L’anesthésie-réanimation est une discipline qui n’a acquis son autonomie que récemment. Jadis sous la direction du chirurgien, l’anesthésiste-réanimateur est, comme son nom l’indique, au cœur d’une profession multidisciplinaire. Si l’acte anesthésique suppose, en aval, l’application de techniques de réanimation, l’inverse n’est pas systématiquement le cas. En effet, l’anesthésiste-réanimateur peut être confronté, dans sa fonction de réanimateur, à la problématique du prélèvement d’organes dont la pratique fait appel à la définition de la mort, définition nécessairement sujette à discussion. Par son objet même, le contentieux civil en anesthésie-réanimation est particulièrement vaste. Son étude mettra en évidence l’élaboration des normes encadrant la discipline, sur laquelle le contexte professionnel exerce une influence déterminante, leur mise en pratique par l’anesthésiste-réanimateur, puis leur adéquation au cas clinique par le juge civil, lorsqu’un patient exercera une action en responsabilité / Anaesthetics and intensive care are closely linked in the French health care system and are always carried out by the same professional. Anaesthetics and intensive care thus form a common discipline which has acquired only recently its autonomy. Formerly under the direction of the surgeon, the anaesthetist is at the core of a multidisciplinary profession. If the anaesthetic treatment supposes, down the line, application of techniques of intensive care, the opposite is not systematically true. Indeed, the anaesthetist, taken as a member of an intensive care unit, can be confronted with the issue of organ removal which practice necessarily relates back to the difficult definition of death. Concerning its object itself, civil dispute regarding anaesthetics and intensive care covers a large-scale field. This in-depth study would highlight the drafting of norms ruling the discipline upon which the professional context has a decisive influence, then their practice by the anaesthetist itself, and finally their appropriateness to the clinical case as considered by the civil judge whenever a patient had brought legal action in responsibility before a tribunal

Introduction: Arterial catherer placement by a general nurse at the departments of intensive care, resuscitation and anaesthesiology is still rather exceptional, despite the fact that this competence was defined in our legal system for the first time already in 2004 by the Decree no. 424/2004 Coll. of the Ministry of Health. The authorisation to execute this highly professional operation by a nurse specialised in intensive care is generally not reflected by the employer in the job description, although it might be one of the possible ways to increase the prestige of this profession. Objectives: The main objective of the thesis was to determine the current state in the area of arterial line placement from the perspective of intensive care nurses, to quantify their interest and clarify their readiness to execute the operation. Methodology: The quantitative method of anonymous questionnaire of own design was selected for the research survey. The questionnaire was distributed in electronic way to hospitals established by the Ministry of Health, regional government or private owners. We contacted one large hospital in every region, with the exception of Prague. The research sample consisted of general nurses working at the departments of intensive care, resuscitation and anaesthesiology, who at the same...

Diploma thesis deals with historical formation of neonatal intensive care in the Czech Republic. Its aim is to map the evolution of intensive care, from the very beginning up to the contemporary period, and provide a concise overview of events leading to Czech Republic being one of the countries where level of neonatal care is considered to be most advanced. Theoretical nature of the thesis required a study of historical and contemporary literature, particurarly artticles and books. As an extra supplement, authentic information have been gathered from the pathfinders. In the introduction to the thesis, reason for choosing the topic is described, then current status of knowledge in this area is summarized. Following that, process of creating of the historical analysis is described. Chapter on neonatology introduces and explains terms that are crucial for comprehending the context stated in the historical part of the thesis. Chapter which maps the historical evolution itself is divided into seven sub chapters which describe course of events in the particular periods. Evolution of perinatal care abroad is also shortly described. Thesis reviews an extraordinary evolution of neonatal intensive care which has occurred in very short period of time. During this period pioneers had to overcome many hurdles,...

M.Cur. / Please refer to full text to view abstract

Magister Curationis - MCur / Parents undergo negative experiences that include parental anxiety, depression, and posttraumatic stress when their new-born babies are hospitalised in neonatal intensive care unit. During this stressful period, parents need assistance from staff in order to cope. A quantitative, descriptive survey design was used to describe parents’ perception of nursing support during their baby’s admission in neonatal intensive care units (NICU) at three selected private hospitals in the city of Cape Town in the Western Cape Province. A structured existing 21- item Likert type questionnaire, the Nurse-Parent Support Tool (NPST) was used to collect data from an all-inclusive sample of 85 parents with a response rate of 78.8% (n=67). The purpose of the questionnaire was to determine their perception of information giving and communication by nurses; emotionally supportive behaviours by nurses; care given support or instrumental support and to identify parents’ perception of esteem or appraisal support while in the NICU environment. The data was analysed using Statistical Package for Social Sciences (SPSS) version 24. The findings of this study suggested that the overall mean score for parents’ perception of nursing support was high 4.6 (±0.5) out of a possible of 5. There was no significant difference in the overall mean perceived support score between the different facilities. No significant differences were found in terms of all the demographics characteristics with regard to perceptions of the support that was received, thus indicating that there was no relationship between the demographic variables and perception of support. The findings suggested that though high parental support was reported, the area of involving parents in the care of their babies i.e. letting them decide whether to stay or leave during procedures need improvement.

