Este estudo objetivou conhecer a prevalência de parada cardiorrespiratória (PCR) atendida pelo SAMU de Araras entre 2001 e 2007, caracterizar as vítimas segundo o sexo, faixa etária, antecedentes mórbidos, natureza traumática do evento; a parada ter sido presenciada, realização de ressuscitação cardiopulmonar (RCP) por familiares/acompanhantes, tempo resposta, tipo de suporte de vida recebido na cena, indicação de choque pelo Desfibrilador Externo Automático (DEA), assim como identificar as variáveis significativas para o retorno da circulação espontânea na cena. Os dados foram coletados retrospectivamente das fichas de atendimento das vítimas de PCR do SAMU de Araras após aprovação do Comitê de Ética em Pesquisa da EEUSP. Foram selecionadas 328 fichas que preencheram os critérios de inclusão. O SAMU de Araras realizou 28.924 atendimentos gerais no período estudado, dos quais em 330 foram iniciadas as manobras de ressuscitação cardiopulmonar. A taxa de PCR no período avaliado é 1,13%, com predomínio do sexo masculino 208 (64,60%) e faixa etária entre 70 e 79 anos, média de idade 63,35 anos. Os antecedentes mórbidos mais citados foram cardiopatias (29,48%), hipertensão arterial sistêmica (25,43%) e diabetes (12,14%), a maioria com citação de um único antecedente ou sem este registro. Não havia trauma associado em 302 (92,64%) vítimas. O DEA foi utilizado em 280 (85,37%) vítimas, com indicação de choque em 95 (29%). A PCR foi presenciada em 115 (35,00%) vítimas, para as quais houve maior percentual de início de RCP (p=0,004) pela família/ acompanhante e houve mais indicação de choque pelo DEA(p<0,001) em relação às vítimas que foram encontradas em PCR. Houve maior proporção do retorno da circulação espontânea nas vítimas que receberam suporte avançado de vida na cena 54(31,76%), (p=0,018) em relação às que receberam somente suporte básico de vida. O tempo resposta médio foi de 05:24 minutos. Pela análise univariada, as seguintes variáveis foram significativas (p<0,05) para o retorno da circulação espontânea: faixa etária (p=0,018), diabetes melitus (p<0,001), responsividade (p=0,041), pulso carotídeo presente na avaliação inicial (p= 0,001), compressões torácicas pelo SAMU (p=0,028), choque pelo DEA (p<0,001), suporte avançado de vida (p=0,018), intubação traqueal (p<0,001). No modelo de regressão logística múltipla apenas \"pulso carotídeo presente na abordagem inicial\" foi selecionada como preditora independente para o retorno da circulação espontânea na cena (Odds Ratio 4,03), p =0,002.Concluiu-se que o serviço oferece um tempo resposta dentro dos padrões mundialmente recomendados e que as vítimas que tiveram PCR presenciada, apesar de receberem proporcionalmente mais RCP pela família/acompanhante e terem mais indicação de choque pelo DEA, não apresentaram mais retorno da circulação espontânea na cena. As vítimas com pulso presente na avaliação inicial do SAMU, isto é, as que tiveram a PCR presenciada pela equipe, ou tempo resposta \"zero\" têm 4,03 mais chances de retorno da circulação espontânea na cena, sendo esta variável a única preditora independente. O investimento em capacitação permanente da equipe do SAMU, ensino da população a reconhecer um evento crítico, iniciar manobras de reanimação e acionar precocemente o SAMU poderão contribuir para aumentar as chances de sobrevivência de vítimas de PCR em ambiente pré-hospitalar / The objective of this study was to know the prevalence of cardiac arrest (CA) assisted by Emergency Medical Service of the City of Araras (SAMU-Araras), SP, Brazil, between 2001 and 2007, classifying victims according to the gender, age groups, morbid antecedents, traumatic nature of the event, witnessed arrest, accomplishment of cardiopulmonar ressuscitation (CPR) by bystanders, time elapsed between the call of SAMU and the arrival of the EMS team to the site (time-response), type of life support received on-scene, shock indication for AED, as well as to compare the outcome of these cases, in terms of return of the spontaneous circulation (ROSC) still on scene, according to those variables. Data were collected from the records of SAMU of Araras, after approval of the Research Ethics Board of the Nurse School of University of São Paulo (EEUSP). 