Introdução: O grande desafio da descontinuação da VM esta em identificar corretamente os pacientes aptos a extubação com sucesso. O índice de respiração rápida e superficial (IRRS) tem sido o mais utilizado dentro desse processo em pacientes de unidade de terapia intensiva (UTI). Objetivos: O objetivo deste estudo foi avaliar o desempenho do ponto de corte, medidas seriadas e melhor método de obtenção do IRRS em predizer o insucesso de extubação para pacientes graves sob VM prolongada com fatores de risco para falha de extubação. Métodos: Estudo prospectivo, incluindo pacientes com 72h ou mais de ventilação mecânica (VM), prontos para o desmame, de acordo com critérios clínicos. O IRRS foi obtido diariamente, a partir do primeiro dia de desmame, com o paciente recebendo suporte ventilatório (IRRS_MIN) (PS 5cmH2O e PEEP 5cmH2O) e pelo ventilômetro em respiração espontânea (IRRS_ESP). Para os pacientes que passaram pelo processo de desmame com sucesso e foi indicada a extubação, o IRRS foi obtido anteriormente ao teste de respiração espontânea (TRE) através do ventilômetro (IRRS_PRE_TUBO_T), e em seguida colocado em TRE por 30 min. Após 30 min se o paciente não apresentou sinais de intolerância a desconexão da VM, o IRRS foi obtido em respiração espontânea (IRRS_PÓS_TUBO_T) e o paciente foi prontamente extubado. Os resultados foram analisados agrupando os pacientes de acordo com o desfecho do desmame: Grupo traqueostomia (GT); Grupo insucesso de extubação (GI), Grupo sucesso de extubação (GS). Resultados: 45 pacientes finalizaram o estudo, sendo 15 (33%) do GT, 11 (37%) do GI e 19 (63%) do GS. Fatores como tempo de intubação, tempo para iniciar o desmame e tempo de desmame foram maiores nos grupos GT e GI (p<0,05). Um novo ponto de corte foi calculado para essa população ( 74 ciclos/min/L), com especificidade de (0,64) e valor preditivo negativo de (0,54), que melhor identificou os pacientes com falha de extubação (FE). Quanto ao método de obtenção, em todos os grupos, o IRRS_MIN foi menor (GT=68,60 ± 35,16; GI=38,64 ± 12,31; GS=34,79 ±14,67) quando comparado ao IRRS_ESP (GT=141,60 ± 70,13; GI=80,09 ± 20,71; GS=60,95 ± 24,64) (p<0,05). As medidas diárias do IRRS apresentaram oscilações no GT, enquanto que nos GS e GI houve uma tendência de melhora. O IRRS_POS_TUBO_T quando comparado a IRRS_PRE_TUBO_T aumentou no GS e GI (GS: 60.95±24.64 e 69.79±22.67; GI: 80.09±20,71 e 87,09±13,28), com valores menores para o GS (p<0,5). As medidas obtidas em respiração espontânea, com o novo ponto de corte e após 30 minutos de TRE identificaram a FE em 90% dos pacientes. Conclusão: Em pacientes graves, as medidas do IRRS em respiração espontânea, com ponto de corte 74 ciclos/min/L e após o TRE melhora a identificação dos pacientes que poderão evoluir com falha de extubação. / Introduction: One of the challenges in the discontinuation of mechanical ventilation (MV) is ability to correctly identify patients able for a successfully extubation. The Rapid Shallow Breathing Index (IRRS) has been widely used in this process in patients of intensive care unit (ICU). Objectives: The aim of this study was to evaluate the performance of the cutting point, serial measurements and best method of obtaining the IRRS in predicting extubation failure in critically ill patients for prolonged MV and with risk factors for extubation failure. Methods: Prospective study, including patients with 72h or more of MV, ready for weaning according to clinical criteria. The IRRS was daily obtained since the first day of weaning, with the patient receiving ventilatory support (IRRS_MIN) (PS 5cmH2O 5cmH2O and PEEP) and spontaneous breathing in the spirometer (IRRS_ESP). For patients who have gone successfully through the process of weaning and the extubation was indicated, the IRRS was obtained prior to the Spontaneous Breathing Test (SBT) through the spirometer (IRRS_PRE_TUBO_T) and then placed on SBT for 30 min. After 30 minutes, if the patient showed no signs of intolerance to disconnect the VM, the IRRS was obtained in spontaneous breathing (IRRS_PÓS_TUBO_T) and