The aim of this thesis is to cover the issue of human dignity and the values of human life of a patient in the intensive care unit. The goal is achieved through a quantitative research, using the data collection technique through questionnaires. The purpose of the research was to determine what areas of human dignity do the patients find hard or problematic. A standardized questionnaire was used for this purpose. Based on theoretical knowledge, a questionnaire of its own design was compiled for the nurses' research group. It focused on the nurses' perception of a patient's dignity and also the value of his or her life during hospitalization in the intensive care unit. This information was quite difficult to determine, which is primarily due to the fact that it deals with topics and opinions which are philosophical, individual and perhaps even personal. The research found that the patients feel a problem only in certain areas that we had investigated in a standardized questionnaire. The patients' evaluation revealed that they do not feel most issues as too much of a problem. The nurses' research group found that the dignity of a patient and the value of his or her life mean something completely individual to each nurse. However, a large number of the nurses said that a patient's dignity is an important aspect, and the value of a patient's life in the intensive care unit is high or even priceless. This thesis could bring the nurses, who work in intensive care units, an incentive to think about the dignity of a patient, the high and untouchable value of his or her life and, last but not least, the individuality of each human being.

Introdução: A Lesão renal aguda (LRA) é uma síndrome de alta incidência (23,2%) e mortalidade (23,0%), que acomete principalmente pacientes críticos, internados em unidades de terapia intensiva (UTI). A sepse é a principal causa de LRA (40,0%). A infecção por microrganismos multirresistentes exige o uso de agentes antimicrobianos potencialmente nefrotóxicos, como as polimixinas (Pmxs). Dentre elas, destaca-se a Pmx B e a colistina (Pmx E) utilizadas no controle de infecções por bacilos gram negativos (BGN). Objetivos: avaliar a incidência de LRA associada ao uso de Pmxs e identificar os fatores de risco para desenvolvimento de LRA associada ao uso de Pmxs. Métodos: Trata-se de um estudo transversal, retrospectivo, de abordagem quantitativa. A amostra foi composta por 1009 pacientes internados em UTI, provenientes de um banco de dados universal (BDU) organizado no período de abril a dezembro de 2012. Resultados: Foram incluídos 936 pacientes. A incidência geral de LRA na amostra foi de 43,1%, enquanto que para pacientes que receberam Pmxs foi de 87,0%. O principal fator de risco para LRA geral foi a pré existência de Doença Renal Crônica. Dentre os pacientes com LRA e que fizeram uso de Pmxs, a maioria era do sexo masculino (69,2%); 54,4±15,7 anos, internação do tipo clínica e com o maior tempo de internação em UTI, as características clínicas mais prevalentes foram o estado de choque (81,5%), a hipertensão arterial sistêmica (35,3%), o Diabetes Mellitus (20,0%) e a sepse (23,0%). Esse grupo apresentou maiores índices de gravidade SAPS II e LODS e o choque se confirmou como fator de risco nesse grupo. Conclusões: As Pmxs confirmaram-se como medicamento nefrotóxico em pacientes críticos (87%), tendo o choque como fator de risco. / Introduction: Acute kidney injury (AKI) is a syndrome of high incidence (23.2%) and mortality (23.0%), which affects mainly critically ill patients admitted to intensive care units (ICUs). Sepsis is the main cause of AKI (40.0%). Infection with multiresistant microorganisms requires the use of potentially nephrotoxic antimicrobial agents, such as polymyxins (Pmxs). Among them, Pmx B and colistin (Pmx E) are used to control gram-negative bacilli (GNB) infections. Objectives: to evaluate the incidence of AKI associated with the use of Pmxs and to identify the risk factors for the development of AKI associated with the use of Pmxs. Methods: It´s a cross-sectional, retrospective, quantitative approach The sample consisted of 1009 patients hospitalized in ICUs from a universal database (BDU) organized from April to December 2012. Results: A total of 936 patients were included. The overall incidence of AKI in the sample was 43.1%, whereas for patients receiving Pmxs it was 87.0%. The main risk factor for overall AKI was the pre-existence of Chronic Kidney Disease. Among the patients with AKI who used Pmxs, the majority were male (69.2%); 54.4 ± 15.7 years, hospitalization of the clinical type and with the longer ICU stay. The most prevalent clinical characteristics in the AKI and Pmx groups were shock state (81.5%), systemic arterial hypertension (35.3%), Diabetes Mellitus (20.0%) and sepsis (23.0% ). This group presented highest SAPS II and LODS severity indexes and the shock was confirmed as a risk factor. Conclusions: Pmxs were confirmed as nephrotoxic drugs in critical patients (87%), with shock as a risk factor.

