Engagement in rehabilitation, such as physiotherapy, is critical to enhanced outcomes from musculoskeletal injuries (MIs) and has been found to be related to psychosocial factors, including increased personal control, higher levels of autonomous-motivation and more problem-focused type coping strategies in sports populations. However, this has not been empirically studied in British military groups, despite MIs being the most common reason for medical discharge from the British armed forces. Military personnel are thought to cope with injury within the context of a 'military culture' that is not found in civilians. This study tested a concept of military culture being related to greater adherence to masculine norms; higher levels of perceived personal control and autonomous motivation; lower levels of emotion-focused coping strategies; a greater use of problem-focused coping strategies and better engagement in rehabilitation. Data from self-report questionnaires and physiotherapist ratings of engagement in rehabilitation, provided by two groups, was compared. Group one consisted of 16 serving male military personnel and group two of 22 committed sports men; all had MIs sustained within the past 6 months, for which they were having physiotherapy. The sports group were found to show statistically significant greater adherence to masculine norms, and use of problem-focused and emotion-focused coping strategies. No significant differences were found between the groups on perceived personal control, autonomous motivation nor engagement in rehabilitation. A military culture defined by greater adherence to masculine norms; higher levels of perceived personal control and autonomous motivation and a greater use of problem-focused coping strategies has therefore not been supported by this study. However, only sufficient power was achieved for the analysis of emotional-focused coping strategies so caution must be taken when interpreting these results. Clinical and research implications are discussed with recommendations for further work with methodological lessons learnt.

Palliative care (PC) is a specialty that improves the quality of care often for terminally ill patients and their family members by providing physical, psychosocial, and spiritual pain and symptom management. PC assists patients in decision making about their goals of care. These goals of care discussions help the treating physicians to better plan more appropriate treatment options specifically tailored for each patient based on their preferences. Due to the illness severity of the patients, approximately 20% of all hospital deaths occur in the intensive care unit (ICU). Recognition of and advocacy for integrating PC in the ICU have increased in the last decade following many studies which have shown the positive effects of PC for critically ill patients and their family members. This was a single-center retrospective study conducted at an academic hospital that examined the effects of a proactive PC intervention and the clinical outcomes on patients who died in the medical and neurological ICUs (MICU and NICU), since the majority of ICU deaths occurred in these two units. This study was a quality improvement project that examined only patients who died, in order to make a similar comparison between patients who ultimately had the same clinical outcome. This pre-intervention (phase 1) and post-intervention three phase analysis measured the effectiveness of a screening tool (phase 2), and a daily ICU huddle (phase 3) compared to the pre-intervention phase. The study analyzed the impact the interventions had on clinical measurable outcomes such as 1) day of PC consultation after ICU admission and after meeting criteria, 2) day of meeting criteria for PC based on a screening tool, 3) hospital and ICU lengths of stay, 4) direct cost per discharge, and 5) the average number of PC consultations per month. Electronic database review of all MICU and NICU patients who died from July 2010 to December 2011 and April 2013 to October 2014 were performed. Comparisons were made between patients who received a PC consultation and those who received usual care, from both pre-intervention and post-intervention phases. A total of 888 patients were included and analyzed in this study. The intervention reduced the average day of PC consultation after ICU admission from 9.55 in phase 1 to 4.95 in phase 2 and to 4.75 in phase 3 after the addition of the daily huddle. The average day of PC consultation after meeting criteria in the ICU was also reduced from 8.0 to 3.08 then to 2.18, respectively. The average number of PC consultations per month increased from 10.6 to 12.8 to 17.7 in the three respective phases. The cost per discharge was not significantly different from patients who received a PC consultation and for patients who received usual care. PC service did not reduce the length of stay for patients when compared to patients who received usual care. The sensitivity and specificity of the screening tool in phase 2 were 66.2% and 70.8%, respectively. The sensitivity and specificity of the screening tool with daily huddle in phase 3 were 65.7% and 62.5%, respectively. Proactive screening for PC eligibility and discussion of that eligibility with the critical care team improves access to PC in the ICU. The screening tool and daily ICU huddle helped critical care physicians identify the group of patients most appropriate for PC consultation. The analysis suggests that the critical care physicians were able to accurately discriminate which end-of-life patients they could manage on their own. However, the low sensitivity and specificity of the screening tool suggests that there is still significant room for refinement in order for the screening tool to be more discriminatory and effective. Further research is needed to confirm these findings.

