Trata-se de um estudo observacional, retrospectivo, cujo objetivo foi descrever o perfil dos pacientes e características da Terapia Nutricional Enteral (TNE) bem como analisar as complicações dessa terapia e os fatores associados em pacientes adultos hospitalizados. O estudo constituiu-se de uma amostra de 214 pacientes internados, no período de 2008 e 2009, em um hospital universitário do Município de São Paulo. Os dados foram coletados dos prontuários e das fichas de avaliação nutricional, em um formulário elaborado para o estudo. Os resultados permitiram verificar que: 1 a-) em relação ao perfil dos pacientes e terapia nutricional enteral, houve predominância do sexo masculino (55,6%), com média de idade de 64,8 anos; internados em unidades de semi-intensiva e UTI (66,8%). b-) Referente à terapia nutricional enteral, a média de dias de nutrição enteral foi de 13,2 dias, e 43,5% dos pacientes receberam-na em até uma semana. Quanto à via de acesso enteral, predominaram as sondas nasoenterais (96,3%) e o método de administração contínuo da dieta (67,3%). 2-) em relação às complicações da TNE e os eventos observados - dos 214 pacientes da amostra, em 200 deles houve complicações durante o uso da nutrição enteral. Verificou-se a ocorrência de complicações: gastrointestinal (90,5%), metabólica (55,0%), mecânica (41,5%) e pulmonar (13,0%). Os eventos observados mais frequentes da complicação gastrointestinal foram: distensão abdominal (33,4%), constipação (17,5%) e alto volume residual gástrico (14,6%). Na complicação metabólica, o evento observado foi hiperglicemia (55,0%), com valor médio de 174,2 mg/dL. Os eventos observados predominantes da complicação mecânica foram: saída não programada da sonda enteral (70,5%), seguida de obstrução da sonda enteral (19,0%). Na complicação pulmonar, a aspiração pulmonar (13,0%) foi o evento observado. 5-) Quanto ao método de infusão houve associação significativa da infusão contínua com os seguintes eventos observados na complicação gastrointestinal: alto VRG (p=0,000), constipação (p=0,010), distensão abdominal (p=0,037). Na complicação mecânica, houve associação significativa com a infusão intermitente nos seguintes eventos: saída não programada da sonda enteral (p=0,005) e deslocamento da sonda enteral (p=0,040). 6-) Quanto à terapia medicamentosa, houve associação significativa da complicação metabólica (hiperglicemia) e o uso de sedativos/opioides (p=0,000) e drogas vasoativas (p=0,000). Este estudo demonstrou que as complicações coexistentes com a TNE são muito prevalentes nesta população (93,5%). Além disso, verificou-se que existe elevada ocorrência de eventos observados (617), sendo as complicações (400) que apresentaram intersecções significativas com outras variáveis acima descritas. Portanto, investigações das condições clínicas, as terapêuticas e os cuidados no uso da sonda enteral devem ser reiteradamente indicadas, sobretudo para os enfermeiros que são responsáveis pela administração e monitoramento da nutrição enteral. / This observational and retrospective study aimed to describe the profile of patients and the characteristics of the Enteral Nutrition Therapy (ENT), as well as to analyze the complications of this therapy and the associated factors in hospitalized adult patients. The study consisted of a sample of 214 patients, hospitalized between 2008 and 2009 at a university hospital in the city of São Paulo. Data were collected from medical records and of nutritional assessment sheets, using a form developed for the study. Results showed that: 1 a-) in relation to patient profiles and enteral nutrition therapy participants were predominantly male (55.6%), with an average age of 64.8 years, hospitalized in semi-intensive and intensive care units (66.8%); b-) Concerning enteral nutrition therapy, the average days of enteral nutrition was 13.2 days, and 43.5% of the patients received it for up to one week. As for the route of enteral access, nasoenteric feeding tube (96.3%) and continuous feeding administration (67.3%) were the most common. 2 -) regarding the complications of ENT and the observed events of the 214 patients of the sample, 200 had complications during the use of enteral nutrition. There was occurrence of gastrointestinal (90.5%), metabolic (55.0%), mechanical (41.5%) and pulmonary (13.0%) complications. The most frequently observed events among gastrointestinal complication were: abdominal distention (33.4%), constipation (17.5%) and high gastric residual volume (GRV) (14.6%). Among the metabolic complication, hyperglycemia (55.0%) was observed, with average of 174.2 mg/dL. The predominant events resulting from mechanical complication were unexpected withdrawal of enteral feeding tube (70.5%), followed by obstruction of enteral feeding tube (19.0%). As for pulmonary complication, pulmonary aspiration (13.0%) was the observed event. 5-) Concerning the method of infusion, there was significant association of continuous infusion with the following events observed in gastrointestinal complication: high GRV (p=0.000), constipation (p=0.010) and abdominal distension (p=0.037). Among the mechanical complication, there was significant association with intermittent infusion at the following events: unexpected withdrawal of enteral feeding tube (p=0.005) and displacement of enteral feeding tube (p=0.040). 6-) Regarding drug therapy, there was significant association of metabolic complication (hyperglycemia) and use of sedatives/opioids (p=0.000) and vasoactive drugs (p=0.000). This study evidenced that complications concomitant with ENT are very prevalent in this population (93.5%). Moreover, it was found that there is a high occurrence of observed events (617), with complications (400) presenting significant intersections with other variables described above. Therefore, research on the clinical conditions, treatments and care to the use of enteral feeding tubes should be constantly indicated, particularly for nurses who are responsible for the administration and monitoring of enteral nutrition.

