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Bakgrund: Tidigare forskning visar på att mellan 32–90% av patienter som genomgått någon form av kirurgi utvecklar oavsiktlig hypotermi perioperativt. Ofta har patienterna redan mild hypotermi vid ankomst till operationssalen. De perioperativt verksamma specialistsjuksköterskorna har ett gemensamt ansvar att förhindra samt åtgärda oavsiktlig nedkylning av patienten perioperativt. Trots mycket forskning om hypotermi och dess konsekvenser visar studier på att det finns kunskapsluckor inom ämnet hos specialistsjuksköterskor som ingår i operationsteamet. Vidare finns det för närvarande inga svenska nationella riktlinjer för värmebevarande åtgärder under kirurgi utan mer övergripande rekommendationer om vikten av att upprätthålla patientens temperatur.  Syfte: Att beskriva hur specialistsjuksköterskor inom dagkirurgi arbetar för att bibehålla normotermi hos patienten.  Metod: Kvalitativ intervjustudie med induktiv ansats. Semi-strukturerade intervjuer med tio specialistsjuksköterskor på två operationsavdelningar med dagkirurgisk verksamhet. Datan analyserades med manifest innehållsanalys enligt Graneheim och Lundman. Resultat: I resultatet framkom tre kategorier: beslut om värmebevarande åtgärder, förutsättningar för att förebygga perioperativ hypotermi och viljan att göra gott. Kategorierna hade sammanlagt åtta tillhörande subkategorier.   Slutsats: Specialistsjuksköterskans arbete för att bibehålla normotermi hos patienten var komplext där många olika faktorer spelade in. Det fanns goda kunskaper om perioperativ hypotermi och värmebevarande åtgärder i operationsteamet. Resultatet synliggjorde dock att arbetet i att förebygga perioperativ hypotermi inte alltid baserades på evidens och att det inte fanns tillräckligt med beslutsunderstöd för värmebevarande åtgärder. / Background: Previous research shows that 32–90% of patients who have undergone some sort of surgery develop accidental perioperative hypothermia. Often, patients already have mild hypothermia upon arrival at the operating room. The perioperative specialist nurses have a shared responsibility to prevent and treat unintended cooling of the patient. Despite a lot of research on hypothermia and its consequences, studies show that there are knowledge gaps within the subject in specialist nurses who are part of the surgical team. Furthermore, there are currently no Swedish national guidelines for perioperative heat conservation measures during surgery, but more general recommendations on the importance of maintaining the patient’s temperature. Aim: To describe how specialist nurses in ambulatory surgery work to maintain normothermia in the patient. Method: Qualitative interview with inductive approach. Semi-structured interviews with ten specialist nurses at two ambulatory surgery departments. The data were analyzed with manifest content analysis according to Graneheim and Lundman.  Results: The results revealed three categories: decisions on heat conservation measures, conditions for preventing perioperative hypothermia and a desire to do good. The categories had a total of eight associated subcategories.  Conclusion: The specialist nurse’s work to maintain normothermia in the patient was complex in which many different factors came into play. There was a good knowledge of perioperative hypothermia and heat conservation measures in the surgical team. However, the results showed that the work in preventing perioperative hypothermia was not always based on evidence and that there was not enough basis for decision for perioperative heat conservation measures.