328 records that fulfilled the criteria were selected. SAMU-Araras accomplished 28.924 general medical attendances in the period of the study. In 330, CPR was performed (1.13%). Man (64.60%) and age group between 70 e 79 years old were predominants, and 63,35 yo. was the average. The mentioned prior diseases were cardiopathy (29.48%), sistemic arterial hypertension (25.43%) and diabetes (12.14%), most of all with just one problem cited or even no prior diseases. There was not associated trauma in 92.64% of the cases. AED was used in 85.37% of the cases were CPR was performed, with shock indication in 95 (29%) victims. CA was witnessed in 115 (35.00%) victims. In these cases, CPR performed by relatives were more frequent (p=0.004), as well as shock was more frequently indicated (p <0.001) compared with those where CA was not witnessed. There was larger proportion (51.83%) of ROSC in the victims that received advanced life support on scene, (p=0.018) comparing to the ones that received only basic life support. The time-response average was 05:24 minutes. The following variables presented statistical association (p <0.05) for ROSC: age group (p=0.018), diabetes (p <0.001), responsivity (p=0.041), carotid pulse present at the time of initial assesment (p=0,001), thoracic compressions by the SAMU team (p=0.028), shock delivered by AED (p <0.001), advanced life support performed (p = 0.018), and use of tracheal tube (p <0.001). In the statistical model of multiple logistics regression only the variable \"carotid pulse present at the time of initial assesment\" was selected as independent predictor for the return of the spontaneous circulation on scene (Odds Ratio 4.03), p =0.002. In conclusion, the SAMU-Araras offers a time-response according to international recommendations. Victims that have had witnessed CA, although received more frequenty CPR and recommended shock, they did not have better outcomes. The victims with present pulse in the initial assessment by the SAMU team, or in other words, the ones that presented CA witnessed by the SAMU team, had 4.03 more times in terms of chances of ROSC on scene, being this an independent predictor. The investment in permanent training of the SAMU professionals, the education for the people recognize a critical event and immediately to begin CPR can contribute to increase the survival chances for victims of CA in prehospital environment

Introdução: No panorama mundial, as doenças cardiovasculares configuram-se como principal causa da parada cardiorrespiratória em adultos, cujas chances de sobrevivência são maiores, quando presenciada por pessoas aptas para prover o suporte básico de vida (SBV) na reanimação imediata. Objetivo: Desenvolver e avaliar o curso online Suporte Básico de Vida: aspectos essenciais no atendimento do adulto em parada cardiorrespiratória. Método: Em primeira etapa, trata de pesquisa aplicada, de produção tecnológica acerca do desenvolvimento do curso online sobre SBV, utilizando design instrucional baseado no modelo ADDIE (Analisys-Análise, Design-Desenho, Development-Desenvolvimento, Implementation-Implementação, Evaluation-Avaliação). Nessa perspectiva, foi avaliado por especialistas e estudantes. A segunda etapa configura-se em delineamento quase-experimental, do tipo antes-depois. O curso online foi aplicado aos estudantes da Escola de Enfermagem da Universidade de São Paulo, como intervenção educacional, em 2014-2015. Os estudantes foram avaliados mediante pré-teste, pós-teste e simulação em prática presencial com dispositivos de feedback. Resultados: O curso online foi implementado em ambiente virtual de aprendizagem; 94 (100%) estudantes aceitaram participar da pesquisa, 88 (94%) acessaram ambiente virtual, 67 (71%) finalizaram parte teórica, 62 (66%) concluíram o curso online. A maioria era do sexo feminino (90,4%), do 1º e 2º ano (65%), idade média 21,48 (DP 2,39). Adotando nível de significância 95%, a média das notas no pré-teste foi 6,4 (DP 1,61), pós-teste 9,3 (DP 