Introdução: A implementação de um protocolo de desmame promove a retirada mais rápida da ventilação mecânica, redução das complicações, redução de falha de extubação e diminuição de custos na unidade de terapia intensiva. Porém, sabe-se que uma nova conduta, comprovada pela literatura, pode levar anos a se tornar um padrão de cuidado na prática diária. Objetivos: Investigar a efetividade de um protocolo em relação ao sucesso do desmame e aderência dos médicos assistentes ao protocolo. Métodos: Estudo prospectivo de coorte. Nós investigamos todos pacientes consecutivos dependentes de ventilação mecânica por mais de 24 hs no período de janeiro de 2004 à dezembro de 2010 admitidos em uma unidade de terapia intensiva médico cirúrgica. Os dados como idade, sexo, causa da insuficiência ventilatória, escore de apache II, resultado do desmame da ventilação mecânica e aderência médica ao protocolo de desmame foram coletados em todos os pacientes. Resultados: Foram incluídos 2.469 pacientes durante 07 anos, sendo 1943 (78%) com sucesso no desmame. A adesão médica ao protocolo de desmame variou durante esses anos, sendo a maior entre 2005 à 2007(38% em 2005 para 86% para 2007 p< 0,01).Quando avaliamos o passo à passo do protocolo de desmame, encontramos uma alta adesão para a ventilação não invasiva (VNI)(95%) e para avaliação dos índices preditores de desmame (91%) e uma baixa adesão para controle do balanço hídrico (54%) e interrupção diária da sedação (24%). O sucesso no desmame foi superior nos pacientes que fizeram protocolo de desmame comparado com aqueles que utilizaram a prática clínica como desmame (85,6% x 67,7%, p< 0,001). Conclusão: A adesão médica ao protocolo de desmame mudou durante os anos do estudo, bem como a implementação das diferentes etapas do protocolo. Isso pode ter ocorrido por diferentes níveis de conhecimento médico e educação oferecidas a equipe do Centro de Terapia Intensiva (CTI) sobre o protocolo de desmame durante os anos do estudo. / Background: The implementation of a weaning protocol is referred to an earlier removal from mechanical ventilation (MV), reduction of complication, extubation failure and intensive care unit (ICU) costs. Moreover, it is know that a new approach, proven by literature, may take several years to become standard of care in daily practice. Objective: To investigate the effectiveness of a protocol in relation to the success of weaning and adherence of medical assistants to the protocol. Methods: We investigated all consecutive patients MV-dependent for more than 24h admitted from Jan-2004 to Dec-2010 in a medical-surgical ICU. Data of age, gender, cause of ventilatory failure, APACHE II score, weaning outcome, and physician adherence weaning protocol were collected in all patients. Results: We enrolled 2,469 patients over 7 years, with 1,943 patients (78.7%) of weaning success. The patient´s physician-adherence ranged to the weaning protocol changed during the study, being greater adherence from 2005 to 2007 (38%% in 2005 up to 86% in 2007, p <0.01). When evaluated weaning protocol step-by-step, we found high adherence for noninvasive ventilation use (NIV) (95%), and for weaning predictor measurement (91%); and lower adherence for control of fluid balance (57%), and for daily interruption of sedation (24%). The weaning success was superior patients that undergone weaning protocol compared to patients that undergone weaning based in clinical practice (85.6% vs. 67.7%, p <0.001). Conclusion: The adherence of physicians to a weaning protocol changed during the study years, as well as implementing the different steps of the protocol. This may have occurred by different levels of knowledge of medical and education offered by the ICU staff about the weaning protocol during the period of the study.