the patient was readily extubated. The results were analyzed by grouping patients according to the outcome of weaning, Tracheostomy Group (TG), Unsuccess Extubation Group (UEG), Success Extubation Group (SEG). Results: 45 patients finished the study, 15 (33%) of TG, 11 (37%) of UEG and 19 (63%) of SEG. Factors such as intubation time, time to start weaning and weaning time were higher in UEG and TG groups (p <0.05). A new cut-off point was calculated for this population ( 74 breaths/min/L), with a specificity of 0.64 and negative predictive value of 0.54, which best identified patients with extubation failure (EF). Regarding the method for obtaining the IRRS, IRRS_MIN was lower (TG=68,60 ± 35,16; UEG=38,64 ± 12,31; SEG=34,79 ±14,67) compared to IRRS_ESP) (TG=141,60 ± 70,13; UEG=80,09 ± 20,71; SEG=60,95 ± 24,64) (p<0,05) in all groups. The daily measurements of the IRRS showed oscillations in UEG, while there was a trend decrease in the SEG and SEG. The IRRS_POS_TUBO_T increased in the SEG and UEG compared to IRRS_PRE_TUBO_T (SEG: 60.95 ± 24.64 and 69.79 ± 22.67, UEG 80.09 ± 20.71 and 87.09 ± 13.28), with lower values for UEG (p <0.5). The measurements obtained in spontaneous breathing identified the EF in 90% of patients when using the new cut-off point and after 30 minutes of SBT. Conclusion: In critically ill patients, the measures of IRRS in spontaneous breathing, with a cutoff 74 breaths/min/L and after SBT improves the identification of patients who may evolve with extubation failure.

A critical care unit is a dynamic and highly technological environment. Professional nurses who have been working in the critical care unit for a period of time are passionate about the environment in which they work. They find their on duty time challenging and stimulating. The critical care environment is slowly changing. Due to the fact that there are fewer professional nurses with an additional qualification in critical care available to work in the critical care units. The utilisation of an increasing number of agency nurses leads to an increase in sub-standard nursing care as well as dissatisfied doctors and patients. The shortage of critical care staff has resulted in the need to find an alternative human resources framework and still provide cost effective, safe quality patient care. This leads to the design and implementation of a team nursing care framework for critical care. The research objectives for this study were: - To explore and describe the experiences of professional nurses with regard to a team nursing care framework in private critical care units. - Develop guidelines to optimize the team nursing care framework in critical care units in a private hospital group. The research is based on a qualitative, explorative, descriptive and contextual research design. The study is based on a phenomenological approach to inquiry. Eleven in-depth semi structured face-to-face phenomenological interviews were utilized as the main means of collecting data. A purposive, criterion based, sampling method was used. Specific inclusion criteria were met and consent was obtained from the participants and from the management of the private clinic where the research was conducted. Two central themes were identified:- Theme One: The professional nurses experienced the team nursing care framework in the critical care unit as a burden. Six sub-themes were identified. - Theme Two: Professional nurses made recommendations for improvement of the team nursing care framework in the critical care unit. By describing the lived experiences of the professional nurses in the critical care units, based on research interviews, the researcher painted a clear picture of the team nursing care framework in the critical care unit. Guidelines were developed based on the identified themes. The broad guidelines are aimed at ensuring that the nurses are competent to care for critical care patients prior to them commencing work in the critical care unit. The researcher concludes this study by making recommendations for Nursing practice, education and research.