0,82), p<0,001. ANOVA para medidas repetidas indicou diferenças significativas (p<0,001) entre médias das notas no pré-teste dos estudantes do 1º e 2º ano 6,2 (DP 1,59) e do 3º e 4º ano 7,2 (DP 0,83). Média das notas do pós-teste foi 9,2 (DP 1,60) nos dois primeiros anos e 9,7 (DP 0,61) nos dois últimos anos, p<0,475. Regressão linear múltipla com inclusão progressiva (forward stepwise) para variáveis associadas ao aprendizado mostrou-se significativa (p<0,015) com ano de curso no Bacharelado -0,542 (EP 0,215) e participação anterior em curso de emergência -0,903 (EP 0,437). Na prática simulada, a média das notas foi de 9,1 (DP 0,95). Registros do checklist indicaram que 98% dos estudantes realizaram exposição do tórax, 97% avaliaram respiração, 76% se lembraram de chamar serviço de emergência, 92% solicitaram desfibrilador, 77% verificaram pulso corretamente, 87% posicionaram as mãos no tórax corretamente, 95% efetuaram ciclo de 30 compressões adequadamente, 89% em profundidade mínima 5 cm, 90% liberaram tórax após compressão, 97% alternaram 2 ventilações corretamente, 97% usaram Desfibrilador Externo Automático, 100% posicionaram as pás corretamente. Registros do dispositivo de feedback indicaram percentual de desempenho equivalente a Reanimação Cardiopulmonar Básica 43,7 (DP 26,86), médias de duração ciclo compressões/seg 20,5 (DP 9,47), do número de compressões 167,2 (DP 57,06), da profundidade compressões/mm 48,1 (DP 10,49), do volume de ventilação 742,7 (DP 301,12), do percentual de fração de fluxo 40,3 (DP 10,03). O curso foi bem avaliado pelos estudantes e especialistas, com reações positivas quanto ao conteúdo, objetividade, clareza, didática, organização, acesso e navegação. Conclusão: Confirmou-se a plausibilidade da hipótese do estudo, corroborando a contribuição do curso online no aprendizado sobre SBV. Mostrando-se efetivo no suporte ao ensino em Enfermagem, o curso online permite integrar apresentações em diferentes disciplinas e capacitações, frente a necessidade de inovações tecnológicas e estratégias educacionais ativas, em ações para identificação precoce da parada cardiorrespiratória e sistematização do atendimento na reanimação cardiopulmonar. / Introduction: In the world scene, cardiovascular diseases constitute the main cause of cardiac arrest in adults, whose chances of survival are higher if witnessed by persons able to provide the basic life support (BLS) in immediate resuscitation. Objective: To develop and to evaluate the online course \"Basic Life Support: essential aspects in adult cardiac arrest. Method: In the first stage it refers to the applied research of production technology on the development of online course on BLS, with the instructional design ADDIE (Analisys, Design, Development, Implementation, Evaluation). In the second stage, in quasi-experimental, before and after design, the online course was applied to students of Escola de Enfermagem, Universidade de São Paulo, as an educational intervention in 2014-2015. Pre-test, post-test and simulation with feedback devices were applied. The online course was evaluated by specialists and students. Results: The course was implemented in the virtual environment and 94 (100%) students who agreed to participate of the research, 88 (94%) accessed the virtual environment, 67 (71%) completed the theoretical part and 62 (66%) completed the online course. The majority were women (90.4%), in the 1st and 2nd year (65%), mean age 21.48 (SD 2.39). With 95% significance level, the mean grade in the pre-test 6.4 (SD 1.61), in the post-test 9.3 (SD 0.82), p <0.001. ANOVA for repeated measures showed significant differences (p <0.001) between the average scores in the pre-tests of students in the 1st and 2nd years 6.2 (SD 1.59) and the 3rd and 4th years 7.2 (SD 0, 83). The averages note in the post-test 9.2 (SD 1.60) in the first two years and 9.7 (SD 0.61) in the last two years, p<0,475. In multiple linear regression with progressive inclusion (stepwise forward) for variables associated with learning, it was significant (p <0.015) for year course -0.542 (SE 0.215), previous participation in