Introdução: Complicações gastrointestinais na terapia nutricional enteral são frequentes e podem afetar negativamente o desfecho de pacientes hospitalizados. Entre os principais problemas gastrointestinais observados na terapia nutricional enteral destacam-se a diarreia e a constipação intestinal, tema principal do presente estudo. Variáveis relacionadas aos pacientes, terapia medicamentosa e a própria terapia nutricional podem ser fatores predisponentes de diarreia e constipação intestinal. O objetivo do presente estudo foi identificar a frequência de diarreia e constipação intestinal em pacientes em terapia nutricional enteral exclusiva internados em hospital geral no Brasil e estudar os fatores associados a estes eventos. Método: Estudo monocêntrico, sequencial de inclusão aleatória e observacional que avaliou, de forma prospectiva e diária, a ocorrência de diarreia e constipação intestinal em pacientes em terapia nutricional enteral exclusiva durante 21 dias. Estudou-se o comportamento de variáveis relacionadas aos pacientes, a influência da terapia medicamentosa e o tipo de fórmula de nutrição enteral. Os pacientes foram categorizados retrospectivamente quanto a evacuação diária em: grupo D (diarreia; definida como três ou mais evacuações no período de 24h); grupo C (constipação intestinal, definida como menos do que uma evacuação em três dias) e grupo N (ausência de diarreia e constipação intestinal). Analisou-se a terapia medicamentosa administrada aos pacientes de acordo com cada classe terapêutica e quantidade recebida. Também se avaliou a presença de fibras na composição de fórmulas de nutrição enteral. Resultados: Dos 110 pacientes analisados, observou-se constipação intestinal em 70,0% (77), diarreia em 12,7% (14) e em apenas 17,3% (19) dos pacientes houve ausência de diarreia e constipação intestinal. A única variável associada à frequência de diarreia foi a terapia medicamentosa. Houve associação entre os medicamentos anti-inflamatórios não esteroidais e diarreia em pacientes que fizeram uso de fórmula de nutrição enteral sem fibras (p=0,021). No grupo constipação intestinal, a internação na UTI e insuficiência respiratória foram variáveis significativas (p=0,036 e p=0,003277, respectivamente). Houve associação também entre os medicamentos antagonistas H2 e constipação intestinal em pacientes que fizeram uso de fórmula de nutrição enteral sem fibras (p=0,013). Fórmula de nutrição enteral com fibra esteve associada à prevenção da constipação intestinal. A classe terapêutica de antidopaminérgico mostrou efeito benéfico na prevenção da diarreia (p=0,023) e de constipação intestinal (p=0,022) quando comparados com grupo N. Conclusão: A constipação intestinal foi mais frequente que diarreia em pacientes em TNE exclusiva, principalmente quando foi usada fórmula de nutrição enteral sem fibras. A classe terapêutica de medicamentos anti-inflamatórios não esteroidais associou-se à diarreia em pacientes que fizeram uso de fórmula de nutrição enteral sem fibras. A constipação intestinal esteve associada à internação na UTI, à indicação de TNE por necessidade de ventilação mecânica e a classe terapêutica de medicamentos antagonistas H2 em pacientes que fizeram uso de fórmula de nutrição enteral sem fibras. A prescrição de medicamentos pró-cinéticos se mostrou benéfica na prevenção de diarreia e constipação intestinal, assim como o acréscimo de fibras na fórmula de nutrição enteral associou-se à prevenção de diarreia e constipação intestinal influenciados pela terapia medicamentosa / Introduction: Digestive complications in enteral nutrition (EN) are frequent and can affect negatively in the clinical outcome of hospitalized patients. Diarrhea and constipation are the main gastrointestinal problems presented in these cases. Variables related to patients, drug therapy and nutritional therapy itself might be predisposing factors for diarrhea and constipation. The aim of this study was to analyze and assess the frequency and risk factors associated with diarrhea and constipation in hospitalized patients receiving exclusive EN therapy in a general hospital. Method: The authors performed a monocentric study, sequential with random inclusion that evaluated prospectively by observation the daily occurrence of diarrhea and constipation in hospitalized adult patients fed exclusively by EN through a feeding tube for 21 days. Variables related to patients, the influence of drug therapy and type of enteral formula were studied too. Patients were categorized retrospectively as evacuation daily: group D (diarrhea, 3 or more watery evacuations in 24 hours), group C (constipation, less than 1 evacuation during 3 days), and group N (absence of diarrhea or constipation). All prescription drugs were recorded, and patients were analyzed according to the type and amount of medication received. The authors also investigated the presence of fiber in the enteral formula. Results: Among the 110 patients included in the study, patients classified in group C represented 70.0% (77) of