O presente estudo de corte transversal teve por objetivo avaliar a intensidade de dor aguda e o comportamento de estresse em crianças de um a sete anos de idade, hospitalizadas em unidade pediátrica de cuidados intensivos, e comparar grupos diferenciados, respectivamente por: tipo de doença (aguda vs. crônica), tipo de tratamento (cirúrgico vs. clínico), fase de desenvolvimento (1-3 anos vs. 4-7 anos) e sexo (meninos vs. meninas). O estudo teve como objetivo secundário comparar duas avaliações de dor e estresse realizadas durante dois procedimentos dolorosos em dias diferentes para verificar a reatividade comportamental das crianças durante a internação. A amostra do estudo foi composta por 44 crianças (59% de meninos) com idade entre um e sete anos (média = 38 meses; ± 23,2), que estavam internadas no Centro de Terapia Intensiva Pediátrico do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo. Os motivos da internação referiam-se a tratamento pós-cirúrgico (n = 30; 68%) ou clínico (n = 12; 32%), havendo uma prevalência de pacientes com doenças crônicas (n = 25; 57%). Foram realizadas duas avaliações de dor aguda e de estresse comportamental (Avaliação 1 e Avaliação 2) no decorrer de procedimento doloroso envolvendo inserção de agulha (tipo punção para coleta de sangue). Para avaliação do indicador de intensidade de dor aguda foi aplicada a escala Face, Legs, Activity, Cry and Consolability (FLACC) e para avaliação do indicador de estresse comportamental foi utilizada a escala Observational Scale of Behavioral Distress (OBSD). O comportamento das crianças foi filmado durante os procedimentos, incluindo as fases de Linha de base, Procedural e de Recuperação, para posterior aplicação das escalas de dor e de estresse. Para obtenção dos indicadores da história dos procedimentos de dor e estresse do contexto foi aplicada a escala Neonatal Infant Stressor Scale (NISS), analisando-se os dados de prontuários médicos das crianças. No tratamento dos dados, foram realizadas análises estatísticas do tipo descritivo, de comparação intragrupo (testes de Wilcoxon e McNemar), ANOVA de medidas repetidas, de comparação entre grupos (teste de Mann-Whitney), de correlação entre duas variáveis numéricas (teste de Pearson) e de associação entre duas variáveis categóricas (teste do Qui-quadrado). Os dados foram analisados por meio do SPSS (versão 25.0, Chicago, Il, USA). O nível de significância de 5% (p <= 0,05) foi adotado em todos os testes do estudo. Os resultados mostraram que as crianças internadas na unidade de tratamento intensivo enfrentaram uma média de 17 eventos estressores por dia e de 47 eventos dolorosos durante a internação até o dia em que foram avaliadas. As crianças apresentaram intensidade de dor classificada como moderada nas duas avaliações (média = 5; ± 2,7 naAvaliação 1, e média = 6; ± 2,7 na Avaliação 2, na fase Procedural). Observou-se uma intensificação estatisticamente significativa da dor do primeiro para o segundo procedimento doloroso na fase Procedural (p = 0,03). Notou-se que na avaliação 2, os meninos apresentaram maior reatividade à dor na fase de Recuperação após o procedimento doloroso (p = 0,02), em comparação às meninas. Em relação ao estresse comportamental das crianças, houve também uma maior sensibilização das crianças para os comportamentos de estresse na segunda avaliação em comparação à primeira, especialmente na Linha de base (média = 3; ± 2,9 na Avaliação 1, e média = 5; ± 3,6 na Avaliação 2; p < 0,001). Na avaliação 1, as crianças que tinham doenças agudas, em comparação às crianças com doenças crônicas, apresentaram maior reatividade à dor e ao estresse nas fases Procedural (p = 0,02, na avaliação de dor, e p = 0,03, na avaliação de estresse) e de Recuperação (p = 0,04, nas avaliações de dor e estresse). Na avaliação 2, as crianças que foram submetidas a cirurgias apresentaram maior reatividade à dor e ao estresse na Linha de base (p = 0,02, na avaliação de dor, e p < 0,001, na avaliação de estresse) e na fase Procedural (p = 0,01, na avaliação de dor, e p < 0,001 na avaliação de estresse), em comparação às crianças que receberam tratamento clínico. Adicionalmente, encontrou-se associação significativa entre os indicadores de dor e estresse comportamental experimentados pelas crianças; quanto maior a intensidade de dor durante o procedimento de inserção de agulha, maior reação de estresse apresentado pelas crianças (r = 0,84; p < 0,001, na Avaliação 1, e r = 0,84; p < 0,001, na Avaliação 2). Não foram encontradas diferenças estatisticamente significativas entre os grupos de idade das crianças analisadas. Conclui-se que as crianças apresentaram altos níveis de exposição a eventos estressores no contexto de cuidados intensivos e níveis moderados de intensidade de dor e estresse comportamental. A reatividade à dor foi mais intensa nos pacientes cirúrgicos e com doenças agudas. Houve uma alta associação entre reatividade à dor e comportamentos de estresse, sendo que ambos se