Zymosan-induced peritonitis is a model commonly used to study systemic inflammatory response syndrome and multiple organ dysfunction syndrome. However, effects of zymosan on cardiac function have not been reported. We evaluated cardiac responses to zymosan in mice and the role of β-Glucan and dectin-1 in mediating these responses. Temperature and cardiac function were evaluated before and after intraperitoneal (i.p.) injection of zymosan (100 or 500 mg/kg) or saline. Chronotropic and dromotropic functions were measured using electrocardiograms (ECGs) collected from conscious mice. Cardiac inotropic function was determined by echocardiography. High-dose zymosan caused a rapid and maintained hypothermia along with visual signs of illness. Baseline heart rate (HR) was unaffected but HR variability (HRV) increased, and there was a modest slowing of ventricular conduction. High-dose zymosan also caused prominent decreases in cardiac contractility at 4 and 24 h. Because zymosan is known to cause gastrointestinal tract pathology, peritoneal wash and blood samples were evaluated for bacteria at 24 h after zymosan or saline injection. Translocation of bacterial occurred in all zymosan-treated mice (n=3), and two had bacteremia. Purified β-Glucan (50 and 125 mg/kg, i.p.) had no effect on temperature or ECG parameters. However, deletion of dectin-1 modified the ECG responses to high-dose zymosan; slowing of ventricular conduction and the increase in HRV were eliminated but a marked bradycardia appeared at 24 h after zymosan treatment. Zymosan-treated dectin-1 knockout mice also showed hypothermia and visual signs of illness. Fecal samples from dectin-1 knockout mice contained more bacteria than wild types, but zymosan caused less translocation of bacteria. Collectively, these findings demonstrate that zymosan-induced systemic inflammation causes cardiac dysfunction in mice. The data suggest that dectin-1-dependent and -independent mechanisms are involved. Although zymosan treatment causes translocation of bacteria, this effect does not have a major role in the overall systemic response to zymosan.

Bakgrund: Postoperativ shivering är ett fenomen som uppstår hos patienter efter kirurgi och anestesi, vilket innebär muskeltremor som får patienten att darra eller huttra okontrollerat. Shivering kopplas ofta till hypotermi även om det ensamt inte helt kan förklara uppkomsten. Det har en negativ effekt på läkningsprocessen, men är också obehagligt och gör att patienten lider. En del patienter beskriver upplevelsen som det värsta de har varit med om. Syfte: Att sammanställa anestesisjuksköterskans åtgärder för att förebygga shivering hos den postoperativa patienten. Metod: Vi har antagit induktiv ansats och gjort en systematisk litteraturöversikt, syntetiserat kvantitativ data som sammanställts i en metaanalys och narrativ syntes. Från artiklar som har liknande design och refererar till samma fråga eller intervention. Behandlingar och insatser kallas interventioner, vilket är ett brett begrepp och inkluderar både medicinska och omvårdnadsmässiga behandlingar för att förebygga och behandla postoperativ shivering. Resultat: För att kunna nå syftet att sammanställa åtgärder, behövdes först orsaker identifieras. Två kategorier identifierades, omvårdnadsåtgärder samt farmakologiska åtgärder, med tillhörande koder. Att åtgärda hypotermi, riskbedöma sårbara patientgrupper, ge premedicinering samt analgesi, ha en medvetenhet kring vätskebehandling samt övervakning av anestesidjup ansågs vara åtgärder för att förebygga postoperativ shivering. Olika läkemedel ger olika resultat i det postoperativa måendet. Slutsats: Mycket talar för att nedkylning och smärta måste motverkas för att minska shivering och bör behandlas preventivt. Medvetenheten kring vikten av temperaturövervakning bör ökas. Studien kom även fram till att en begreppsdefinition och standardmetod att behandla postoperativ shivering är önskvärt. / Background: Postoperative shivering is a phenomenon that occurs in patients after surgery and anesthesia, which means muscle tremors that cause the patient to tremble or shake uncontrollably. Shivering is often linked to hypothermia, although it alone cannot fully explain its occurrence. It has a negative effect on the healing process, but is also unpleasant and causes the patient to suffer. Some patients describe the experience as the worst they have been through. Aim: To compile the anesthesia nurse's measures to prevent shivering in the postoperative patient. Method: We have adopted an inductive approach and performed a systematic literature review, synthesized quantitative data compiled in a meta-analysis and narrative synthesis. From articles that have a similar design and refer to the same question or intervention. Treatments and efforts are called interventions, which is a broad term and includes both medical and nursing treatments to prevent and treat postoperative shivering. Results: In order to achieve the aim of compiling measures, causes first needed to be identified. Two categories were identified, nursing measures and pharmacological measures, with associated codes. Correcting hypothermia, risk assessment of vulnerable patient groups, giving premedication and analgesia, having an awareness of fluid treatment and monitoring the depth of anesthesia were considered measures to prevent postoperative shivering. Different drugs give different results in the postoperative mood. Conclusion: Much suggests that cooling and pain must be counteracted to reduce shivering and should be treated preventively. Awareness of the importance of temperature monitoring should be increased. The study also concluded that a conceptual definition and standard method to treat postoperative shivering is desirable.