the study population; group D comprised 12.7% (14), and group N represented 17.3% (19). The only variable associated with frequency of diarrhea was drug therapy. There was an association between anti-inflammatory drugs and diarrhea in patients who used formula for enteral nutrition without fiber (p=0.021). In the constipation group, the ICU admission and orotracheal intubation as the indication for EN were significant variables (p=0.036 and p=0.003277, respectively). There was also an association between H2 drugs antagonists and constipated patients who used formula for enteral nutrition without fiber (p=0.013). Enteral nutrition formula with fiber was associated to prevention of constipation. The antidopaminergic therapeutic class showed beneficial effect in the prevention of diarrhea (p=0.023) and constipation (p=0.022) when compared with group N. Conclusion: Constipation was more frequent than diarrhea in patients fed exclusively by EN through a feeding tube, especially when it was used enteral nutrition formula without fiber. The therapeutic class of anti-inflammatory drugs was associated with diarrhea in patients who used formula for enteral nutrition without fiber. Constipation was associated with ICU admission, TNE indication for mechanical ventilation and therapeutic class of H2 drugs antagonists in patients who used formula for enteral nutrition without fiber. The prescription of prokinetic drugs seems to be beneficial in the prevention of diarrhea and constipation, as well as the addition of fiber in enteral nutrition formula was associated with prevention of diarrhea and constipation influenced by drug therapy

Submitted by Filipe dos Santos (fsantos@pucsp.br) on 2016-11-17T11:23:57Z No. of bitstreams: 1 Manoela Machado Gleke.pdf: 1377562 bytes, checksum: 11ce1589d554402e1e702e8cc823b6aa (MD5) / Made available in DSpace on 2016-11-17T11:23:57Z (GMT). No. of bitstreams: 1 Manoela Machado Gleke.pdf: 1377562 bytes, checksum: 11ce1589d554402e1e702e8cc823b6aa (MD5) Previous issue date: 2016-09-20 / People suffering from chronic illness or even acute whose oral nutrition is impossible, may require use of a catheter introduced in nose or oral cavity which reaches the gastrointestinal tract, called enteral catheter (EC). From the moment that the nurse insert this catheter into the patient, it takes several maintenance care to remain to remain as long as necessary without risk of obstruction or inadvertent removal. The introduction of this catheter is a private task of the nurse, according to COFEN Resolution (Federal Nursing Council) number 0453/2014 and needs care throughout the proceedings. The survey, through indicators, noted the continuing occurrence of loss of EC in the Intensive Care Unit of a public hospital in the state of São Paulo. From there, it was applied a training course with the nursing staff through the realistic simulation as a teaching and learning methodology. Objectives: To measure the effectiveness of training for EC conservation, to identify the theoretical knowledge of the professional previous and after the educational intervention. Method: through a quantitative approach to exploratory, the survey was traced a quasi-experimental study. As criteria for inclusion and exclusion, each professional training conducted in their working hours at a ICU bed, in order to adjust the availability of time, space and routine of the institution. Results: The final sample was composed of 54 professionals being that 14 (25.9%) nurses and 40 (74.1%) nursing technicians. The 54 participants were sufficient to test a difference in withdrawal indicator unplanned the EC equal to 16% before and 1.2% after the training; indicating (p <0.001) and established a 0.05 significance level (5%). Conclusion: The data showed that there is reliability and validity in the training of nursing staff demonstrating effectiveness in reducing the incidence of EC loss in quality indicator / As pessoas que sofrem de alguma doença crônica ou, até mesmo aguda, cuja alimentação por via oral é impossibilitada, podem necessitar do uso de um cateter introduzido na narina ou na cavidade oral o qual chega ao trato gastrointestinal, denominado cateter enteral (CE). A partir do momento que este cateter é inserido no paciente, são necessários vários cuidados de manutenção para que permaneça, sem riscos de obstrução ou retirada inadvertida. A introdução deste cateter é privativa do enfermeiro, de acordo com a Resolução COFEN (Conselho Federal de Enfermagem) Nº 0453/2014 e requer cuidados durante todo o processo. Foi observada, por meio de indicadores, nas Unidades de Terapia Intensiva de um Hospital público do Estado de São Paulo, a ocorrência contínua de perda de CE. Diante deste cenário, aplicou-se uma capacitação com a equipe de enfermagem por meio da simulação realística como uma metodologia de ensino e aprendizagem. Objetivos: Avaliar a efetividade da capacitação para a manutenção de CE, identificar o conhecimento teórico do profissional prévio e posterior à intervenção