Fundamento: A fraqueza muscular periférica possui associação direta com a mortalidade intra-hospitalar em pacientes internados em unidades de terapia intensiva (UTIs). Dessa forma, a estimulação elétrica neuromuscular (EENM) tem sido indicada como uma forma de mobilização precoce para preservação ou aumento da massa e força muscular nesses indivíduos. Objetivo: O objetivo deste estudo foi revisar sistematicamente os efeitos da EENM comparada com cuidados usuais ou EENM placebo sobre a espessura muscular em pacientes críticos internados em UTIs. Métodos: Foi realizada uma busca nas bases Cochrane CENTRAL, MEDLINE, Lilacs, PEDro, e busca manual em referências de estudos publicados até maio de 2015. Foram incluídos ensaios clínicos randomizados (ECRs) que compararam EENM vs. cuidados usuais ou EENM placebo sobre a espessura muscular do músculo reto femoral avaliada por meio de ultrassonografia em pacientes críticos internados na UTIs. Os estudos foram analisados separadamente em relação ao tempo de início da EENM: precoce (início da EENM inferior a sete dias de internação) e tardio (início da EENM superior a 14 dias de internação). Resultados: Foram identificados 1.719 artigos, sendo incluídos dois ECRs. Na aplicação com início precoce, foi observado que a EENM preserva a espessura muscular comparado com cuidados usuais, porém sem diferença significativa (0,09 mm; IC95% -0,08 a 0,25). Tardiamente, apenas um estudo avaliou esse efeito, sendo observado que a espessura aumentou significativamente com EENM (p=0,036), permanecendo inalterada no grupo controle (p=0,162), sendo superior ao grupo controle (p=0,013). Conclusões: A aplicação precoce da EENM não alterou significativamente a espessura muscular do reto femoral em pacientes críticos internados em UTIs. Porém, a aplicação com início tardio, aumentou significativamente essa variável. No entanto, devido à escassez de pesquisas com a análise desse desfecho específico, novos estudos são necessários para confirmação dos achados. / Background: Peripheral muscle weakness has direct association with intra-hospital mortality in patients hospitalized in intensive care units (ICUs). Thus, neuromuscular electrical stimulation (NMES) has been indicated as a form of early mobilization to preserve or increase muscle mass and strength in these patients. Objective: The objective of this study was to systematically review the effects of NMES compared with usual care or placebo NMES on muscle thickness in hospitalized critically ill patients in ICUs. Methods: A search of the Cochrane CENTRAL, MEDLINE, Lilacs, PEDro, and manual search of published studies on references by May 2015 was performed. Included were randomized controlled trials (RCTs) that compared NMES vs. usual care or placebo NMES on the muscular thickness of the rectus femoris muscle assessed by means of ultrasound in critically ill patients hospitalized in ICU. The studies were analyzed separately in relation to start of the NMES: early (early NMES less than seven days of hospitalization) and late (early NMES than 14 days of hospitalization). Results: Was identified 1719 articles, which included two RCTs. In application with early start, it was observed that NMES preserves muscle thickness compared with usual care, but with no significant difference (0.09 mm, 95% CI -0.08 to 0.25). Belatedly, only one study has evaluated this effect being noted that the thickness increased significantly with NMES (p = 0.036) and remained unchanged in the control group (p = 0.162), higher than the control group (p = 0.013). Conclusions: Early application of NMES does not has significantly changed the thickness of the rectus femoris muscle in critical patients hospitalized in ICUs. However, the application with late onset, significantly increased this variable. However, due to scarcity of research with the analysis of this specific outcome, further studies are needed to confirm the findings.

