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

Objetivo: Realizar a tradução, validação cultural para a língua portuguesa do Brasil e análise de concordância e confiabilidade entre avaliadores das escalas de mobilidade em unidade de terapia intensiva (UTI) Perme Intensive Care Unit Mobility Score - Perme Score e a Intensive Care Unit Mobility Scale - IMS. Métodos: O processo de tradução e adaptação seguiu as seguintes etapas: Preparação, tradução, reconciliação e síntese, tradução reversa, revisão, aprovação e pré-teste. Após estes processos, a versão em português das duas escalas foi utilizada por dois pesquisadores na avaliação de 103 pacientes críticos internados em UTI. O índice de Kappa e a análise de Bland-Altman foram utilizados para verificar a concordância entre as escalas. O coeficiente ? de Cronbach foi utilizado para verificar a confiabilidade entre os avaliadores no uso das escalas. A correlação entre as escalas foi verificada pelo teste de Spearman. Resultados: Ambas as escalas, Perme Escore e Escala de Mobilidade na UTI - EMU, foram devidamente traduzidas para o Português falado no Brasil. As características dos pacientes críticos avaliados neste estudo demonstrou uma predominância masculina 56 (54%) com idade média de 52±18 anos, apresentando SAPS 3 = 66 (24%). O principal motivo de internação nas UTIS foi descompensação clínica de origem respiratória (44%). Ambas as escalas apresentaram excelente concordância (k > 0,90) e confiabilidade (alfa > 0,90) para todos os domínios. Na análise de Bland-Altman, constatou-se um baixo viés entre os avaliadores tanto para o EMU (-0,048 ± 0,35) quanto para o Escore de Perme (-0,06 ± 0,73). Os limites superiores e inferiores de 95% de concordância foram de 0,64 a -0,73 para o EMU e de 1,36 a -1,5 para o Perme Escore. Além disso, verificou-se forte correlação positiva entre as duas escalas utilizadas para avaliar os pacientes ( =0,941). Conclusão: A versão em português do Escore Perme de mobilidade em UTI (Perme Escore) e da escala de mobilidade em unidade de terapia intensiva (EMU) apresentaram alta concordância e confiabilidade entre os avaliadores / Objectives: Translate, cross cultural validate to Brazilian Portuguese language and analyze the inter-rater reliability with both instruments Perme Score and IMS. Methods: The translation process and the cross cultural validation followed the following steps: preparation, translation, synthesis, back translation, review, approval and pre-test. After this process the Brazilian Portuguese version of the both scales were used by two researchers to evaluated 103 critical care patients. The weighted kappa and Bland Altman analysis were used to verify inter rater agreement. Cronbach-? test was used to evaluate inter rate reliability. The correlation between the scales was verified by the Spearman correlation test. Results: Both scales, Perme escore e EMU, were translated to the Brazilian Portuguese. Most of the patients were male 56 (54%), mean age 52±18, SAPS 3 = 66 (24%). Respiratory failure was the most prevalent reason for admission (44%). Both scales showed an excellent inter rater agreement (k > 0,90) and reliability (alpha > 0,90) for all domains. Bland-Altman analysis showed a low bias between raters either for EMU (-0,048 ± 0,35) and Perme Escore (-0,06 ± 0,73). Upper and lower 95% limits of agreement were 0.64 to -0.73 for the EMU and 1.36 - 1.5 for the Perme Escore. Moreover, it also presented a strong positive correlation between the two instruments ( = 0,941). Conclusion: The Brazilian Portuguese version of the Perme Escore and EMU showed a high agreement and reliability between the raters

Made available in DSpace on 2017-06-01T18:08:35Z (GMT). No. of bitstreams: 1 dissertacao_fernanda_lima.pdf: 947900 bytes, checksum: d0f0cf3a17b2a07a142b0c7884e9e1fa (MD5) Previous issue date: 2011-04-29 / This dissertation aimed to investigate the experience and coping strategies of sons and daughters whose mother or father are hospitalized in an Intensive Care Unit. The study is divided in two parts: A theoretical paper, based on a bibliographic review of SCIELO, BIREME and PSYCHINFO databases. In such review, studies focusing on specific relatives were not found, except when it comes to parents whose babies are in Neonatal Intensive Care; there is a lack of investigations