educativa. Material e método: Delineou-se um estudo quase- experimental, com abordagem quantitativa do tipo exploratória. Para adequação da disponibilidade de tempo, espaço e rotina da instituição, a capacitação foi realizada no horário de trabalho de cada profissional, em um leito disponível da UTI, conforme critérios de inclusão e exclusão. Resultados: A amostra final do estudo foi composta por 54 profissionais, sendo 14 (25,9%) enfermeiros e 40 (74,1%) técnicos de enfermagem. Os 54 participantes foram suficientes para testar uma diferença no indicador de retirada não planejada do CE igual a 16% pré e 1,2% após a capacitação; indicando um (p-valor <0,001) e estabelecido um nível de significância de 0,05 (5%). Conclusão: Os dados obtidos apontaram que há confiabilidade e validade na capacitação da equipe de enfermagem demonstrando efetividade na redução da incidência da perda do CE no indicador de qualidade

Objetivo: trata-se de revisão integrativa da literatura realizada com o objetivo de identificar os estudos primários que abordam os eventos adversos relacionados à sonda nasogástrica / nasoentérica (SNG/SNE) em pacientes adultos. Método: a busca foi realizada no mês de abril de 2017 nas bases de dados PubMed, CINAHL, LILACS, EMBASE e Scopus. Para realizar a busca foram utilizadas palavras-chave e encontradas 1.020 citações. Destas, 988 artigos foram excluídos a partir da leitura de títulos e resumos. Em seguida, procedeu-se a leitura, na íntegra, de 32 artigos, dos quais 12 foram excluídos. Logo, um total de 20 artigos foram incluídos no estudo. Foi realizada, também, busca manual nas referências dos artigos incluídos com o intuito de encontrar estudos que não foram recuperados anteriormente nas bases de dados supracitadas. Foram obtidos 84 artigos, dos quais 30 foram excluídos, a partir da leitura de títulos e resumos. Dos 54 artigos recuperados, quatro foram excluídos após leitura na íntegra e um artigo durante a extração dos dados. Resultados: para esta revisão integrativa, foram incluídos um total de 69 artigos. Os dados foram analisados e posteriormente classificados em duas categorias principais que evidenciaram os eventos adversos relacionados ao uso de SNG/SNE: incidentes mecânicos (complicações respiratórias, complicações no esôfago ou faringe, obstrução da sonda, perfuração intestinal, perfuração intracraniana e saque não planejado da sonda) e outros incidentes (lesão por pressão relacionada à fixação e conexão errada). A maior parte dos artigos recuperados foi incluída na subcategoria \"complicações respiratórias\" devido ao posicionamento inadequado da extremidade distal da sonda no trato respiratório, o que resultou em pneumotórax e/ou óbito. Outros eventos adversos estavam relacionados à obstrução da sonda, perda da mobilidade das cordas vocais, perfuração intestinal com consequente infecção, lesão na pele e mucosas, e queimadura corporal devido à desconexão. Conclusão: os resultados sintetizados nesta revisão permitem que os profissionais da saúde, especialmente os da enfermagem, reflitam sobre a segurança dos pacientes em uso de SNG/SNE e que repensem a maneira como as sondas estão sendo manuseadas na prática clínica / Objective: an integrative literature review was developed to identify the primary studies on the adverse events related to nasogastric / nasoenteral tubes (NGT/NET) in adult patients. Method: the search was undertaken in April 2017 in the databases PubMed, CINAHL, LILACS, EMBASE and Scopus. Keywords were used for the search and 1,020 citations were found. After reading titles and abstract, 988 of these articles were excluded. Next, 32 articles were fully read, 12 of which were excluded. Hence, in total, 20 articles were included in the study. In addition, a manual search was undertaken in the references of the included articles, aiming to find studies that had not been retrieved earlier in the abovementioned databases. Eighty-four articles were found, 30 of which were excluded after reading the titles and abstracts. Of the 54 retrieved articles, four were excluded after reading the full version and one article during the extraction of the data. Results: for this integrative review, in total, 69 articles were included. The data were analyzed and then classified in two main categories that evidenced the adverse events related to the use of NGT/NET: mechanic incidents (respiratory complications, esophageal or pharyngeal complications, tube obstruction, intestinal perforation, intracranial perforation and unplanned tube withdrawal) and other incidents (wrong connection and fixationrelated pressure ulcer). Most of the articles were included in the subcategory \"respiratory complications\" due to improper positioning of the distal end of the tube in the respiratory tract, resulting in pneumothorax and/or death. Other adverse events were related to tube obstruction, loss of vocal chord mobility, intestinal perforation with consequent infection, skin and mucous membrane ulcers, and body burns due to detachment. Conclusion: based on the results synthesized in this review, health professionals, especially in nursing, can reflect on the safety of patients using NGT/NET and reconsider the manipulation of the tubes in clinical practice