emergency course -0.903 (SE 0.437). In simulated practice the mean score was 9.1 (SD 0.95). The checklist records showed 98% students performed exposure of the chest, 97% observed the breathing, 76% remembered to call emergency services, 92% requested defibrillator, 77% checked the pulse correctly, 87% positioned their hands properly, 95% effected 30 compressions cycle properly, 89% in minimum depth 5 cm, 90% released after chest compression, 97% correctly applied 2 breaths, 97% used External Automatic Defibrillator, 100% positioned blades correctly. Feedback device records indicated equivalent percentage of performance Basic CPR 43.7 (SD 26.86), the averages of duration compressions cycle / second 20.5 (SD 9.47), compressions number 167.2 (SD 57.06) depth compressions/mm 48.1 (SD 10.49), ventilation volume 742.7 (SD 301.12), percentage flow fraction 40.3 (SD 10.03). The course was evaluated as good quality by participants, with positive reactions about the content, objectivity, clarity, teaching, organization, access and navigation. Conclusion: The plausibility of the hypothesis of this study was confirmed, corroborating the online courses contribution in the BLS learning. In support teaching in Nursing, it lets to compose presentations in different disciplines and training, arising from the need for technological innovations and active educational strategies in action for early identification of cardiac arrest and systematization of care in cardiopulmonary resuscitation.

O objetivo deste estudo foi desenvolver o conceito de morte digna da criança na Unidade de Terapia Intensiva pediátrica. O Modelo Híbrido de Desenvolvimento de Conceitos foi aplicado em suas três fases: Teórica, de Campo e Analítica Final. Na Fase Teórica, foram analisados 49 artigos nas áreas Médica e de Enfermagem que estudaram e focalizaram a morte digna da criança. A Fase de Campo foi conduzida através de entrevistas semi-estruturadas com nove enfermeiras e sete médicos que atuavam em UTI pediátrica. Os dados da Fase de Campo foram analisados utilizando-se os resultados da Fase Teórica como eixo teórico e a Análise de Conteúdo como referencial metodológico. Na Fase Analítica Final, os resultados da Fase Teórica e de Campo foram comparados, analisados e integrados. Os dados evidenciam que a MORTE DIGNA na UTI pediátrica é ter um tratamento clínico de excelência no final de vida, com honra aos benefícios da evolução natural da doença, respeito aos aspectos socioculturais, conforto físico e bem-estar. A morte digna ocorre em um contexto de veracidade e parceria entre a equipe e a família, no qual é possível expressar expectativas e receios. O resultado da morte digna é o alívio do sofrimento tanto da criança quanto da família. Os dados da Fase Teórica apontam os antecedentes, atributos e conseqüências da morte digna como situações protocolares, porém, na Fase de Campo foi possível identificar o componente experiencial que está por trás das condutas dos profissionais diante da criança em final de vida. Assim, pôde-se compreender como se dá a manifestação do conceito na prática clínica, possibilitando a ampliação dos dados identificados na Fase Teórica. Clarificar o conceito de morte digna na UTI pediátrica permite fortalecer teorias sobre os cuidados no final de vida à criança e à família, bem como possibilita aos profissionais que atuam na prática clínica refletirem sobre as motivações que pautam atitudes e decisões diante da criança fora de possibilidade de cura / The purpose of this research was to develop the concept of dignified death for children in the Pediatric Intensive Care Unit. The Hybrid Model of Concept Development was applied in its three phases: Theoretical, Fieldwork and Final Analytical. In the Theoretical Phase 49 papers in the Medical and Nursing fields were analyzed, which studied and focused on the dignified death for children. The Fieldwork was conducted through semi-structured interviews with nine doctors and seven registered nurses who worked in pediatric ICUs. The data from the Fieldwork Phase was analyzed having the results of Theoretical Phase as the theoretical