intensificaram durante o tratamento das crianças. Cuidados de manejo não farmacológico à dor aguda devem ser implementados como medida preventiva e de alívio de dor. / The present cross-sectional study aimed to evaluate acute pain intensity and distress behavior in children aged one to seven years hospitalized in the Pediatric Intensive Care Unit (PICU), and to compare groups differentiated by: type of disease (acute vs. chronic), type of treatment (surgical vs. clinical), developmental phase (1-3 years vs. 4-7 years), and gender (boys vs. girls). The secondary objective of the study was to compare two pain and distress assessments performed during painful procedures on different days to verify the behavioral reactivity of the children during the hospitalization. The study sample consisted of 44 children (59% boys) aged between one and seven years (mean = 38 months ± 23), who were hospitalized at the PICU of the Hospital of Clinics, Ribeirão Preto Medical School, University of São Paulo. The reasons for hospitalization were post-surgical (n = 30; 68%) or clinical treatment (n = 12; 32%), with a prevalence of patients with chronic diseases (n = 25; 57%). Two evaluations of acute pain and behavioral distress (Assessment 1 and Assessment 2) were performed during painful procedure involving needle insertion (type of puncture for blood collection). The Face, Legs, Activity, Cry and Consolability (FLACC) scale was used to evaluate the acute pain intensity indicator and the Observational Scale of Behavioral Distress (OBSD) was used to evaluate the behavioral distress indicator. The behavior of the children was video recorded during the procedures, including the Baseline, Procedural, and Recovery phases for later scoring of the pain and distress scales. The Neonatal Infant Stressor Scale (NISS) was used to obtain the indicators of the history of the pain and stress events of the context, analyzing the medical records. In the treatment of the data, descriptive statistical data analyzes, within groups comparison (Wilcoxon and McNemar tests), repeated measures ANOVA, comparison between groups (Mann-Whitney test) and correlation analysis between two numerical variables (Pearson\'s test) and association of variables for two categorical variables (Chisquare test) were performed. Data were analyzed using SPSS (version 25.0, Chicago, Il, USA). The significance level of 5% (p <= 0.05) was adopted in all study tests. The results showed that the children hospitalized in the intensive care unit faced an average of 17 stressors per day and 47 painful events during hospitalization until the day they were evaluated. The children presented pain intensity classified as moderate in both evaluations (mean = 5 ± 2,7, in Assessment 1, and mean = 6 ± 2,7, in Assessment 2 in the Procedural phase). There was a statistical significant increase in pain from the first to the second painful procedure in the Procedural phase (p = 0.03). It was observed in the Assessment 2 that the boys presented greater reactivity to the pain in the Recovery phase of the procedure (p =0.02), compared to the girls. Regarding the behavioral distress of the children, there was also a greater sensitization of the children for distress in the second assessment compared to the first, especially in the Baseline (mean = 3 ± 2,9, in Assessment 1, and mean = 5 ± 3,6, in Assessment 2, p <0.001). In the Assessment 1, children who had acute diseases compared to children with chronic diseases showed greater reactivity to pain and distress in the Procedural phase (p = 0.02, in the pain assessment, and p = 0.03, in the distress assessment), and Recovery phase (p = 0.04, in pain and distress assessments). In the assessment 2, children who underwent surgeries presented greater reactivity to pain and distress in the Baseline (p = 0.02, in the pain assessment, and p <0.001, in the distress assessment) and in the Procedural phase (p = 0.01, in the pain assessment, and p <0.001 in the distress assessment), compared to the children who received clinical treatment. Additionally, a significant association was found between the indicators of pain and behavioral distress experienced by children; the higher the pain intensity during the needle insertion procedure, the higher the distress reactions presented by the children (r = 0.84, p <0.001, in Assessment 1, and r = 0.84, p <0.001, in Assessment 2). No statistically significant differences were found between the age groups of the children. In conclusion, children presented high levels of exposure to stressors in the context of intensive care and moderate levels of pain intensity and behavioral distress. The reactivity to pain was more intense in surgical patients and with acute diseases. There was a high association between reactivity to pain and distress behaviors, both of which intensify during the treatment of the children. Non-pharmacological management of acute pain should be implemented as a preventive and pain relief measure.