Bakgrund: artificiell nutrition är en behandling som förekommer i vården och skapar olika upplevelser hos patienter, bland annat oro och sociala begränsningar vid behandlingen. Anhöriga upplever även de en oro men även en okunskap över situationen. För att uppnå trygghet behöver patienter och deras anhöriga stöttning samt vägledning av sjuksköterskor. Syfte: att skapa en översikt över sjuksköterskors upplevelser av artificiell nutrition. Metod: allmän litteraturöversikt enligt Friberg, där 15 artiklar med kvalitativa och kvantitativa ansatser valdes ut. Resultat: liknande syften sågs i flertalet studier och en av de vanligaste metoderna för att samla in data var via intervjuer. I resultatet skapades tre teman för att lyfta fram aspekter av ansvar, kunskaper samt sjuksköterskors möte med artificiell nutrition. Bland annat visade det att olika ansvarsroller, tidsbrist samt sjuksköterskors tidigare kunskaper hade betydelse för vården av patienter och anhöriga. Slutsats: sjuksköterskors erfarenheter skapar en tryggare vård för anhöriga samt för de patienter som behandlas med artificiell nutrition. Ansvar i vården och kunskapen om artificiell nutrition är två andra aspekter som är avgörande för hur sjuksköterskor förhåller sig till vårdandet kring artificiell nutrition.

O objeto de estudo foi o preparo e a administração de medicamentos por cateter pela enfermagem em pacientes que recebem nutrição enteral. O objetivo geral foi investigar o padrão de preparo e administração dos medicamentos por cateter em pacientes que recebem nutrição enteral concomitante. Os objetivos específicos foram apresentar o perfil dos medicamentos preparados e administrados de acordo com a possibilidade de serem administrados por cateter enteral e avaliar o tipo e a freqüência de erros que ocorrem no preparo e administração de medicamentos por cateter. Tratou-se de uma pesquisa com desenho transversal de natureza observacional, sem modelo de intervenção. Foi desenvolvida em um hospital do Rio de Janeiro onde foram observados técnicos de enfermagem preparando e administrando medicamentos por cateter na Unidade de Terapia Intensiva. Foram observadas 350 doses de medicamentos sendo preparados e administrados. Os grupos de medicamentos prevalentes foram os que agem no Sistema Cardiovascular Renal com 164 doses (46,80%), seguido pelos que agem no Sistema Respiratório e Sangue com 12,85% e 12,56% respectivamente. Foram encontrados 19 medicamentos diferentes do primeiro grupo, dois no segundo e cinco no terceiro. As categorias de erro no preparo foram trituração, diluição e misturas. Encontrou-se uma taxa média de 67,71% no preparo de medicamentos. Comprimidos simples foram preparados errados em 72,54% das doses, e todos os comprimidos revestidos e de liberação prolongada foram triturados indevidamente entre sólidos a categoria de erro prevalente foi trituração com 45,47%, preparar misturando medicamentos foi um erro encontrado em quase 40% das doses de medicamentos sólidos. A trituração insuficiente ocorreu em 73,33% das doses de ácido fólico, do cloridrato de amiodarona (58,97%) e bromoprida (50,00%). A mistura com outros medicamentos ocorreu em 66,66% das doses de bromoprida, de besilato de anlodipina (53,33%), bamifilina (43,47%), ácido fólico (40,00%) e ácido acetilsalicílico (33,33%). Os erros na administração foram ausência de pausa e manejo indevido do cateter. A taxa média de erros na administração foi de 32,64%, distribuídas entre 17,14% para pausa e 48,14% para manejo do cateter. A ausência de lavagem do cateter antes foi o erro mais comum e o mais incomum foi não lavar o cateter após a administração. Os medicamentos mais envolvidos em erros na administração foram: cloridrato de amiodarona (n=39), captopril (n=33), cloridrato de hidralazina (n=7), levotiroxina sódica (n=7). Com relação à lavagem dos cateteres antes, ela não ocorreu em 330 doses de medicamentos. O preparo e administração inadequados de medicamentos podem levar à perdas na biodisponibilidade, diminuição do nível sérico e riscos de intoxicações para o paciente. Preparar e administrar medicamentos são procedimentos comuns, porém apresentou altas taxas de erros, o que talvez reflita pouco conhecimento desses profissionais sobre as boas práticas da terapia medicamentosa. Constata-se a necessidade de maior investimento de todos os profissionais envolvidos, médicos, enfermeiros e farmacêuticos nas questões que envolvam a segurança com medicamentos assim como repensar o processo de trabalho da enfermagem. / This studys object was the medications preparation and administration by nursing probes in patients receiving enteral nutrition. The overall objective was to investigate the preparation pattern and drugs administration through tubes in patients receiving concomitant enteral nutrition. The specific objectives were to