Introdução: Diferentes critérios são apresentados na literatura para definir constipação, o que pode explicar a grande variabilidade de incidência desse desfecho. No Brasil, pouco se sabe sobre constipação e seus determinantes em adultos criticamente doentes. Objetivo: Avaliar a incidência e os fatores associados a constipação em adultos críticos. Método: De novembro de 2015 a setembro de 2016, foi conduzida uma coorte prospectiva de adultos que foram acompanhados desde a sua admissão no Centro de Tratamento Intensivo até sua saída. Os pacientes foram diariamente avaliados por uma equipe capacitada previamente quanto a variáveis clínicas, terapêutica instituída, características e frequência das evacuações. Constipação foi definida pela ausência de evacuação por três dias consecutivos. Para fins de análise, os dados foram censurados no décimo dia de internação. Após análise univariada, foi empregada Regressão Múltipla de Cox, na qual estabeleceu-se o número de dias até o primeiro episódio de evacuação como variável de tempo. Foi adotado método “enter” para o processamento do modelo, sendo removidas as variáveis, uma a uma, a partir do maior valor-p, durante a modelagem. O ajuste do modelo foi testado por meio do teste Omnibus. O projeto do presente estudo foi aprovado quanto aos seus aspectos éticos e metodológicos pelo Comitê de Ética da instituição sede do estudo. Resultados: Nos 157 pacientes acompanhados, a mediana de dias até a primeira evacuação foi de 4 (P25: 2 – P75: 6). A incidência de constipação foi de 75,8%. A análise univariada mostrou que pacientes constipados eram mais jovens, usaram mais sedação e apresentaram mais motivos respiratórios e pós-operatórios como causas para internação, enquanto pacientes não constipados internaram mais por motivos gastroenterológicos. O uso de drogas vasoativas, ventilação mecânica e hemodiálise foi semelhante entre constipados e não constipados. A análise multivariada, os dias de uso de docusato + bisacodil (HR: 0,79; IC95%: 0,65 – 0,96) de omeprazol ou ranitidina (HR: 0,80; IC95%: 0,73 – 0,88) e de lactulose (HR: 0,87; IC95%: 0,76 – 0,99) foram fatores independentes de proteção para constipação. Conclusão: Constipação é muito incidente em adultos críticos. Os dias de uso de medicamentos com ação no trato digestório (lactulose, docusato + bisacodil e omeprazol e/ou ranitidina) são capazes de prevenir esse desfecho. / Introduction: The literature present different criteria to define constipation, which may explain the great variability of its incidence. In Brazil, little is known about constipation and its determinants in critically ill adults. Objective: To evaluate the incidence and factors associated with constipation in critical adult patients. Method: From the November of 2015 to September 2016, a prospective cohort of critically ill adults was conducted. Patients were followed from their admission to the Intensive Care Unit until their discharge from the Intensive Care Unit or death. Trained team daily evaluated patients. Clinical variables, established therapy, characteristics and frequency of bowel movements were registered. Constipation was defined by absence of evacuation for three consecutive days. After univariate analysis, Cox Multiple Regression was used. In this analysis, the time variable was the number of days until the first evacuation episode. Enter method was used to the model processing, and the variables were removed one by one from the largest p-value during the statistical modeling. The Omnibus test was utilized to test the model adjustment. The study was approved by the ethics committee of the institution’s head office regarding its ethical and methodological aspects. Results: To the 157 patients followed up, the median number of days until the first evacuation was 4 (2 - 6). The incidence of constipation was 75.8%. Univariate analysis showed that constipated patients were younger, they used more sedation and presented more respiratory and postoperative reasons as causes for hospitalization, while non-constipated patients were more frequently admitted for gastroenterological reasons. The use of vasoactive drugs, mechanical ventilation and renal replacement therapy (hemodialysis) was similar in constipated and non-constipated patients. In Multivariate analysis the days of use of docusate + bisacodyl (HR0.79; CI95%: 0.65 – 0.96), omeprazole or ranitidine (HR: 0,80; CI95%: 0.73 – 0.88) and lactulose (HR: 0.87; CI95%: 0.76 – 0.99) were independent protective factors for constipation. Conclusion: Constipation has high incidence among critical adult patients. Days using drugs with a digestive tract action (lactulose, docusate + bisacodyl and omeprazole and / or ranitidine) are able to prevent this issue.