axis and the Content Analysis as the methodology. In the Final Analytical Phase, the results from the Theoretical and Fieldwork Phases and were compared, analyzed and integrated. The data show that the DIGNIFIED DEATH for children in the pediatric ICU means having a clinical treatment of excellence at the end-of-life, honoring the benefits of the natural evolution of the disease, respecting the socio-cultural aspects, physical comfort and welfare. A dignified death occurs in a context of veracity and partnership between the team and the family, in which it is possible to express hopes and fears. The result of the dignified death is the relief of suffering from both the child and the family. Data from the Theoretical Phase suggests that the antecedents, attributes and consequences of dignified death as being protocol situations, however, in the Fieldwork it was possible to identify the component of the experience behind the conduct of the professionals when dealing with children at end-of-life. Thus, it was possible to understand how the manifestation of the concept occurs in clinical practice, allowing the expansion of the data identified in the Theoretical Phase. Clarifying the concept of dignified death in the pediatric ICU can strengthen theories about end-of-life care to children and families and makes it possible to professionals who work in clinical practice to reflect on the motivations that guide their attitudes and decisions when dealing with a child in life-sustaining condition

"The National Aeronautics and Space Administration (NASA) plans to send a human exploration team to Mars within the next 25 years. In support of this effort Hamilton Standard Space Systems International (HSSSI), current manufacturers of the Space Shuttle spacesuit, began exploring alternative solutions for supporting an astronaut during a Martian surface exploration. A design concept was developed by HSSSI to integrate a minimally equipped Martian spacesuit with a robotic support cart capable of providing life support assistance, communications, and independent navigational functions. To promote NASA's visionary efforts and increase university relations, HSSSI partnered with Worcester Polytechnic Institute (WPI) to develop a proof-of-concept robotic support cart system, FIDOE - Fully Independent Delivery of Expendables. As a proof-of-concept system, the primary goal of this project was to demonstrate the feasibility of current technologies utilized by FIDOE's communication and controls system for future Martian surface explorations. The primary objective of this project was to procure selected commercial-off-the-shelf components and configure these components into a functional robotic support cart. The design constraints for this project, in addition to the constraints imposed by the Martian environment and HSSSI's Martian spacesuit, were a one-year time frame and a $20,000 budget for component procurement. This project was also constrained by the protocols defined by the NASA demonstration test environment. The final design configuration comprised of 37 major commercial off-the-shelf components and three individual software packages that integrated together to provide FIDOE's communications and control capabilities. Power distribution was internally handled through a combination of a main power source and dedicated power supplies. FIDOE also provided a stowage area for handling assisted life support systems and geological equipment. The proof-of-concept FIDOE system proved that the current technologies represented by the selected components are feasible applications for a Mars effort. Specifically, the FIDOE system demonstrated that the chosen technologies can be integrated to perform assisted life support and independent functions. While some technologies represented by the proof-of-concept system may not adequately address the robustness issues pertaining to the Mars effort, e.g., voice recognition and power management, technology trends indicate that these forms of technology will soon become viable solutions to assisting an astronaut on a Martian surface exploration."