present the medications profile prepared and administered in accordance with the possibility to be administered by enteral probes and assess the errors type and frequency that occur in the medicines preparation and administration by probes. This was a cross-sectional survey of the observational nature without intervention model. It was developed in a hospital in Rio de Janeiro city, Brazil, observing practical nurses preparing and administering medications through tubes in the Intensive Care Unit. We observed the preparation of 350 medicines doses and subsequent administration to the patients. The prevalent drug groups were those acting on Cardiovascular Renal System with 164 doses (46.80%), followed by those acting on the Respiratory System and Blood with 12.85% and 12.56% respectively. We found 19 different drugs from the first group, two from the second group, and five in the third one. The error categories in the preparation were milling, mixing and dilution. We found a mean rate of 67.71% in medication preparation. Simple tablets were prepared by wrong way in 72.54% of the doses and all coated tablets and those of extended release were crushed incorrectly. Among solids, the prevalent error category was milling with 45.47%. The preparation by mixing drugs was an error in almost 40% from the solid drugs doses. The insufficient grinding occurred in 73.33% from the folic acid doses, amiodarone hydrochloride (58.97%), and from bromopride (50.00%). Mixing with other drugs occurred in 66.66% from bromopride doses, amlodipine besylate (53.33%), bamifilina (43.47%), folic acid (40.00%), and acetylsalicylic acid (33.33 %). The administration errors were no breaks and improper probe handling. The average errors rate of administration was 32.64%, being 17.14% for pause and 48.14% for the probe handling. Failure to wash the probe before administration was the most common mistake and not to wash the probe after that was the most unusual. The drugs most commonly involved in errors in the administration were amiodarone hydrochloride (n=39), captopril (n=33), hydralazine hydrochloride (n=7), and levothyroxine sodium (n=7). In 330 medication dosages, the probes were not washed, before the administration. The drugs inadequate preparation and administration can lead to losses in bioavailability, decreased serum levels, and risk of patient poisoning. Preparing and administering medications is a common procedure but showed high error rates, maybe reflecting little knowledge from these professionals about the best practices in drug therapy. There is a need for greater investment by all involved professionals, doctors, nurses, and pharmacists on issues involving the drug safety and rethink the process of nursing work.

Delayed gastric emptying, that manifests clinically as intolerance to enteral feeding, occurs in over 50% of critically ill patients and has a major impact on patient morbidity and mortality. Despite the recognition that the proximal stomach has a major role in gastric emptying of liquids, only the motor activity of the antro-pyloro-duodenal region has been evaluated in detail. In addition, many of the proposed risk factors for the gastric dysmotility, particularly a prior history of diabetes mellitus, have not been evaluated formally but have been extrapolated from data from non-critically ill patients. The currently available prokinetic drugs, erythromycin and metoclopramide, are considered to be the first line treatment for feed intolerance. However, neither data comparing the effectiveness of these agents nor the data on the effects of combination of therapy in the treatment of feed intolerance are available. The aims of this thesis were, therefore, to examine: (i) proximal gastric motor activity and the association between proximal and distal motility; (ii) the relationship between entero-gastric humoral responses to nutrients, gastric emptying and feed intolerance; (iii) the impact of admission diagnoses, choice of sedations, timing of initiation of feeding, and pre-existing history of diabetes mellitus on gastric emptying and feed intolerance; and (iv) the efficacy of erythromycin, metoclopramide and combination of these drugs in treatment of feed intolerance in critically ill patients. The current thesis indicates that motor activity is impaired in multiple regions of the stomach in the critically ill. When compared to healthy humans, proximal gastric relaxation was prolonged and fundic wave activity was educed during small intestinal nutrient infusion in critically ill patients. In addition, simultaneous assessment of proximal and distal gastric motility demonstrated a possible disruption of the motor integration between the proximal and distal stomach. In light of the recent data that suggested a significantly greater proportion of meal distributed proximally in critically ill patients with delayed gastric emptying (Nguyen, et al. 2006), the disruption of the gastric motor integration and the prolonged gastric relaxation in response to duodenal