Orientador: Emílio Carlos Elias Baracat / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-26T18:52:29Z (GMT). No. of bitstreams: 1 SaoPedro_TaisdaCosta_M.pdf: 2742388 bytes, checksum: 2d73b02a2f0669996f10824db4a4d519 (MD5) Previous issue date: 2015 / Resumo: Introdução: A sepse ainda representa a principal causa de mortalidade em crianças. As complicações e a sobrevida na sepse dependem do diagnóstico precoce, do tratamento instituído, da resposta do paciente e do sítio de infecção. Outras variáveis epidemiológicas ou clínicas podem estar envolvidas na evolução desfavorável em pacientes admitidos em unidades de tratamento intensivo pediátrico. Identificá-las pode contribuir para uma melhor orientação de protocolos atualizados de diagnóstico e tratamento da doença. Objetivo: Determinar a etiologia e as manifestações clínicas e evolutivas da sepse em crianças e adolescentes internados em unidade de terapia intensiva. Hipótese: A inclusão das vacinas pneumocócica e meningocócica no calendário básico vacinal modificou a etiologia da sepse. Mudanças no perfil epidemiológico de crianças e adolescentes com sepse e nas manifestações clínicas e evolutivas da doença interferiram no prognóstico e na sobrevida. Métodos: Estudo de coorte prospectivo e retrospectivo. Coleta de dados nos prontuários médicos de pacientes com diagnóstico de sepse internados na unidade de terapia intensiva pediátrica do Hospital Municipal Dr. Mário Gatti, em Campinas-SP, de janeiro de 2011 a dezembro de 2013. Foram estudadas e comparadas nos grupos sobrevida e óbito, as variáveis: idade, gênero, comorbidade, esquema vacinal, agente etiológico, dados clínicos à admissão e presença de complicações na evolução. Resultados: 115 pacientes fizeram parte do estudo, com média de idade de 30,5 meses. Das culturas positivas (40), os agentes infecciosos isolados mais comuns foram Staphylococcus aureus (27,5%), Klebsiella pneumoniae (17,5%), Neisseria meningitidis (12,5%), Pseudomonas aeruginosa (10%) e Escherichia coli (10%). Sepse grave predominou nos pacientes de maior idade. Na comparação das variáveis gênero, idade, presença de comorbidades, esquema vacinal e uso de antibioticoterapia prévia, não foram encontradas diferenças significativas entre os grupos sobrevida (n=100) e óbito (n=15). A presença de complicações durante a internação foi fator associado ao óbito (RCP=27,7). Houve maior número de complicações no grupo com idade maior de 36 meses (p=0,003). Perfusão periférica alterada à admissão e o diagnóstico de sepse grave mostraram-se como fatores associados às complicações. Conclusão: Staphylococcus aureus e bactérias Gram negativas predominaram como agentes etiológicos no grupo de pacientes admitidos em terapia intensiva com diagnóstico de sepse. A gravidade da sepse e a perfusão periférica alterada à admissão estiveram associadas às complicações na evolução clínica. A presença de complicações durante a internação foi fator associado ao óbito / Abstract: Background: Sepsis is still the main cause of child mortality. Complications and survival in cases of sepsis depend on previous diagnosis, the type of treatment, the patient response and the infection site. Other epidemiological or clinical variables may be involved in the unfavorable evolution in patients admitted to pediatric intensive care unit. Identify them may contribute to a better orientation of updated diagnostic protocols and treatment of the disease. Objective: Determine the etiology and clinical/evolution variables of sepsis associated with complications and death in children and adolescents admitted in intensive care unit. Hipothesis: The inclusion of pneumococcal and meningococcal vaccines in the official vaccination schedule has changed the sepsis etilogy. Changes in the epidemiology of children and adolescents with sepsis and in clinical/evolution manifestations of this disease have influenced its prognostic and survival. Methods: Prospective and retrospective cohort study. Data were collected from medical records of patients diagnosed with sepsis, assisted at the pediatric intensive care unit of Hospital Municipal Dr. Mário Gatti, in Campinas-SP, from January 2011 to December 2013. The variables age, gender, comorbidity, vaccination schedule, etiologic agent, clinical data at admission and complications during evolution were analyzed and compared in survival and death groups. Results: One hundred and fifteen patients comprised the study, with an average of 30,5 months of age. From positive cultures (40), the most common isolated infectious agents were Staphylococcus aureus (27.5%), Klebsiella pneumoniae (17.5%), Neisseria meningitidis (12.5%), Pseudomonas aeruginosa (10%) and Escherichia coli (10%). Severe sepsis was more common in older patients. There was no difference between the survival (n=100) and death (n=15) groups in the comparison of the variables gender, age, presence of comorbidities, vaccination schedule and use of previous antibiotic therapy. The presence of complications during hospitalization was a death-associated factor (RCP=27,7). There was a higher number of complications in the group with age over 36 months (p=0,003). Altered peripheral perfusion at admission and diagnosis of severe sepsis showed as factors associated with complications. Conclusion: Staphylococcus aureus and Gram-negative bacteria predominated as etiological agents in the group of patients admitted in intensive therapy with diagnosis of sepsis. Sepsis severity and altered peripheral perfusion at admission were associated with complications in clinical evolution. The presence of complications during hospitalization was a factor associated with death / Mestrado / Saude da Criança e do Adolescente / Mestra em Ciências