Introduction: The problems and the complications regarding hypothermia in the operating room are well known historically. The struggle of keeping the patient warm is still problematic. Hypothermia creates extensive complications and suffering for patients and is potentially lethal. Purpose: To explore the operating- and anesthesia nurses experiences in preventing hypothermia perioperative Method: A qualitative interview study using phenomenografic approach. The research group consisted of operating- and anesthesia nurses from a medium sized hospital in Sweden. Semi structured interviews were conducted. Results: The study revealed three concept categories. That knowledge leads to understanding which indicated that the knowledge of why hypothermia needs to be prevented raised awareness and compliance. Understanding the importance of communication and teamwork that highlighted the importance of communicating and strive towards the same goal. Working with conditions and obstacles that showed the importance of using available instrumentalities to prevent those obstacles that remains. Conclusion: This master thesis contributes to highlighting the importance of knowledge in the preventive work around hypothermia. Strengthened teamwork between operating nurses and anesthesia nurses creates a better condition in protecting patients against unwanted hypothermia and creating a safer surgical care.

INTRODUÇÃO: Evidências relevantes acerca dos benefícios da hipotermia terapêutica provieram da utilização de técnicas de resfriamento sistêmico. Essas técnicas, no entanto, podem causar complicações graves que poderiam ser evitadas com métodos de hipotermia encefálica seletiva. O presente estudo objetiva: 1) verificar a viabilidade da hipotermia encefálica exclusiva através de um sistema de resfriamento nasofaríngeo concomitante ao de preservação da temperatura corpórea em suínos e 2) investigar os efeitos da hipotermia encefálica exclusiva nas variáveis fisiológicas sistêmicas e encefálicas. MÉTODOS: Dez suínos híbridos foram submetidos a resfriamento nasofaríngeo durante 60 minutos e subsequente reaquecimento espontâneo. Foram obtidos dados referentes a: pressão arterial média, débito cardíaco, temperatura encefálica, pressão parcial de oxigênio do tecido encefálico (PbtO2, do inglês, pressure of brain tissue O2), velocidade do fluxo sanguíneo nas artérias encefálicas, índice de resistência e índice de pulsatilidade. RESULTADOS: O resfriamento nasofaríngeo associou-se à um decréscimo gradual da temperatura encefálica, que foi mais marcante no hemisfério cerebral esquerdo (p < 0,01). Neste hemisfério, houve redução de 1,47 ± 0,86°C nos primeiros 5 minutos (p < 0,01), 2,45 ± 1,03°C aos 10 minutos e 4,45 ± 1,36°C após 1 hora (p < 0,01). A diferença entre as temperaturas cerebral sistêmica foi 4,57 ± 0,87°C (p < 0,01). As temperaturas centrais (retal, esofágica e da artéria pulmonar), assim como a hemodinâmica encefálica e sistêmica, mantiveram-se estáveis durante o procedimento. Houve diminuição significativa da PbtO2, concomitantemente ao decréscimo da temperatura encefálica. CONCLUSÕES: A indução de hipotermia encefálica exclusiva é possível através de resfriamento nasofaríngeo associado a medidas de preservação da temperatura sistêmica. O