Este estudo teve como objetivos: compreender como se dá o processo de o enfermeiro exercer sua autonomia nas decisões de final de vida vivenciadas em UTI adulto; identificar os significados que ele atribui à experiência de tomar decisões e de exercer sua autonomia nas situações de final de vida dos pacientes internados na UTI adulto; construir uma teoria substantiva sobre a compreensão de exercer a sua autonomia nas tomadas de decisão em situações de final de vida dos pacientes na UTI adulto. Utilizou-se como referencial teórico o Interacionismo Simbólico e como referencial metodológico a Teoria Fundamentada em Dados. A análise comparativa dos dados possibilitou desvendar o significado de exercer autonomia do enfermeiro com pacientes em final de vida internados na UTI adulto. Foi possível serem identificados três fenômenos que compõem esta experiência. O primeiro,Trabalhando num ambiente de pressão, representa a etapa inicial da experiência do enfermeiro, agrega não somente o contexto que permeia o seu trabalho na UTI, mas também os aspectos clínicos do paciente, as interações com os outros profissionais e com a família nas tomadas de decisão de final de vida. O segundo,Buscando empoderar-se para poder decidir, mostra o movimento, no qual o enfermeiro cria estratégias para ampliar as oportunidades a fim de poder exercer autonomia. O terceiro,Revendo os espaços para exercer autonomia, reconsidera outros espaços onde possa atuar no processo de final de vida, em relação ao planejamento do cuidado ao paciente, no acolhimento das famílias nas tomadas de decisão ou, ainda, na interface com os membros da equipe e a instituição. A articulação destes fenômenos permitiu identificar a categoria central AMPLIANDO AS OPORTUNIDADES PARA EXERCER A AUTONOMIA, que representa o processo vivido pelo enfermeiro na busca de espaços de poder de decisão e de ação ao assumir seu papel nos cuidados no processo de final de vida. / The purpose of this study is to: understand the process of autonomy exercised by nurses when making decisions related to end-of-life situations they in the adult ICU; to identify the meanings that nurses attribute to the experience of making decisions and of exercising their autonomy in end-of-life situations of adult patients in ICU; to construct a theoretical model about the process of understanding the exercise of their autonomy in decision-making relating to end-of-life situations of adult patients in the ICU. The study used as a theoretical reference the Symbolic Interactionism, and as methodological reference, the Grounded theory. The comparative analysis of the data has permitted the understanding of the meaning of nurses experience in exercising autonomy relating to life-ending adult patients in the ICU. Three phenomena that compose this experience have been identified: The first, \"Working in an environment of pressure,\" represents the initial phase of nurses experience, adding not only the features that exist within the ICU where the work is done, but also the clinical aspects of patients interaction with other professionals and family in end of life decision-making. The second, \"Seeking to gain power in order to be allowed to make decisions,\" shows the movement in which nurses create strategies for expanding opportunities in order to exercise autonomy. The third phenomena, \"Reviewing the spaces to exercise autonomy,\" reconsiders other spaces where nurses can act in end-of-life situations regarding planning of patient care, supporting families on their decision making and interface with health team members and the institution. The articulation of these phenomena has permitted the identification of the central category EXPANDING-THE-OPPORTUNITIES-FOR-EXERCISE AUTONOMY, based on which it has been possible to propose a theoretical model that explains the experience. It represents the process experienced by nurses in seeking spaces of power regarding decision making and action to assume the care role in end-of-life process.

No description available.

Thesis (Master of Civil Engineering) University of California, Berkeley, December 1996. / "December 1996." Includes bibliographical references (l. 76-79). Also available online.

Thesis (Ph.D. in Nursing) -- University of Colorado at Denver and Health Sciences Center, 2005. / Typescript. Includes bibliographical references (leaves 139-146). Free to UCDHSC affiliates. Online version available via ProQuest Digital Dissertations;