on coping strategies used by relatives in this situation and studies using both qualitative and quantitative methods were not found. Considering this, an empirical research was carried on focusing on such aspects, with a qualitative-quantitative approach. Participants were 30 sons or daughters of patients in ICU s. Chosen instruments were: a socio-demographic form; the Coping Strategies Inventory by Folkman and Lazarus (1985), adapted by Savóia and cols (1996); and a semi-structured interview. The Inventory allowed the identification of the following predominant coping strategies: Positive Reappraisal (97%); Social Support (93%) and Problem Solving (77%). Spearman correlation coefficients were estimated for the 66 questions on the Inventory and some variables: Religion presented negative correlation with item 51; Age above 50 presented positive and negative correlations with items 14 and 31, respectively; Education (university level) presented positive correlation with items 2 and 61 and negative correlation with items 25 and 32. There was an association between parenthood (sons with mothers in UCI) and questions 2, 3, 12, 25, 27, 34, 35 e 39. Despite that, it is not possible to stand that there is a significant positive or negative correlation among these variables and specific coping strategies. The following negative feelings where verified on the interviews: suffering, preoccupation, fear of death and shock; the fact that the patient spends most of the time alone is the biggest source of concern; the relatives routine is impaired due to the parent s hospitalization. Personal, spiritual and professional growth came out as positive reappraisal and participants were satisfied with the hospital staff attention regarding themselves and their parents. These results reinforce the need of a Life Quality Program for Relatives with parents in ICU, which could promote an opportunity to talk, listen and exchange experiences, including their fantasies regarding the ICU scenario, as well as coping strategies used during the period their parents are hospitalized / Esta dissertação buscou investigar a experiência de filhos que possuem a mãe ou o pai internado em uma UTI e as estratégias de enfrentamento utilizadas por eles nesta situação. O trabalho está organizado em duas partes: Um artigo teórico, baseado em um levantamento bibliográfico realizado nas seguintes bases de dados: Scielo, Bireme, Psychinfo. Na pesquisa bibliográfica não foram encontrados estudos que foquem um grau de parentesco específico de pacientes, exceto quando se trata de pesquisas com pais de bebês em UTI Neonatal; há escassez de estudos que investiguem as estratégias de enfrentamento utilizadas por estes familiares nesta situação e não foram localizadas pesquisas que utilizem técnicas qualitativas e quantitativas, simultaneamente. A partir destas constatações foi realizado um estudo empírico enfocando estes aspectos. Tal pesquisa teve um caráter qualitativo-quantitativo. Os participantes foram 30 filhos de pacientes em UTI. Os instrumentos escolhidos foram: uma Ficha Sócio-Demográfica; o Inventário de Estratégias de Coping, de Folkman e Lazarus (1985), adaptado por Savóia et al (1996) e uma Entrevista Semi-Estruturada. Com o Inventário foram verificadas as estratégias de enfrentamento predominantes, a saber: Reavaliação Positiva (97%); Suporte Social (93%) e Resolução de Problemas (77%). Foi realizado o cálculo dos coeficientes de Correlação de Spearman entre as 66 questões do Inventário e algumas variáveis: Religião que apresentou correlação negativa com o item 51; Faixa etária acima de 50 anos apresentou correlação positiva e negativa com as questões 14 e 31, respectivamente; Escolaridade (nível superior) teve correlação positiva com as questões 2 e 61 e negativa com os itens 25 e 32 e houve associação entre a filiação (filhos com a mãe na UTI) com as questões 2, 3, 12, 25, 27, 34, 35 e 39. Apesar disso, não é possível afirmar que existe correlação significativa positiva ou negativa entre estas variáveis e determinadas estratégias. Com as entrevistas constataram-se os sentimentos negativos: sofrimento, preocupação, medo da morte e susto; o fato de o paciente ficar a maior parte do tempo sozinho (a) é o que mais os preocupa; a rotina de vida dos filhos fica prejudicada diante da internação do pai/mãe; como formas de reestruturação positiva foram apontados os crescimentos pessoal, espiritual e profissional e, por fim, os participantes se mostraram satisfeitos com o tratamento que lhes é dispensado e aos seus familiares enfermos pela equipe do hospital. Estes resultados reforçam a necessidade da criação de Programas de Qualidade de Vida dos Familiares de pacientes em UTI. Isso poderia proporcionar um espaço de fala, escuta e troca de experiências, onde os mesmos poderiam ressaltar, inclusive, as fantasias referentes ao cenário da UTI, bem como as estratégias de enfrentamento utilizadas neste período de internação do familiar