Masters of Science - Msc (Physiotherapy) / The Physiotherapist is an important member of the multidisciplinary team managing critically ill patients in the ICU. Physiotherapy practice in the ICU has shown itself to be effective, whereas the lack of physiotherapy management in the care of critically ill patients may prolong recovery. Therefore, the knowledge and attitudes about physiotherapy management by the other Health Care Professionals of the team is essential in order to facilitate efficient and effective medical services. This study aimed to determine other Health Care Professional' knowledge, attitudes regarding physiotherapy management in the ICU. As well as, it determined the current physiotherapy practices applied by physiotherapists in ICUs in Khartoum State - Republic of Sudan. The study was conducted due to limited studies in this field.

Att vårdas i respirator innebär att den verbala kommunikationsförmågan förloras, vilket kan medföra känslor av frustration och maktlöshet hos patienter. För att uppnå en vårdande relation är samtalet av stor betydelse, vilket försvåras om kommunikationsförmågan är nedsatt. Syftet är att beskriva intensivvårdssjuksköterskors upplevelser av kommunikation med lätt sederade, respiratorbehandlade patienter. En kvalitativ ansats har använts. Halvstrukturerade forskningsintervjuer utfördes med åtta intensivvårdssjuksköterskor från två sjukhus. En kvalitativ innehållsanalys användes för att analysera materialet, vilket resulterade i två kategorier med tre subkategorier vardera. Intensivvårdssjuksköterskors upplevelser av kommunikation med lätt sederade respiratorbehandlade patienter beskrivs som att finnas där och att nå fram. Genom att finnas där bjuder intensivvårdssjuksköterskor in patienter, erhåller känslomässiga gensvar samt förmedlar budskap genom sitt kroppsspråk och sin personlighet. För att nå fram måste intensivvårdssjuksköterskor skapa gynnsamma förhållanden för kommunikation och hitta ett gemensamt språk med patienter, vilket är beroende av både intensivvårdssjuksköterskans och patientens bagage. Intensivvårdssjuksköterskors egna kroppar är centrala i kommunikationen med dessa patienter. Kroppsspråk och beröring används för att bekräfta intensivvårdssjuksköterskors närvaro, förmedla närhet och trygghet samt för att utveckla en vårdande relation till patienter. Att lära sig läsa patienter, då de responderar ljudlöst, är en annan stor del av kommunikationen. Även här är kroppen central, då intensivvårdssjuksköterskors förmåga att läsa patienters kroppar och dess signaler är väsentligt för att nå fram, vilket underlättas av att lära känna patienten. Erfarenhet och utbildning kan medföra att intensivvårdssjuksköterskor känner trygghet i sig själva, vilket bidrar till att de har modet att finnas där hos patienter och därmed utveckla en vårdande relation. / Program: Specialistsjuksköterskeutbildning med inriktning mot intensivvård

Jordan is a developing country which is taking measures to make the situation in the society more equal between males and females. Former research has showed that it, worldwide, sometimes is great differences between the genders in the health care. This thesis illuminates how it is to work in an intensive care unit and if there are differences between male and female intensive care nurses influencing on the provided care. Twenty intensive care nurses from four intensive care units at Jordan University Hospital were included in the study. Both field notes and an observation schedule were used to gather data. The field notes captured the overall experience of working in the intensive care area and were analyzed by thematic content analyze. The observation schedule concentrated on how long time was spent and which activities were performed bedside. Data from the schedule was compared between the units and between male and female intensive care nurses caring for male and female intensive care patients. The field notes showed that even if the units were busy and crowed the silence and calmness were present. Cooperation was essential and trust and knowledge were spread. Often a warm and comfortable feeling surrounded the personnel and they seemed to like it at work. The observation schedule showed that in the medical and surgical intensive care units the intensive care nurses spent more time and performed a greater number of bedside activities compared to the pediatric and main intensive care units. Female intensive care nurses who cared for male intensive care patients performed less bedside activities and when they cared for a female intensive care patient they spent less time bedside compared to the other groups. In all the units and all the groups the most frequent performed activity was to have a look at the equipment, followed by have a look at the patient. The results can however be questioned since it is a small study accomplished by a single researcher, in some few intensive care units at one hospital. / Program: Specialistsjuksköterskeutbildning med inriktning mot intensivvård