nutrients may play a significant role in the pathogenesis of slow gastric emptying during critical illness, especially as liquid formulae. The entero-gastric hormonal feedback responses were also disturbed during critical illness. Both fasting and duodenal nutrient-stimulated plasma CCK and PYY concentrations were significantly higher in critically ill patients, particularly those who did not tolerated gastric feeds. The rate of gastric emptying of a liquid meal was inversely related to both fasting and postprandial plasma CCK and PYY concentrations, supporting the potential role of plasma CCK and PYY in the pathogenesis of gastric dysmotility in critically ill patients. Admission diagnosis, choice of sedative drug and blood glucose control but not the timing of enteral feeds were important factors for delayed gastric emptying and feed intolerance in these patients. In particular, delaying enteral feeding by 4 days had no impact on the rate of gastric emptying, intra-gastric meal distribution, or plasma CCK and PYY concentrations. Contrary to traditional belief, critically ill patients with a pre-existing diagnosis of type 2 DM have only a minor disturbance to the proximal stomach, a relatively normal gastric emptying and are at no higher risk of feed intolerance than those without DM, suggesting the presence of pre-existing DM 2 in critically ill patients should not influence the standard practice of gastric feeding. Therapeutically, short-term treatment with low dose erythromycin was more effective than metoclopramide, but the effectiveness decreased rapidly overtime at similar rate as observed with metoclopramide. In patients who failed to response to either agent, treatment with both agents was highly effective in re-establishing feeding success. The use of combination therapy as the initial treatment for feed intolerance was also more effective than erythromycin alone and had less tachyphylaxis. Treatment with erythromycin and metoclopramide, either as a single agent or in combination did not associated with major cardiovascular adverse side effects. Although diarrhoea was a common side effect and was highest with combination therapy, it was not associated with Clostridium difficile infection and settled quickly after the cessation of the prokinetic therapy. In summary, the work performed in the current thesis has provided substantial insights into the understanding of the nature, risk factors, pathogenesis and treatment of disturbed gastric motor function in critically ill patients. Not only do these findings stimulate further research into the mechanisms responsible for gastric dysmotility in critical illness, they also lead to the development of new strategies for optimizing the management of feed intolerance. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1320667 / Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2008

Background: It is necessary for a company to hold some unique and irreplicable competitive advantage in order to be able to succeed in a market. In a market where public procurement is an important part the competitive advantages will be characterized by the fact that some of the participants on the market are public organizations and that their actions as for procurement fall under the legislation LOU. The characteristics of competitive advantage also depend on and change with continuous changes on a market. Purpose: The purpose of this thesis is to study the competitive advantages that are presenton a current market characterized by public procurement and how these are created. The purposes is also to based on the trends on the market today study and predict the nature of the competitive advantage on the market in the future as well as the changes that we think will occur on the relevant market. Realization: We have performed a case study of the market for enteral nutrition where data have been gathered from interviews with participants in the market and from studying the law of public procurement. The data is gathered and analysed based on an adapted model that we have derived from two theoretical perspectives of competitive advantage. The model that looks to the nature and the origin of competitive advantage has been tested and evaluated through application on the market. Results: Strategic assets are of great importance in order for a company to create a competitive advantage in the form of being established, relations, being established in municipalities and the offer on the market of enteral nutrition today. These strategic assets and competitive advantages will in the future be characterized by the trends that are present on the market today. These trends are identified as an increasing knowledge, products for specific diseases, cooperation, limited procurements, alternative distribution channels and working towards the patients. The creation and the nature of competitive advantage is shaped by an interaction between the resources and capabilities of the firm and the needs and the needs and the demands of the market.