resfriamento encefálico exclusivo não influencia as funções hemodinâmicas sistêmicas e encefálicas, contudo reduz significativamente a PbtO2 / INTRODUCTION: Relevant evidences for the use of therapeutic hypothermia derive from studies using whole body cooling methods. These methods can lead to serious complications. To avoid such complications, selective brain cooling methods were developed. The objective of this study was: 1) to verify the feasibility of exclusive brain hypothermia by means of nasopharyngeal cooling along with measures of systemic temperature preservation in an experimental swine model, and 2) to investigate the influence of the exclusive brain cooling on cerebral and systemic hemodynamics as well as on cerebral oxygenation. METHODS: Ten hybrid swine underwent nasopharyngeal cooling for 60 minutes, followed by spontaneous rewarming. A number of physiological variables were monitored: arterial blood pressure, cardiac output, temperature in the right and left cerebral hemispheres, pressure of brain tissue O2, cerebral blood flow velocities, resistance index, and pulsatility index. RESULTS: Nasopharyngeal cooling was associated with decrease in brain temperature, which was more significant in the left cerebral hemisphere (p < 0,01). There was a reduction of 1.47 ± 0.86°C in the first 5 minutes (p < 0.01), 2.45 ± 1.03°C within 10 min, and 4.45 ± 1.36°C after 1 hour (p < 0.01). The brain-core gradient was 4.57 ± 0.87°C (p < 0,001). Rectal, esophageal, and pulmonary artery temperatures, as well as brain and systemic hemodynamics, remained stable during the procedure. PbtO2 values significantly decreased following the brain cooling. CONCLUSION: Achievement of exclusive brain hypothermia is feasible by means of nasopharyngeal cooling associated with measures of systemic temperature preservation. Selective brain cooling does not influence both systemic and cerebral hemodynamics, except PbtO2, which decreased significantly

5 Summary: Currently, the outcomes from traumatic exsanguination cardiac arrest (CA) show that over 50% of deaths due to trauma occur at the scene, where medical care is limited. Less than 10% of patients who become pulseless from trauma survive. However, in an appropriate setting, some of those traumatic injuries could be surgically repairable. Emergency preservation and resuscitation (EPR) is a novel approach for resuscitation of exsanguination CA victims. EPR uses deep hypothermic preservation for prolonged CA to buy time for transport, damage control surgery, and delayed resuscitation with cardiopulmonary bypass (CPB). Initially, we used a dog model to maximize clinical relevance. We showed that the efficacy of EPR is related to the depth of hypothermia and duration of CA. Pharmacologic adjuncts tested to augment hypothermia generally failed. Extended hemorrhagic shock did not prevent the success of EPR vs. conventional resuscitation if extended post-resuscitative hypothermia was provided. Oxygenation of the flush allowed extending of survivable duration of deep hypothermic CA. Because of the lack of molecular tools available for use in dogs, we developed a rat EPR model to study the cellular and molecular mechanisms underlying deep hypothermic neuroprotection to allow us to define specific targets for...