Cette thèse sur la « fabrique des soins en réanimation » a pour ambition de montrer comment la prise en charge de patients « techniqués » relève d’une catégorisation à la fois sociologique et anthropologique. Partant d’une approche sociohistorique visant à retracer la constitution d’une médecine d’urgence et d’incertitude, il s’agit d’identifier les soubassements professionnels et les conditions d’émergence d’un segment soignant de réanimation. Cette approche conduit à interroger plus précisément l’évolution de ce segment dans le cadre de la modernisation de l’hôpital public. La prolifération normative engagée par les autorités publiques invite à reconsidérer des pratiques soignantes singulières aux prises avec l’incertitude médicale qui résulte de la prise en charge de patients dont le pronostic vital est engagé. Singulières au regard des patients admis dans les unités, les pratiques soignantes le sont aussi compte tenu des « routines de l’urgence » convoquées dans le contrôle du travail. Enfin, elles le sont également en raison des conduites morales qui commandent au maniement des « matériaux humains ». La fabrique des soins de réanimation invite ainsi à saisir les enjeux socioanthropologiques qui se dévoilent un peu plus chaque jour à travers l’ouverture progressive des services aux publics. / This thesis on The Manufacturing of Care in Intensive Care Units aims to show how provision of care for patients requiring highly technical treatment is part of a categorization which is both sociological and anthropological. From a socio-historical approach which aims to retrace how a medical practice of emergency and uncertainty was built up, this involves identifying the professional substructures and the conditions under which the care segment of intensive care has emerged. This approach leads us to question more specifically the evolution of this segment within the framework of the modernization of public hospitals. The standardization undertaken by public authorities invites us to reconsider singular care practices which are grappling with the medical uncertainty resulting from the provision of care to patients whose lives are in danger.These practices are singular in relation to 'emergency routines' which are applied in work supervision, as well as in relation to the patients admitted for treatment. This singularity applies also to the moral behaviour which leads the handling of 'human materials'. The manufacturing of care in intensive care units thus invites us to grasp the socio-anthropological issues which the gradual opening of services to the public reveals a little more each day.

Thesis (M.Med. (Paediatrics and Child Health)) -- University of Limpopo, 2021 / Nosocomial infection constitutes a major health problem associated with high morbidity and mortality. This study is aimed at investigating the prevalence of nosocomial infections in paediatric intensive care unit of Pietersburg hospital, Limpopo, South Africa and identify the pathogens responsible for such infections and determine their anti-microbial activity. The study applied a retrospective quantitative descriptive study design to execute the objectives of the study. Convenience sampling was applied to select 98 participants that met the selection criteria to collect the data set from the hospital files between 1st January 2017 to 31st December 2017 in a self-designed template. Results shows that the prevalence of nosocomial infections in children admitted from 1st January 2017–31st December 2017 at Pietersburg hospital was 13.27% where majority were females at 61,5% with the remaining 38,5% being male. Majority of participants that developed HAI were below 24 months of age (69%). Hospital stay was a mean of 23 days. The underlying conditions in participants who developed HAI were mostly HIV in 4 of 13 (31%) and had association with hospital stay (Chi-square = 140,14; pvalue=0,0034). Majority of patients that acquired HAI were admitted for a respiratory condition n=12; (92%) mainly Pneumonia and Bronchiolitis. Potential risks factors for developing HAI were endotracheal intubation, mechanical ventilation; central venous catheter (Chi- square =21,195; p value= 0,0035); Peripheral vascular catheter (Chisquare = 17,106; p-value= 0,0167); urethral catheter (Chi-square = 20,013; p-value= 0,0055) and surgery since admission (Chi-square = 27,649; p-value= 0,0003). There was a strong correlation between hospital stay and mortality rate (r=36%; p- value<0.0001). Klebsiella pneumonia was the most identified pathogen from the respiratory site (50%). Coagulase-negative staph aureus was the most identified organism in the bloodstream. The study found that the development of HAI was associated with increased length of hospital stay and an increased rate of mortality.