Introdução: As infecções primárias da corrente sanguínea associadas ao cateter venoso central (IPCS) são um grande problema nas unidades de terapia intensiva (UTI) pediátricas e neonatais em todo o mundo. Evidências sugerem que a prevenção das IPCSs é crucial para o atendimento seguro ao paciente. Uma percentagem significativa (65-70%) das IPCSs são evitáveis utilizando as estratégias baseadas em evidências, incluindo os bundles. Estas medidas têm um papel bem estabelecido em pacientes adultos.O objetivo deste estudo foi avaliar, a partir de uma ampla revisão sistemática da literatura, o benefício da implementação do bundle do cateter central na prevenção das IPCSs em pacientes pediátricos e neonatais internados em UTI. Métodos: Foram pesquisadas as bases de dados Cochrane Library, Medline, Latin American and Caribbean Health Science Literature (LILACS), Centre for Reviews and Dissemination (CRD), Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), além de busca manual e literatura cinzenta entre 1 de janeiro de 2005 até 31 de dezembro de 2015. Não houve restrição dos estudos com relação ao idioma, a data ou status de publicação. Para avaliar o benefício do bundle do cateter central, foram selecionados estudos envolvendo pelo menos dois componentes (higiene de mãos, precauções de barreira máxima, antissepsia da pele, seleção adequada do sítio do cateter, revisão diária da necessidade do cateter) como medida preventiva para pacientes com cateter venoso central (CVC). O desfecho foi o número de IPCSs por 1000 cateteres-dias antes e depois da implementação do bundle. Resultados: Foram identificados inicialmente 6369 estudos, após a exclusão dos títulos duplicados e os inelegíveis, 31 estudos preencheram os critérios de elegibilidade. Os estudos foram heterogêneos tanto na composição do bundle quanto na estratégia de implementação. A mediana da densidade de incidência de IPCS foi de 5.9 por 1000 cateteres-dias (2.6-23.1) nas unidades de terapia intensiva pediátricas (UTIP) e 4.9 por 1000 cateteres-dias (2.0-24.1) nas unidades de terapia intensiva neonatais (UTIN). Após a implementação do bundle do cateter central, a densidade de incidência de IPCS variou de 0 a 14.9 por 1000 cateteres-dias (mediana de 2.1) nas UTIPs e 0.3 a 13.9 (mediana de 2.8) nas UTINs. Conclusões: As IPCSs continuam sendo um problema significativo em unidades de terapia intensiva pediátricas e neonatais, mas a implementação do bundle do cateter central pode reduzir significativamente as taxas dessas infecções. Intervenções assistenciais com as melhores práticas baseadas em evidência permitem uma redução substancial das IPCSs pela promoção de grupos ou bundles de procedimentos e tecnologias, e pela utilização de uma estratégia multimodal para a educação, formação, implementação e divulgação. / Background: Central-line-associated bloodstream infections (CLABSIs) are a major problem in neonatal and pediatric intensive care units (ICUs) worldwide. Evidence suggests that CLABSI prevention is crucial for safe patient care. A significant percentage of CLABSIs (65- 70%) are preventable using evidenced-based guidelines. Strategies to prevent these infections have included a myriad of different preventive maneuvers gathered as “bundles”. These measures have a well established role in the adult ICU setting. We aimed to assess the benefit of the implementation of central-line bundles to prevent CLABSIs in neonatal and pediatric ICU patients, populations where their actual efficacy is yet to be proven. Methods: We searched Cochrane Library, Medline, Latin American and Caribbean Health Science Literature (LILACS), Centre for Reviews and Dissemination (CRD), Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), manual