS e insuficiência respiratória aguda hipoxêmica. O objetivo secundário foi avaliar o tempo livre de ventilação mecânica invasiva em 28 dias e a mortalidade hospitalar em 60 dias. MÉTODOS: Foram estudados 30 pacientes adultos com HIV/AIDS e insuficiência respiratória aguda hipoxêmica. Todos os pacientes receberam uma sequência randomizada de PEEP não invasivo (os valores usados foram 5, 10 ou 15 cmH2O) por vinte minutos. A PEEP foi fornecida através de máscara facial com pressão suporte (PSV) de 5 cmH2O e uma FiO2 = 1. Um período de washout de 20 minutos com respiração espontânea foi permitido entre cada PEEP. Variáveis clínicas e uma gasometria arterial foram registradas após cada etapa de PEEP. RESULTADOS: Analisando os 30 pacientes, a oxigenação melhorou linearmente com a elevação da PEEP, contudo, estudando os pacientes conforme a PEEP inicial randomizada, a oxigenação foi similar independentemente da primeira PEEP randomizada (5, 10 ou 15 cmH2O), e somente o subgrupo com PEEP inicial = 5 cmH2O melhorou mais a oxigenação quando PEEPs maiores foram usadas. A PaCO2 também aumentou junto com a elevação da PEEP, especialmente com uma PEEP = 15 cmH2O. O uso de PSV = 5 cmH2O foi associado com significante e consistente melhora da sensação subjetiva de dispnéia e da frequência respiratória com PEEP de 0 a 15 cmH2O. CONCLUSÕES: Os pacientes com SIDA e insuficiência respiratória hipoxêmica melhoram a oxigenação com a elevação progressiva e sequencial da PEEP até 15 cmH2O, contudo a elevação da PaCO2 limita a PEEP até 10 cmH2O. Uma PSV = 5 cmH2O promove uma melhora da sensação subjetiva da dispnéia independentemente do uso de PEEP / INTRODUTION: The acquired immunodeficiency syndrome (AIDS) is a pandemic, and lung diseases are the leading cause of morbidity and mortality and are often associated with respiratory infections, hypoxemia and death. The noninvasive ventilation with positive pressure refers to the provision of mechanical ventilatory assistance without the need for artificial airway invasion, being recognized for improving oxygenation and dyspnea in patients with hipoxemic respiratory failure. Patients with AIDS and hypoxemic respiratory failure often require invasive mechanical ventilation, which is independently associated with mortality. Given the uncertainties about response in oxygenation with PEEP in patients with AIDS with acute hypoxemic respiratory failure and using the rational for progressive pressurization of the airway and its potential benefits on blood oxygenation, we made the hypothesis that increased levels of sequential PEEP up to 15 cmH2O may improve blood oxygenation without affecting the comfort and hemodynamics of the patient. The main objective of this study was to investigate the effects of different sequences of PEEP levels on gas exchange, the sensation of dyspnea and hemodynamics in patients with AIDS and acute hypoxemic respiratory failure. The secondary objective was to assess the time free of invasive mechanical ventilation in 28 days and hospital mortality within 60 days. METHODS: We studied 30 adults patients with HIV/AIDS and acute hypoxemic respiratory failure. All patients received a randomized sequence of noninvasive PEEP (the values used were 5,10 or 15 cmH2O) for twenty minutes. PEEP was delivered via face mask with pressure support (PSV) of 5 cmH2O and FiO2 = 1. A washout period of 20 minutes with spontaneous breathing was allowed between each PEEP trial. Clinical variables and arterial blood gases were recorded after each PEEP step. RESULTS: Analyzing the 30 patients, oxygenation improved linearly with increasing PEEP, however studying the patients randomized according to the initial PEEP, oxygenation was similar regardless of the first randomized PEEP (5,10 or 15 cmH2O), and only the subgroup with initial PEEP = 5 cmH2O further improve the oxygenation when high PEEP were used. The PaCO2 also rose beside the PEEP elevation, especially with a PEEP = 15 cmH2O. The use of PSV = 5 cmH2O was associated with significant and consistent improvement of subjective sensation of dyspnea and respiratory rate with a PEEP from 0 to 15 cmH2O. CONCLUSION: AIDS-patients with hypoxemic respiratory failure improve oxygenation with a progressive sequential elevation of PEEP up to 15 cmH2O, however the elevation of PaCO2 limit the PEEP up to 10 cmH2O. A PSV = 5 cmH2O promotes an improvement of subjective sensation of dyspnea independently from the use of PEEP

Critical care has undergone several developments in the recent years leading to improved survival. However, acquired muscle weakness in the intensive care unit (ICU) is an important complication that affects severely ill patients and can prolong their ICU stay. Critical illness myopathy (CIM) is the progressive decline in the function and mass of the limb muscles in response to exposure to the ICU condition, while ventilator-induced diaphragm dysfunction (VIDD) is the time dependent decrease in the diaphragm function after the initiation of mechanical ventilation. Since the complete underlying mechanisms for CIM and VIDD are not completely understood, there is a compelling need for research on the mechanisms of CIM and VIDD to develop intervention strategies targeting these mechanisms. The aim of this thesis was to investigate the effects of several intervention strategies and rehabilitation programs on muscle wasting associated with ICU condition. Moreover, muscle specific differences in response to exposure to the ICU condition and different interventions was investigated. Hence, a rodent ICU model was used to address the mechanistic and therapeutic aspects of CIM and VIDD. The effects of heat shock protein 72 co-inducer (HSP72), BGP-15, on diaphragm and soleus for rats exposed to different durations of ICU condition was investigated. We showed that 5 and 10 days treatment with BGP-15 improved diaphragm fiber and myosin function, protected myosin from posttranslational modification, induced HSP72 and improved mitochondrial function. Moreover, BGP-15 treatment for 5 days improved soleus muscle fibers function, improved mitochondrial structure and reduced the levels of some ubiquitin ligases. In addition to BGP-15 treatment, passive mechanical loading of the limb muscles was investigated during exposure to the ICU condition. We showed that mitochondrial dynamics and mitophagy gene expression was affected by Mechanical silencing while mechanical loading counteracted these effects. Our investigation for other pathways that can be involved in muscle wasting associated with ICU condition showed that the Janus kinase 2/ Signal transducer and activator of transcription 3 (JAK2/STAT3) pathway is differentially activated in plantaris, intercostals and diaphragm. However, further studies are required with JAK2/STAT3 inhibitors to fully examine the role of this pathway in the pathogenesis of CIM and VIDD prior to translation to clinical research.