Mechanically ventilated critically ill patients treated in the intensive care unit (ICU) require enteral feedings to maintain adequate nutrition during critical illness. Delivery of adequate enteral nutrition is also critical to the recovery of critically ill patients. Enteral nutrition has been shown to decrease length of time on the ventilator, decrease length of stay and ICU and decrease mortality. Despite all the evidence regarding the benefits of enteral nutrition, critically ill patients continue to receive less than their prescribed calories and protein. Nurses are in a unique position to influence the delivery of enteral nutrition. Nursing practices that contribute to underfeeding must be identified and corrected to ensure adequate delivery of nutrients is achieved. The purpose of the study was to describe the professional practice of critical care nurses regarding enteral feeding in mechanically ventilated critically ill patients. Several barriers were identified by the participants in the study that contributed to underfeeding including inconsistent practice regarding gastric residual volume, holding feeds when changing patient position and lack of a standardized protocol for enteral feeding. Also identified in the study was the idea that nurses do not see enteral feeding as a life-saving intervention. It is not the “sexy part” of what ICU nurses do. Enteral feeding guidelines need to be developed to include those interventions that are important to nursing practice in order to increase enteral feeding times and improve patient outcomes.

The purpose of this study was to measure and evaluate the clinical presentation, outcome and longterm effects of tuberculosis in children admitted to the paediatric intensive care unit at Tygerberg Hospital. A retrospective, descriptive study was conducted among 57 children admitted to the paediatric intensive care unit between January 1991 to December 1994. The sample comprised all the children with tuberculosis aged one month to twelve years who were admitted to the paediatric intensive care unit. Audit measures were taken to ensure that all the children with tuberculosis were identified. Data was collected by means of a structured working sheet and questionnaire that was sent to the clinics. Respondents completed the questionnaire in the clinics. There was an increase in the incidence of children suffering from pulmonary or disseminated tuberculosis who required admission to the PICU, although the incidence of HIV was low. None of the index cases had MDR-TB. Fifty-one percent of children were admitted to the PICU because of primary tuberculosis or complications of the disease. Of these children 69 % had respiratory failure who required ventilation. Thirty percent were admitted to the PICU for respiratory failure and were subsequently diagnosed as having tuberculosis. Tuberculosis was incidently found amongst 4 children when they were routinely examined in the PICU. Due to the difficulty in confirming the diagnosis of tuberculosis in children, a large proportion of cases go unrecognised. The chest radiographs demonstrated that hilar ( 40 % ) and paratracheal (32 % ) adenopathy was the most common findings. Bronchial compressions was present in 12 % of cases. A significantly positive Mantoux skin test was reported in 35 % of cases and 53 % had a positive Tine skin test. Gastric aspirates positive for M. tuberculosis were obtained in 42 % of cases and of cultures other than gastric aspirates, 44 % were positive. Other special investigations to confirm the diagnosis of tuberculosis included CT scan and bronchoscopies. Bronchoscopies were performed on 13 children and found to be abnormal in 12 cases. The most common finding was nodal compression of the airways. Overall the diagnosis of confirmed tuberculosis was made in 47% and of probable tuberculosis in 53 % of cases. The length of stay in the PICU was 10.2 + 22.4 days. The PICU mortality was 23%, with a total hospital mortality of 26%. The mortality for the TBM subgroup was 75 % . Although a good compliance (82 % ) was recorded by the clinics in the follow-up study, they experienced problems with the notifications. The follow-up study pointed out that communication was a problem between the referring hospital and the clinics. Thirty-one percent of the clinics made suggestions for improving the communication. The findings demonstrates that in an area with a high incidence of TB, children do develop severe disease requiring admission to the PICU. This places a considerable clinical and financial burden on the already limited health system. Early diagnosis of TB should prevent severe disease and subsequent admission to the PICU. The increasing incidence of HIV and MDR-TB will undoubtedly pose a major risk to ICU staff and the prevention of infection is of primary concern for those who may be exposed in this area. Due to this, certain recommendations regarding guidelines for admission to the PICU, investigations of patients exposed of having TB in the PICU, prevention of infection and detection of disease in staff in the PICU, the need for increase beds in the PICU and recommendations post discharge from the PICU were made.