search and gray literature to identify studies reporting the implementation of central-line bundles in pediatric ICU (PICU), or neonatal ICU (NICU) patients. We searched for studies published between Jan 1, 2005, and December 21, 2015, without language restriction. To evaluate the benefit of the central line bundle were selected studies involving at least two components (hand hygiene, maximal barrier precautions, skin antisepsis, optimal catheter site selection and daily review of line necessity) as a preventive measure to patients with central venous catheter (CVC). The outcome was the number of CLABSIs per 1000 catheter-days before and after implementation. Results: We initially identified 6369 records, and after excluding duplicates and those ineligible, 31 studies met the eligibility criteria. The studies reviewed were quite heterogeneous both in bundle composition and implementation strategy. Median CLABSIs incidence were 5.9 per 1000 catheter-days (range 2.6–23.1) on PICUs and 4.9 per 1000 catheter-days (range 2.0–24.1) on NICUs. After implementation of central-line bundles the CLABSI incidence ranged from 0 to 14.9 per 1000 catheter-days (median 2.1) on PICUs and 0.3 to 14.9 (median 2.8) on NICUs. Conclusions: CLABSIs remain a significant problem in neonatal and pediatric critical care units, but implementation of catheter care bundles can significantly reduce rates of these infections. Best practice interventions allow substantial CLABSI reduction by promotion of groups or bundles of procedures and technology, and by use of a multimodal strategy for education, training, implementation, and dissemination.

Introduction: Les survivants d’unité de soins intensifs (SI) présentent souvent des incapacités physiques et neuropsychologiques en raison de l’alitement prolongé et des traitements agressifs reçus dans ce type d’unité. La mobilisation précoce en position debout est une intervention prometteuse pour prévenir ces incapacités et amorcer la récupération de celles- ci. Les activités impliquant la mobilisation en position debout produiraient des bienfaits supplémentaires par rapport aux interventions de mobilisation au lit. Cependant, la mobilisation en position debout comportent des risques plus importants pour la sécurité des patients aux SI, par rapport aux mobilisations au lit. Il n’existe pas de synthèse de l’ensemble des critères de sécurité qui sont utilisés dans les études où les patients de SI ont participé à des mobilisations en position debout. De plus, il n’existe pas de recommandations sur les critères les plus pertinents à utiliser par l’équipe multidisciplinaire pour mobiliser en position debout les patients aux SI. Objectifs: 1- Recenser les critères de sécurité utilisés dans les études dans lesquelles des patients adultes aux SI ont participé à des activités de mobilisation en position debout. 2- Consulter un panel de professionnels de la santé expérimentés en SI afin qu’ils puissent sélectionner et proposer les critères de sécurité les plus pertinents et faisables en clinique à partir des critères recensés dans la littérature. Méthode: Une recension systématique a été réalisée pour déterminer quels critères de sécurité ont été utilisés dans les études où des patients adultes aux SI ont participé à des activités de mobilisation en position debout. Suite à cette recension, l’équipe de recherche a produit une liste synthèse de critères de sécurité utilisés dans la littérature. Un panel local de professionnels de la santé expérimentés en SI a été consulté par la méthode Delphi en trois rondes pour sélectionner et proposer les critères de sécurité les plus pertinents et faisables à partir de la liste synthèse de critères extraits de la littérature. Ce panel local incluait des physiothérapeutes, infirmières, inhalothérapeutes et médecins. Résultats: Soixante-deux articles ont été inclus dans la recension. De ces articles, 381 différents critères à respecter pour assurer la sécurité lors des mobilisations en position i debout aux SI ont été extraits. Ces critères recensés ont été catégorisés selon qu’ils étaient liés aux systèmes cardiovasculaire, respiratoire, neurologique, musculosquelettique ou qu’ils étaient de nature générale. De plus, ils comprenaient deux types de critères soit, les critères à respecter avant de débuter la mobilisation (critères d’initiation) et les critères pour décider s’il faut mettre fin à la mobilisation pour des raisons de sécurité (critères d’arrêt). On note une hétérogénéité dans la formulation et les valeurs seuils des critères recensés (ex. : critère d’arrêt: saturation périphérique d’O2 inférieure à 85% versus inférieure à 88%). De l’ensemble des critères recensés, l’équipe de recherche a produit une liste-synthèse de 34 critères de sécurité qui couvraient l’ensemble des catégories et des types de critères. Un panel local de douze cliniciens expérimentés en SI (tous en provenance de la province de Québec, au Canada) a statué par consensus que 34 critères de sécurité étaient pertinents et de 31 faisables. De ces critères retenus par le panel, 28 provenaient de la liste-synthèse des critères recensés et 6 ont été proposés par les panélistes eux-mêmes. Conclusion: Les critères à respecter pour assurer la sécurité des patients lors de mobilisation en position debout aux SI sont décrits dans la littérature actuelle. Un panel local de cliniciens expérimentés en SI a permis de mettre en évidence 34 critères de sécurité pertinents et 31 faisables à respecter lors de la mobilisation debout aux SI, dont 28 provenaient de la littérature recensée. / Introduction: Survivors of intensive care units (ICU) often present physical and neuro- psychological impairments following the frequently prolonged bed rest and aggressive resuscitation treatments inherent to care received in these units. Early weight-bearing mobility in a standing position is a promising method to limit the extent of, and initiate recovery from these impairments. Activities that incorporate the standing position seem to be more beneficial than other bedside interventions. However, for ICU patients, activities performed in a standing position may be riskier. No existing report incorporates all of the safety criteria used in the ICU studies in which ICU patients were mobilized in a standing position. Moreover, there are no existing recommendations related to the most relevant and feasible safety criteria for weight-bearing in ICU patients. Purpose: 1- To determine the safety criteria needed to mobilize in a weight-bearing standing position critically ill adult patients in the ICU. 2- Identifying safety criteria, and selecting and ranking the most relevant and feasible ones from the literature by a panel of local experienced ICU clinicians. Methods: A systematic review determined which safety criteria were used in adult ICU patient studies addressing mobilization in a standing position. From this systematic review, we extracted an overview and listed safety criteria. Then, local experienced ICU clinicians were consulted with three Delphi method rounds aiming to achieve consensus on the most relevant and feasible criteria. The panel included physiotherapists, nurses, intensivists and respiratory therapists. Results: Sixty-two articles were included in the review, yielding 381 different safety criteria for adult ICU patient mobilization in a weight-bearing standing position. These criteria were categorized into cardiovascular, respiratory, neurological, musculoskeletal and general safety items. They were also subdivided into criteria to be respected before mobilization (initiation criteria) and criteria suggesting stopping a mobilization for safety reasons (termination criteria). A wide variety in the definitions and cut-off values for certain criteria (ex. termination criteria of peripheral oxygen saturation below 85% versus below 88%) were iii identified. A synopsis listing of 34 criteria, selected by the research team from all extracted criteria to represent the criteria categories and types, was presented to a group of 12 local experienced ICU clinicians (all from the province of Quebec, Canada). Consensus was reached as to the relevance of 34 and feasibility of 31 safety criteria. Among them, 28 were from the literature-based synopsis and six criteria were proposed by the panelists. Conclusion: The literature provides safety criteria needed to mobilize ICU patients in a weight-bearing position. A panel of local experienced ICU clinicians helped establish a list of 34 relevant and 31 feasible safety criteria for safety mobilization of ICU patients in standing position among witch 28 originating from the literature review.