In the care for the critically ill patient the next of kin is of great importance. Their support, love and care for the patient, increases the wellbeing and makes a connection to the patient’s normal lifeworld. For the next of kin to be able to be that support the next of kin needs to be helped to maintain the basic need of for example their sleep, food, hygiene and psychosocial support. The critical care nurse must see to the patient’s whole lifeworld which includes their next of kin.The aim of the study was to identify the resources available for the next of kin in intensive care units in Sweden. The study has its origin in a quantitative approach and a multiple choice questionnaire survey was selected as the data collection method. The respondents were intensive care employees from all over Sweden. At the time of the study, there were 86 intensive care units in Sweden which all were invited to participate in the study. Answers were received from 53 respondents representing ~62 % of ICUs in Sweden.The findings revealed that the resources for next of kin among the responding units were overall good to maintain the basic needs. The units mainly provided 1-2 rooms for the next of kin to use for resting and recovery while staying at the hospital. All the units were available to telephone 24 hours a day but there were some units that had restrictions when it came to visiting the critically ill patient. All ICUs in Sweden were invited to participate in the study but there were 38 % which chose not to participate. The outcome of the study could therefore have been different if the nonparticipant ICUs had different resources and opinions when it came to the care for the next of kin of patients staying at ICU. The conclusion is that intensive care units in Sweden has overall good resources to care for next of kin while visiting and staying at ICUs. / Program: Specialistsjuksköterskeutbildning med inriktning mot intensivvård

Både över- och undersedering kan öka riskerna för både morbiditet och mortalitet. Genom att ge rätt sederingsnivå till patienterna kan intensivvårdssjuksköterskor medverka till ett snabbare tillfrisknande och mindre vårdrelaterade komplikationer. Sedering är en viktig del i vården av respiratorpatienter och kräver stor kunskap hos intensivvårdssjuksköterskor. Syftet med studien var att undersöka hur intensivvårdssjuksköterskor upplevde omvårdnaden kring lätt sederade intensivvårdspatienter under respiratorbehandling. Uppsatsen är en kvalitativ studie och datainsamling genomfördes med hjälp av intervjuer med sex intensivvårdssjuksköterskor på en intensivvårdsavdelning i Västra Sverige. Intervjuerna har analyserats med kvalitativ innehållsanalys. Resultatet presenteras med hjälp av kategorier och subkategorier. Kategorierna var: Sederingsgrad, Kommunikation och information, Upplevelser av ångest, oro, rädsla, smärta och stress, Vårdmiljö och behov av normal dygnsrytm, Förändringar i sederingsrutiner, Närståendes betydelse, och Minnen och behov av bearbetning efter intensivvårdstiden. De flesta sjuksköterskorna upplevde att lätt sedering hos intensivvårdspatienter under respiratorbehandling var positivt, men det fungerade inte på alla patienter. Med individuellt anpassad omvårdnad, en adekvat sederingsnivå och smärtlindring anser vi att intensivvårdssjuksköterskor kan bidra till en bättre vård för patienterna, och förhoppningsvis även påverka patienternas minnen av tiden på IVA positivt. Kontinuitet och att skapa tillit och förtroende ses som betydelsefullt för patienternas tillfrisknande och sjuksköterskor har en viktig roll i att ge stöd och information till både patienten och de närstående. / <p>Program: Specialistsjuksköterskeutbildning med inriktning mot intensivvård</p><p>Uppsatsnivå: D</p>