Made available in DSpace on 2014-07-29T12:03:34Z (GMT). No. of bitstreams: 1 tese Ingrid Atayde.pdf: 585619 bytes, checksum: 763b46c7c1dddbf4008bed6da5a452ac (MD5) Previous issue date: 2008-06-13 / Hypothermia is a frequent event in the per-operative period. Usually neglected in Brazil, it may lead to complications such as delay on anesthetic recovery, blood gas impairment, brain and myocardial ischemia and postoperative shivering. Prevention of hypothermia includes aspects from hospital facilities to training the nurse team. Heated fluid infusion is an aid on maintaining body temperature. A recent release of Brazilian industry, the SAF® Fluid Heating System, is a device which maintains warm the fluid to be infused, intended to reduce risks related to per-operative hypothermia. The following study aimed to evaluate clinical and electrocardiographic parameters, blood gas analysis, and serum biochemistry of female dogs submitted to elective ovariohysterectomy and infusion of 0,9% saline solution heated at 37ºC by SAF®. Thirteen female dogs were allocated in two groups: GI control (n=6), and GII treatment (n=7), in an operating room acclimatized at 22ºC. The parameters were evaluated along 90 minutes from pre-anesthetic medication. There were no significant clinical or biochemical variations; however there was group effect on the variables mean arterial pressure, urea, ALT, ALP and hypnosis time. There was no expressive variation on blood gas analysis, although some variables presented significant differences along the moments, but not between the groups. Electrocardiographic significant alterations were not evident, except for P wave, indicating atrial overload in GI. The isolated use of SAF®, on the conditions and degree of hypothermia of this study, was not enough to avoid hypothermia in female dogs submitted to general inhalatory anesthesia. / A hipotermia é um evento de ocorrência comum no período per-operatório. Freqüentemente negligenciada no Brasil, pode trazer complicações como o retardo da recuperação anestésica, desequilíbrio ácido-base, isquemia cerebral e miocárdica, coagulopatias e tremor pós-operatório. A prevenção da hipotermia per-operatória compreende aspectos abrangentes que incluem desde a estrutura física do hospital até o treinamento da equipe de enfermagem. A infusão de fluidos aquecidos é uma opção no auxílio da manutenção da temperatura corpórea. Recente lançamento na indústria nacional, o SAF® Sistema de Aquecimento de Fluidos consiste de um aparelho que mantém o fluido a ser infundido aquecido, desenvolvido como objetivo de minimizar os riscos relativos à ocorrência de hipotermia peroperatória. O presente trabalho objetivou avaliar os parâmetros clínicos, hemogasométricos, eletrocardiográficos e bioquímica sérica de cadelas submetidas à ovariohisterectomia eletiva recebendo, durante o procedimento cirúrgico, infusão de solução salina 0,9% aquecida a 37ºC pelo SAF®. Foram utilizadas 13 cadelas, divididas em dois grupos: GI controle (n=6), e GII tratamento (n=7), em centro cirúrgico climatizado em 22ºC. Foram feitas avaliações clínicas, hemogasométricas, eletrocardiográficas e bioquímicas ao longo de 90 minutos contados a partir da medicação pré-anestésica. Não foram evidenciadas alterações clínicas e bioquímicas significativas, mas houve efeito de grupo sobre as variáveis pressão arterial média, uréia, ALT, ALP e tempo de hipnose. Não houve alterações expressivas nos valores dos parâmetros hemogasométricos, mas algumas variáveis apresentaram diferenças significativas ao longo dos momentos, mas não entre os grupos. Não foram evidenciadas alterações eletrocardiográficas significativas, com exceção da onda P, demonstrando alterações sugestivas de sobrecarga atrial em GI. O uso isolado do SAF®, nas condições e grau de hipotermia desse estudo, não foi suficiente para evitar o estabelecimento da hipotermia em cadelas submetidas a anestesia geral inalatória.