Les technologies du sommeil connaissent une révolution numérique à laquelle nous avons apporté une validation avec pour objectif une meilleure analyse des troubles du sommeil en Unité de Soins Intensifs, dans la maladie d’Alzheimer et dans l’évaluation de l’hypovigilance en vol de longue durée en milieu militaire. Ainsi, nous avons évalué le temps de sommeil sur 24 heures en relation avec les nuisances sonores en soins intensifs. Cette évaluation a été réalisée à l’aide d’un nouveau polysomnographe l’Actiwave couplé à un polygraphe Nox T3 qui ont permis d’enregistrer les cycles du sommeil et les niveaux sonores sur les 24 heures dans une Unité de Soins Intensif. Nous avons montré que l’Actiwave est un outil performant pour enregistrer le sommeil dans de telles conditions. Combiné au Nox T3, il permet d’explorer l’impact des niveaux sonores sur la qualité et quantité du sommeil. Nous avons retrouvé un Temps Total de Sommeil médian de 6 heures par nuit et de 2,5 heures pendant la journée, la qualité de sommeil étant plus perturbée que sa quantité. Nous avons démontré que 60% des éveils intra-sommeil étaient associés à un bruit supérieur à 77 dB et identifié les sources sonores principales qui agissent sur la pathogénèse des troubles du sommeil en Unité de Soins Intensif, à savoir les alarmes des respirateurs mécaniques avec un risque relatif de 10.9 (9.8-11.9) et les alarmes des constantes vitales avec un risque relatif de 9.8 (8.6-11.3). Une deuxième étude, l’évaluation de l’hypovigilance en vol de longue durée, a été réalisée à l’aide de l’ActiWave. Pour cela, nos équipes ont conçu un algorithme d’analyse automatique de détection du sommeil. Nous avons montré que l’ActiWave est un polysomnographe fiable en conditions extrêmes, l’analyse automatique montrant une bonne concordance avec l’analyse manuelle de deux experts du sommeil (Kappa>80%). Nous démontrons donc qu’il est possible de coder automatiquement les stades de sommeil à l’aide du ratio (+)/ sur la région occipitale O1-M2 vs C3-M2 (p<0.05). Nous avons validé un nouvel actimètre le MotionWatch 8 pour l’évaluation du temps de sommeil chez 208 patients présentant la maladie d’Alzheimer. Ce travail a permis de montrer que le MotionWatch 8 est un outil fiable avec de bonnes sensibilité et spécificité dans l’évaluation des troubles du sommeil chez ces patients. Le Temps Total de Sommeil est dans la norme (TTS moyen 7h35 minutes) et est significativement associé au score d’apathie (7h46 minutes vs 7h26 minutes ; p=0.04). Le marqueur chrono-biologique SIJ est également associé à l’apathie (p=0.04) ainsi qu’aux troubles cognitifs (p=0.02). Finalement, la fragmentation de rythmes veille/sommeil (VIJ) est associée au score du handicap de la maladie d’Alzheimer (p=0.02). Dans une quatrième étude, nous nous sommes intéressés à la nouvelle technologie de télé-observance dans le traitement du syndrome d’apnées du sommeil par pression positive continue, qui permet d’alerter le médecin de la compliance du patient. Nous avons validé un nouveau dispositif médical de télé-observance du traitement du syndrome d’apnées du sommeil, le NOWAPI. Nous montrons que le NOWAPI mesure avec précision et de manière fiable les niveaux de pressions et de débits des PPC disponibles sur le marché et qu’il permet de calculer les indicateurs d'observance des patients souffrants du syndrome d’apnées du sommeil (IAH Nowapi de 2,5 (-1.4 ; 3.6)/h vs IAH Polygraphie respiratoire de 2,3 (1.2 ;3.4)/h). En conclusion, les études présentées ici mettent en exergue l’importance de l’innovation technologique dans le domaine du sommeil pour une meilleure prise en charge des patients. A l’ère du 21ème siècle, une nouvelle médecine commence à émerger, la médecine 2.0, avec pour corollaire l’eSanté. (...) / Scientific research into sleep over the past thirty years has progressed so speedily that it is now possible to speak of “Sleep Medicine”. This specialty is placed incontestably at the frontier of Science and Medicine. The issues have been recently driven by the advances in the technology of recording biological parameter and analysis of the data, in parallel with a deeper understanding of the physiopathology and therapeutic advances in sleep disorders. The subject of this thesis lies at the crossover of two areas of professional expertise; sleep technology and bio-engineering, with notably the aim of validating new tools in research as well as in the diagnosis and treatment of sleep disorders. We have tested a miniaturized polysomnographic new technology, the Actiwave, capable of detecting sleep and alert states in extreme conditions, notably in patients hospitalized in Intensive Care Units and in aircraft pilots in long duration military flights. In intensive care units, we have explored the relation between sleep and noise in the immediate environment of the patients. In brief, Total Sleep Time was not disturbed whereas the sleep quality was altered. Wake episodes after sleep onset were mostly associated with noise over 77 dB, and the main disturbances were triggered by the alarms of breathing machines and those from vital parameters. In military flights of long duration, we have explored the presence of hypovigilance episodes. This allowed us to validate the Actiwave for polysomnography in extreme conditions. In a third study, we have analyzed the sleep patterns in a total of 202 patients with Alzheimer’s disease by using a new actimeter, the MotionWatch8. We have shown that the latter device has a good sensitivity and specificity or evaluating sleep-wake parameters in these patients. In particular, we find that the TST is in the normal range and is associated with the aptathy score. The SIJ score is associated with the apathy score and also with the cognitive impairments. Finally, the sleep fragmentation is associated with the disability status. In a last study, we explored the parameter of sleep apneas in patients with SAS using the NOWAPI. We validated this new device by demonstrating that it provides on-line reliable data about pressure and flow levels of various CPAP. In conclusion, this thesis considers possible future avenues of research into sleep technology and discusses the crucial importance of a scientific approach capable of leading the development of appropriate and lasting diagnostic and therapeutic tools. The next step will be the era of the 2.0 medicine for which I am developing the iSommeil application that will allow patients to be the actual actors of their disease and also to facilitate the diagnostic and the prevention of sleep disorders.