Introduction : L’hypothermie accidentelle est associée à un taux important de morbidité et de mortalité, notamment en cas d’hypothermie accidentelle sévère où le risque d’arrêt cardiaque est très élevé. L’Extracorporeal Life Support (ECLS) est le traitement de référence dans le cas d’hypothermie avec arrêt cardiaque ou instabilité hémodynamique réfractaire. Il n’existe pas de recommandations concernant les modalités optimales de réchauffement.L’objectif de ce travail était de développer un modèle expérimental porcin d’arrêt cardiaque en hypothermie profonde afin d’étudier la réponse physiopathologique cardiaque et pulmonaire pendant le refroidissement et le réchauffement par ECLS. Nous avons également évalué l’impact de différentes stratégies de réchauffement (en terme de débit d’ECLS et de delta de température entre l’ECLS et la température centrale) sur les lésions cardiaques et pulmonaires.Méthode : Deux protocoles expérimentaux ont été réalisés. Les animaux ont été canulés pour ECLS, refroidis jusqu’à l’obtention d’un arrêt cardiaque (AC) en hypothermie profonde et soumis à 30 minutes d’ischémie complète. Protocole A (n = 24) : durant la phase de réchauffement, les animaux étaient randomisés en 4 groupes selon un plan factoriel 2x2 comparant un débit normal d’ECLS de 3l/min (groupe NF) à un débit réduit de 1,5 l/min (groupe LF) ainsi qu’un delta de température entre la température centrale et le circuit d’ECLS limité à 5°C, ou une température d’ECLS à 38°C. Protocole B (n = 20) : les animaux ont été randomisés en 2 groupes pendant le réchauffement : un groupe NF et un groupe LF avec un delta de température de 5°C. L’impact de l’ECLS sur le débit cardiaque en fin de réchauffement a été évalué par une technique de thermodilution (site d’injection du catheter positionné dans le ventricule droit) et contrôlé par une technique écho-doppler. Le débit cardiaque, l’hémodynamique et des paramètres de fonction pulmonaire étaient évalués. Des marqueurs biologiques de lésions d’ischémie/reperfusion étaient mesurés.Résultats : Protocole A : Le débit cardiaque final était réduit dans les groupes LF comparé aux groupes NF (1.96±1.4 vs. 3.34±1.7 L/min, p=0.05). L’augmentation de RAGE était plus élevée dans les groupes avec une température d’ECLS à 38°C comparée aux groupes avec delta contrôlé. Protocole B : Durant la phase de refroidissement, le débit cardiaque, la fréquence cardiaque et la pression artérielle ont diminué de façon continue. La pression artérielle pulmonaire avait tendance à augmenter à 32°c comparée à la valeur initiale (20.2±1.7 vs. 29.1±5.6 mmHg, p=0.09). Pendant le réchauffement, la pression artérielle moyenne était plus élevée dans le groupe NF vs. groupe LF à 20°C et 25°C (p=0.003 and 0.05, respectivement). Après réchauffement à 35°C, le débit cardiaque était de 3.9±0.5L/min dans le groupe NF vs. 2.7±0.5 L/min dans le groupe LF (p=0.06). Sous ECLS, le débit cardiaque gauche était inversement proportionnel au débit d’ECLS. En fin de réchauffement, le débit ECLS n’avait pas d’impact significatif sur les résistances pulmonaires.Conclusion : Nos résultats suggèrent que le réchauffement par ECLS des arrêts cardiaques en hypothermie profonde, en utilisant un débit d’ECLS normal avec un delta de température n’excédant pas 5°C par rapport à la température centrale, pourrait être la stratégie la moins délétère au niveau cardiaque et pulmonaire. L’ECLS à débit normal diminuait la dysfonction myocardique en fin de réchauffement et ne majorait pas les résistances vasculaires pulmonaires par rapport au groupe avec un débit d’ECLS réduit. Un delta important entre la température centrale et celle de l’ECLS augmentait le taux du biomarqueur associés aux lésions pulmonaires. Ce modèle expérimental apporte des éléments physiopathologiques dans le choix des modalités de réchauffement des patients victimes d’hypothermie accidentelle profonde et pourrait permettre d’évaluer d’autres stratégies thérapeutiques dans ce contexte. / Introduction: Accidental hypothermia is associated with significant mortality and morbidity, especially when core temperature is under 28°C with an increased risk of cardiac arrest. Extracorporeal life support (ECLS) is the preferred treatment in case of cardiac arrest or hemodynamic instability not responding to medical treatment. There are no current guidelines concerning the optimal rewarming strategy. The aim of this work was to develop a porcine experimental model of deep hypothermic cardiac arrest (DHCA) in order to assess the cardiac and pulmonary pathophysiological response during cooling and rewarming with ECLS. We also aimed to assess the impact of different ECLS blood flow rates on cardiopulmonary lesions.Method: Two experimental protocols were performed. Pigs were cannulated for ECLS, cooled until DHCA occurred and subjected to 30 min of cardiac arrest. Protocol A (n = 24): during the rewarming phase, pigs were randomized into 4 groups with 2X2 factorial design. We compared a low blood flow rate of 1.5 L/min (group LF) vs. a normal flow rate of 3.0 L/min (group NF) and a temperature during ECLS adjusted to 5°C above the central core