Magister Artium - MA / Background: Physiotherapists are involved in the management of patients in the cardiothoracic Intensive Care Unit (ICU). Patient and family perception of care has become an important measure in evaluating the quality of care, including care in the intensive care setting. Overall Aim: To explore and describe the family and patient perception of physiotherapy care rendered in a public sector cardiothoracic ICU in the Western Cape, South Africa. Method: This study was conducted in two phases. Phase 1 (scoping review) identified and described available outcomes for measuring family perception of ICU care by searching six databases from inception to the 20th June 2018. Results from the scoping review informed the discussion schedule for the first primary study of Phase 2. Phase 2 (two exploratory descriptive qualitative primary studies) explored and described i) family perception and ii) patient perception of physiotherapy care in a cardiothoracic ICU. Audio-taped, individual face to face semi-structured interviews were conducted with family and patient participants that met the inclusion and exclusion sampling criteria (purposive sampling). Data was transcribed verbatim and analysed using deductive-inductive thematic content analysis. The data was coded, categorised and themes were generated. Trustworthiness of the data was ensured through methods addressing credibility, dependability, confirmability and transferability. Results: A total of ten full text studies were included in the scoping review. Included studies were published between 2006 and 2017, were conducted in both developed and developing countries, in different ICUs (except cardiothoracic ICU)and all used different quantitative outcome measures to measure family perception of ICU care. Thirteen cardiothoracic ICU patients and their respective family members partook in the studies describing patient and family perception of cardiothoracic ICU physiotherapy care. The median patient age was 62 years; the mean ICU length of stay 6 days and the median family age was 55. Themes arising from the family perception of care data analysed included: i) understanding of physiotherapy care (the role of the physiotherapist, perceived benefit of physiotherapy and communication), family involvement in physiotherapy care (physical presence during physiotherapy sessions and decision-making), and satisfaction of physiotherapy ICU care. Themes arising from patient perception of care data analysed included: i) Physiotherapy management of patients, ii) The Physiotherapists – skill, iii) knowledge and professionalism, iv) Continuity of Care, v) Tangibility, vi) Physiotherapy benefits, vii) Decision-Making, viii) Communication, ix) Satisfaction of Physiotherapy ICU care. Overall, family and patients were satisfied with the physiotherapy care in the cardiothoracic ICU. However, there were areas of improvement such as the understanding of physiotherapy care, communication, family involvement in the physiotherapy care and decision-making. Conclusion: While there are multiple quantitative measures for measuring family perception of ICU care there is no “gold” standard measure that has been identified. A qualitative measure and research design would allow richer in-depth information on family perception of ICU care. The findings from the family and patient perception of cardiothoracic ICU physiotherapy care are influenced by many factors. While family and patients perceive cardiothoracic ICU physiotherapy care both positively and negatively, the majority of patient and family were satisfied overall with the care the patient received. Family perception of ICU physiotherapy care should be evaluated in order to identify areas for improvement in quality of care and could add to the body of evidence in ICU physiotherapy practice.

Objective: The purpose of this study was to determine the characteristics, assessment, and treatment of infants with Neonatal Abstinence Syndrome (NAS) as perceived by Speech-Language Pathologists (SLP) and whether it differed from those of other Neonatal Intensive Care Unit populations. Methods: A secure web-based questionnaire with 62 questions collected information on NAS, caseloads, treatment environment, and demographics. Twenty-six respondents initiated the survey; 42% completed most or all questions. Response analyses included descriptive and nonparametric inferential statistics. Results: Infants with NAS were on the caseloads of 73% of respondents. The majority (79%) only saw infants with NAS and feeding problems. Primary problems included incomplete or increased time to complete feeds, increased/excessive/irregular sucking rates, and reflux. Working on teams, respondents provided assessment, treatment, and education of infant feeding and state. Conclusion: Growing demand for SLP intervention with infants with NAS is likely to persist if opioid use continues to increase as projected.