MCur / Department of Advanced Nursing Science / Background: Doctors and nurses working in ICU are always confronted with ethical dilemmas when caring for critically ill patients no matter where they practice. The ethical dilemmas experienced by ICU nurses and doctors include amongst other: freedom of choice, truth telling, distribution of resources and confidentiality. Purpose: The study sought to explore the ethical dilemmas experienced by healthcare professionals working in ICU, Vhembe district in Limpopo province. Setting: The setting of the study was Tshilidzini hospital, Vhembe district in Limpopo Province Methodology: A qualitative, explorative, descriptive design was used. The population was nurses and doctors working in ICU, Tshilidzini hospital, Vhembe district in Limpopo province. A purposive sampling was used to select the study sample, and the study hospital. Data was collected by means of Semi-structured, in-depth interviews. Data was analyzed using Tesch`s method. Ethical considerations were adhered to. Findings: Participants expressed ethical dilemmas related to lack of resources, unsuitable infrastructure, hospital policies and patient`s decision making. Recommendations: The study recommends better policies by government and critical care societies to help guide resource allocation for ICU services. The number of ICU beds must be allocated according to the population it serves, in-service trainings to be conducted on regular bases in order to equip ICU health care professionals with knowledge of ethics and skills of decision-making, an active ethics committee to be elected to assist ICU practitioners when they encounter ethically challenging situation. / NRF

Cotutelle internationale avec l'université de Caen / La complexité des patients de réanimation justifie le recours à des systèmes d’aide à la décision thérapeutique. Ces systèmes rassemblent des protocoles automatisés de prise en charge permettant le respect des recommandations et des simulateurs physiologiques ou patients virtuels, utilisables pour personnaliser de façon sécuritaire les prises en charge. Ces dispositifs fonctionnant à partir d’algorithmes et d’équations mathématiques ne peuvent être développés qu’à partir d’un grand nombre de données de patients. Le principal objectif de cette thèse était la mise en place d’une base de données haute résolution automatiquement collectée de patients de réanimation pédiatrique dont le but sera de servir au développement et à la validation d’un simulateur physiologique : SimulResp©. Ce travail présente l’ensemble du processus de mise en place de la base de données, du concept jusqu’à son utilisation. / The complexity of the patients in the intensive care unit requires the use of clinical decision support systems. These systems bring together automated management protocols that enable adherence to guidelines and virtual physiological or patient simulators that can be used to safely customize management. These devices operating from algorithms and mathematical equations can only be developed from a large number of patients’ data. The main objective of the work was the elaboration of a high resolution database automatically collected from critically ill children. This database will be used to develop and validate a physiological simulator called SimulResp© . This manuscript presents the whole process of setting up the database from concept to use.