temperature vs. 38°C maintained throughout the rewarming phase. Protocol B (n = 20): Animals were also randomized in 2 groups during rewarming, a group NF and a group LF with a controlled temperature delta of 5°C. In order to assess the physiological impact of ECLS on cardiac output at the end of rewarming we measured flow in the pulmonary artery using a modified thermodilution technique using the Swan-Ganz catheter (injection site inserted in the right ventricle) controlled also by an echocardiographic measurement. Cardiac output, hemodynamics and pulmonary function parameters were evaluated. Biological markers of ischemia/reperfusion injuries were analyzed.Results: Protocol A : The final cardiac output was reduced in the low flow rate versus the high flow rate groups (1.96±1.4 versus 3.34±1.7 L/min, p=0.05). The increase in the serum RAGE concentration was higher in the 38°C rewarming temperature groups compared to 5°C above adjusted temperature.Protocol B: During the cooling phase, cardiac output, heart rhythm, and blood pressure decreased continuously. Pulmonary artery pressure tended to increase at 32°C compared to initial value (20.2 ± 1.7 vs. 29.1 ± 5.6 mmHg, p=0.09). During rewarming, arterial blood pressure was higher at 20° and 25°C in group NF vs. Group LF (p=0.003 and 0.05, respectively). After rewarming at 35°C, cardiac output was 3.9 ± 0.5 in the group NF vs. 2.7 ± 0.5 L/min in group LF (p=0.06). Under ECLS cardiac output was inversely proportional to ECLS flow rate. ECLS flow rate did not significantly change pulmonary vascular resistance.Conclusion: Our results suggest that ECLS rewarming for DHCA patients, using a normal inflow rate of ECLS and a controlled temperature with less than 5°C between ECLS and core temperature could be the less deleterious rewarming strategy to limit cardiac and pulmonary dysfunction. A normal inflow rate of ECLS decreased cardiac dysfunction after rewarming and did not increased pulmonary vascular resistance compared to a low flow rate. A non controlled temperature delta between core temperature and ECLS increased biomarkers level of lung injury. This experimental model on pigs bring some pathophysiological finding for the rewarming strategy of patients who suffer deep accidental hypothermia and could allow to assess different therapeutic strategy in this context.

abstract: Medical students acquire and enhance their clinical skills using various available techniques and resources. As the health care profession has move towards team-based practice, students and trainees need to practice team-based procedures that involve timely management of clinical tasks and adequate communication with other members of the team. Such team-based procedures include surgical and clinical procedures, some of which are protocol-driven. Cost and time required for individual team-based training sessions, along with other factors, contribute to making the training complex and challenging. A great deal of research has been done on medically-focused collaborative virtual reality (VR)-based training for protocol-driven procedures as a cost-effective as well as time-efficient solution. Most VR-based simulators focus on training of individual personnel. The ones which focus on providing team training provide an interactive simulation for only a few scenarios in a collaborative virtual environment (CVE). These simulators are suited for didactic training for cognitive skills development. The training sessions in the simulators require the physical presence of mentors. The problem with this kind of system is that the mentor must be present at the training location (either physically or virtually) to evaluate the performance of the team (or an individual). Another issue is that there is no efficient methodology that exists to provide feedback to the trainees during the training session itself (formative feedback). Furthermore, they lack the ability to provide training in acquisition or improvement of psychomotor skills for the tasks that require force or touch feedback such as cardiopulmonary resuscitation (CPR). To find a potential solution to overcome some of these concerns, a novel training system was designed and developed that utilizes the integration of sensors into a CVE for time-critical medical procedures. The system allows the participants to simultaneously access the CVE and receive training from geographically diverse locations. The system is also able to provide real-time feedback and is also able to store important data during each training/testing session. Finally, this study also presents a generalizable collaborative team-training system that can be used across various team-based procedures in medical as well as non-medical domains. / Dissertation/Thesis / Ph.D. Biomedical Informatics 2014