<p>Background: It is necessary for a company to hold some unique and irreplicable competitive advantage in order to be able to succeed in a market. In a market where public procurement is an important part the competitive advantages will be characterized by the fact that some of the participants on the market are public organizations and that their actions as for procurement fall under the legislation LOU. The characteristics of competitive advantage also depend on and change with continuous changes on a market. </p><p>Purpose: The purpose of this thesis is to study the competitive advantages that are presenton a current market characterized by public procurement and how these are created. The purposes is also to based on the trends on the market today study and predict the nature of the competitive advantage on the market in the future as well as the changes that we think will occur on the relevant market. </p><p>Realization: We have performed a case study of the market for enteral nutrition where data have been gathered from interviews with participants in the market and from studying the law of public procurement. The data is gathered and analysed based on an adapted model that we have derived from two theoretical perspectives of competitive advantage. The model that looks to the nature and the origin of competitive advantage has been tested and evaluated through application on the market. </p><p>Results: Strategic assets are of great importance in order for a company to create a competitive advantage in the form of being established, relations, being established in municipalities and the offer on the market of enteral nutrition today. These strategic assets and competitive advantages will in the future be characterized by the trends that are present on the market today. These trends are identified as an increasing knowledge, products for specific diseases, cooperation, limited procurements, alternative distribution channels and working towards the patients. The creation and the nature of competitive advantage is shaped by an interaction between the resources and capabilities of the firm and the needs and the needs and the demands of the market.</p>

Delayed gastric emptying, that manifests clinically as intolerance to enteral feeding, occurs in over 50% of critically ill patients and has a major impact on patient morbidity and mortality. Despite the recognition that the proximal stomach has a major role in gastric emptying of liquids, only the motor activity of the antro-pyloro-duodenal region has been evaluated in detail. In addition, many of the proposed risk factors for the gastric dysmotility, particularly a prior history of diabetes mellitus, have not been evaluated formally but have been extrapolated from data from non-critically ill patients. The currently available prokinetic drugs, erythromycin and metoclopramide, are considered to be the first line treatment for feed intolerance. However, neither data comparing the effectiveness of these agents nor the data on the effects of combination of therapy in the treatment of feed intolerance are available. The aims of this thesis were, therefore, to examine: (i) proximal gastric motor activity and the association between proximal and distal motility; (ii) the relationship between entero-gastric humoral responses to nutrients, gastric emptying and feed intolerance; (iii) the impact of admission diagnoses, choice of sedations, timing of initiation of feeding, and pre-existing history of diabetes mellitus on gastric emptying and feed intolerance; and (iv) the efficacy of erythromycin, metoclopramide and combination of these drugs in treatment of feed intolerance in critically ill patients. The current thesis indicates that motor activity is impaired in multiple regions of the stomach in the critically ill. When compared to healthy humans, proximal gastric relaxation was prolonged and fundic wave activity was educed during small intestinal nutrient infusion in critically ill patients. In addition, simultaneous assessment of proximal and distal gastric motility demonstrated a possible disruption of the motor integration between the proximal and distal stomach. In light of the recent data that suggested a significantly greater proportion of meal distributed proximally in critically ill patients with delayed gastric emptying (Nguyen, et al. 2006), the disruption of the gastric motor integration and the prolonged gastric relaxation in response to duodenal nutrients may play a significant role in the pathogenesis of slow gastric emptying during critical illness, especially as liquid formulae. The entero-gastric hormonal feedback responses were also disturbed during critical illness. Both fasting and duodenal nutrient-stimulated plasma CCK and PYY concentrations were significantly higher in critically ill patients, particularly those who did not tolerated gastric feeds. The rate of gastric emptying of a liquid meal was inversely related to both fasting and postprandial plasma CCK and PYY concentrations, supporting the potential role of plasma CCK and PYY in the pathogenesis of gastric dysmotility in critically ill patients. Admission diagnosis, choice of sedative drug and blood glucose control but not the timing of enteral feeds were important factors for delayed gastric emptying and feed intolerance in these patients. In particular, delaying enteral feeding by 4 days had no impact on the rate of gastric emptying, intra-gastric meal distribution, or plasma CCK and PYY concentrations. Contrary to traditional belief, critically ill patients with a pre-existing diagnosis of type 2 DM have only a minor disturbance to the proximal stomach, a relatively normal gastric emptying and are at no higher risk of feed intolerance than those without DM, suggesting the presence of pre-existing DM 2 in critically ill patients should not influence the standard practice of gastric feeding. Therapeutically, short-term treatment with low dose erythromycin was more effective than metoclopramide, but the effectiveness decreased rapidly overtime at similar rate as observed with metoclopramide. In patients who failed to response to either agent, treatment with both agents was highly effective in re-establishing feeding success. The use of combination therapy as the initial treatment for feed intolerance was also more effective than erythromycin alone and had less tachyphylaxis. Treatment with erythromycin and metoclopramide, either as a single agent or in combination did not associated with major cardiovascular adverse side effects. Although diarrhoea was a common side effect and was highest with combination therapy, it was not associated with Clostridium difficile infection and settled quickly after the cessation of the prokinetic therapy. In summary, the work performed in the current thesis has provided substantial insights into the understanding of the nature, risk factors, pathogenesis and treatment of disturbed gastric motor function in critically ill patients. Not only do these findings stimulate further research into the mechanisms responsible for gastric dysmotility in critical illness, they also lead to the development of new strategies for optimizing the management of feed intolerance. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1320667 / Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2008