Introduction : La tolérance induite par l’utilisation prolongée des opiacés peut se traduire par un syndrome de sevrage aux opiacés (SDSO). Il n’existe aucun consensus sur la méthode idéale de sevrage des opiacés pour prévenir le SDSO chez la clientèle des soins intensifs pédiatriques (SIP). L’objectif de cette étude était de comparer l’efficacité de deux stratégies de sevrage des opiacés, à savoir la méthadone et la morphine administrées par voie entérale, à prévenir le SDSO. Devis : Essai clinique randomisé à double aveugle chez les enfants sous ventilation mécanique hospitalisés aux SIP. Méthode : Nous avons comparé la durée totale de sevrage, l’incidence et la sévérité du SDSO chez les enfants à risque au moins modéré de SDSO sevrés avec la méthadone et la morphine entérales. Les enfants inclus étaient ceux hospitalisés au Centre Hospitalier Universitaire Sainte-Justine ou au Centre Mère-Enfant Soleil de Québec entre le 1er novembre 2003 et le 31 mai 2009. Résultats : Quarante-huit patients (22 groupe méthadone et 26 groupe morphine) ont été inclus et 30 patients ont complété le protocole de sevrage (16 groupe méthadone et 14 groupe morphine). La durée médiane de sevrage était de 5.4 jours dans le groupe méthadone comparativement à 5.8 jours pour le groupe morphine (p=0.49). Il n’y avait pas de différence dans l’incidence du SDSO (62.5% versus 42.9%; p=0.46), et dans sa sévérité (12.5% versus 14.3% de SDSO sévère; p=0.62). Conclusion : L’efficacité d’un sevrage standardisé des opiacés par la méthadone était comparable à celle de la morphine. / Background : The prolonged use of opioids has been associated with opioid tolerance and weaning is necessary to prevent opioid withdrawal symptoms (OWS). Little research exist for an ideal effective opioid taper to reduce the prevalence of OWS. This study aim to compare the effectiveness of two opioid taper strategies, enteral’s methadone and morphine, in preventing the occurrence of OWS among pediatric intensive care patients. Design: Double-blinded randomized controlled trial in mechanically ventilated children (MVCs) hospitalized in 2 pediatric intensive care units (PICU). Methods: Eligible patients were MVCs at moderate risk of OWS admitted in PICU of the Centre Hospitalier Universitaire Sainte-Justine or the Centre Mère-Enfant Soleil de Québec between November 1, 2003 and May 31, 2009. We assessed the total weaning duration, the OWS’s incidence and the OWS’s severity in a methadone’s and a morphine’s taper schedule. Results: Forty-eight patients were included, 22 in the methadone group and 26 in the morphine group and 30 patients completed the weaning protocol (16 methadone and 14 morphine). The median duration of weaning was 5.4 days among methadone’s patients as opposed to 5.8 days among morphine’s group (p=0.49). There was no statistical difference between groups for OWS’s incidence (62.5% vs 42.9%; p=0.46), nor for its severity (12.5% vs 14.3% of severe OWS; p=0.62). Conclusion: The use of a standardized opioid weaning protocol with enteral methadone was as effective as the enteral morphine one’s to prevent OWS. Further studies are needed to determine an ideal opioid taper to reduce OWS.

Introduction to the issue: Stay in an intensive care unit or anaesthesiology and resuscitation department has a demonstrable effect on the quality of life, whether mental, physical, or mental. A large percentage of patients experience post intensive care syndrome. The huge challenge for nursing care is to reduce this percentage and enable patients to recover in the best possible way and return to normal life of the same quality as before the hospitalization Methodology: The aim of this work is to find out how the quality of life of patients is affected after hospitalization in the intensive care unit or anaesthesiology and resuscitation department, with a proportion of acute renal failure and the need for continuous renal replacement. First, patients were evaluated with APACHE II score, SOFA and TISS 2. Next, questionnaires in which they responded to the period before hospitalization (SF 36, DEMMI, ADL, IADL) were filled, when released from ARO they went through the test of physical capability, (30s sit-up test, 6-minute walk test), further measurements when released from ICU took place (HADS, MAF, DEMMI, ADL, 30s sit-p test, 6-minute walk test), and after three months (SF 36, HADS, MAF, DEMMI, IADL, ADL 30s sit-up test, 6-minute walk test and a week of wearing a Garmin vivofit bracelet). Main...