INTRODUÇÃO: Evidências relevantes acerca dos benefícios da hipotermia terapêutica provieram da utilização de técnicas de resfriamento sistêmico. Essas técnicas, no entanto, podem causar complicações graves que poderiam ser evitadas com métodos de hipotermia encefálica seletiva. O presente estudo objetiva: 1) verificar a viabilidade da hipotermia encefálica exclusiva através de um sistema de resfriamento nasofaríngeo concomitante ao de preservação da temperatura corpórea em suínos e 2) investigar os efeitos da hipotermia encefálica exclusiva nas variáveis fisiológicas sistêmicas e encefálicas. MÉTODOS: Dez suínos híbridos foram submetidos a resfriamento nasofaríngeo durante 60 minutos e subsequente reaquecimento espontâneo. Foram obtidos dados referentes a: pressão arterial média, débito cardíaco, temperatura encefálica, pressão parcial de oxigênio do tecido encefálico (PbtO2, do inglês, pressure of brain tissue O2), velocidade do fluxo sanguíneo nas artérias encefálicas, índice de resistência e índice de pulsatilidade. RESULTADOS: O resfriamento nasofaríngeo associou-se à um decréscimo gradual da temperatura encefálica, que foi mais marcante no hemisfério cerebral esquerdo (p < 0,01). Neste hemisfério, houve redução de 1,47 ± 0,86°C nos primeiros 5 minutos (p < 0,01), 2,45 ± 1,03°C aos 10 minutos e 4,45 ± 1,36°C após 1 hora (p < 0,01). A diferença entre as temperaturas cerebral sistêmica foi 4,57 ± 0,87°C (p < 0,01). As temperaturas centrais (retal, esofágica e da artéria pulmonar), assim como a hemodinâmica encefálica e sistêmica, mantiveram-se estáveis durante o procedimento. Houve diminuição significativa da PbtO2, concomitantemente ao decréscimo da temperatura encefálica. CONCLUSÕES: A indução de hipotermia encefálica exclusiva é possível através de resfriamento nasofaríngeo associado a medidas de preservação da temperatura sistêmica. O resfriamento encefálico exclusivo não influencia as funções hemodinâmicas sistêmicas e encefálicas, contudo reduz significativamente a PbtO2 / INTRODUCTION: Relevant evidences for the use of therapeutic hypothermia derive from studies using whole body cooling methods. These methods can lead to serious complications. To avoid such complications, selective brain cooling methods were developed. The objective of this study was: 1) to verify the feasibility of exclusive brain hypothermia by means of nasopharyngeal cooling along with measures of systemic temperature preservation in an experimental swine model, and 2) to investigate the influence of the exclusive brain cooling on cerebral and systemic hemodynamics as well as on cerebral oxygenation. METHODS: Ten hybrid swine underwent nasopharyngeal cooling for 60 minutes, followed by spontaneous rewarming. A number of physiological variables were monitored: arterial blood pressure, cardiac output, temperature in the right and left cerebral hemispheres, pressure of brain tissue O2, cerebral blood flow velocities, resistance index, and pulsatility index. RESULTS: Nasopharyngeal cooling was associated with decrease in brain temperature, which was more significant in the left cerebral hemisphere (p < 0,01). There was a reduction of 1.47 ± 0.86°C in the first 5 minutes (p < 0.01), 2.45 ± 1.03°C within 10 min, and 4.45 ± 1.36°C after 1 hour (p < 0.01). The brain-core gradient was 4.57 ± 0.87°C (p < 0,001). Rectal, esophageal, and pulmonary artery temperatures, as well as brain and systemic hemodynamics, remained stable during the procedure. PbtO2 values significantly decreased following the brain cooling. CONCLUSION: Achievement of exclusive brain hypothermia is feasible by means of nasopharyngeal cooling associated with measures of systemic temperature preservation. Selective brain cooling does not influence both systemic and cerebral hemodynamics, except PbtO2, which decreased significantly

Therapeutic hypothermia (TH) is the only clinically used intervention that suppresses nearly all manifestations of ischemia-reperfusion injury after cardiac arrest. Experimental models has proven that exogenous antioxidants have positive impact on ischemia-reperfusion injury and it is able to prevent it as well. Results in this thesis are based on application of high dosages of N-acetylcystein (NAC) on ischemia-reperfusion injury after experimental cardiac arrest in a porcine model. It was used as a form of monoteraphy or in combination with TH. During the experiment animals were randomized into 5 groups: administration of NAC and TH (group A), administration of NAC during cardiac arrest (group B), induction of TH (group C), without any intervention (group D) and administration of NAC after return of spontaneous circulation (group E). We were not able to confirm additive effect of NAC in combination with TH. Administration of NAC during cardiac arrest led to statistically important reduction of oxidative stress but in the same time anafylactic reaction led to higher mortality in group B and changes in hemodynamical parameters in group E. Key words: Therapeutic hypothermia, cardiac arrest, N-acetylcysteine, ischemia-reperfusion injury, cardiopulmonary resuscitation, oxidative stress, oxygen radicals