A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / The role of enzyme‐assisted subcutaneous fluid administration (EASFA) in treating mild to moderate dehydration in pediatrics, geriatrics, and palliative care has been studied in developed countries. However, it has historically been underutilized due to widely available health care and alternative treatments, namely peripheral intravenous (IV) fluid administration. Fluid infusions in the subcutaneous tissue have a low risk of infection, are easy to administer, and have wide potential use. The use of EASFA in low resource settings to treat those with difficult IV access or where skilled healthcare workers are not as readily available could prove to be a live saving measure in many situations, including the care of patients in remote areas of the world, mass casualty events, or other disasters. Our objective was to determine if EASFA is a valid and appropriate technique to utilize in pediatric and elderly patients, and evaluate if it could be a safe and efficient way to provide fluid resuscitation in low resource settings. For this systematic review MEDLINE and Cochrane Library were searched from January 1950 to December 2015 to recover all available literature relevant to this topic. Studies that met the inclusion criteria were analyzed using Cohen’s D. This was calculated using the mean difference between intervention and control divided by the pooled standard deviation. For dichotomous outcome of the placement success rate the odds ratios were calculated with 95% confidence intervals. In reviewing 7 articles using Cohen’s D to compare mean differences to determine effect size, we found that catheter placement success rates and infusion rates were similar between EASFA and peripheral intravenous fluid administration. Additionally, it was found that the odds of correct initial needle placement was 7.19 times higher in EASFA versus intravenous administration. EASFA is a comparable alternative to intravenous fluid administration when delivering fluids to pediatric and elderly patients with mild to moderate dehydration. While infusion rates and total volume of fluids administered were similar, the high rate of success with placement of the subcutaneous catheter proves it to be more useful in some situations. Venous cannulation is difficult, even for a trained healthcare provider, and the ease of placement of subcutaneous catheters makes training lay people to administer subcutaneous fluids a possibility. Additionally, this type of fluid administration may lead to less psychological trauma to a child from multiple needle sticks, while still achieving a similar outcome of effective volume replacement. Based on the results of this study, further research is needed to evaluate the effectiveness of utilizing EASFA in low resource settings.

Bakgrund Sjukvårdspersonal får dagligen handskas med etiska överväganden och beslut. Ställningstagandet om när livsuppehållande behandling ska fortsätta eller avslutas är ett komplext beslut som kräver flera överväganden. Läkaren har det fulla ansvaret vid ställningstagandet om att avsluta livsuppehållande behandling. Sjuksköterskan besitter ofta viktig kunskap och kännedom om patientens behov, vilket kan bidra till beslutsprocessen med betydelsefull information. Syfte Syftet med litteraturstudien var att belysa sjuksköterskans upplevelse av delaktighet och kommunikation gällande det etiska ställningstagandet om att avsluta eller avstå från patientens livsuppehållande behandling. Metod Beskrivande litteraturöversikt av tio kvalitativa vetenskapliga artiklar. Resultat Analysen resulterade i två teman; delaktighet och kunskapsbrist. Resultatet visade att sjuksköterskor ansåg sitt deltagande i ställningstagandet om att bibehålla eller avsluta livsuppehållande behandling som bristande. Sjuksköterskan upplevde att samarbetet med läkaren i beslutsprocessen inte fungerade och kände ofta en frustration över att inte bli tillräckligt lyssnad på. Ytterligare hinder för sjuksköterskans delaktighet i beslutsprocessen framkom av sjuksköterskors kunskapsbrist gällande lagar, riktlinjer och etik samt bristande arbetserfarenhet och självförtroende.  Slutsats Sjuksköterskans delaktighet i vårdteamet kring ställningstagandet om att bibehålla eller avsluta livsuppehållande behandling är bristfälligt. Ytterligare belyser studien sjuksköterskans behov av ökad kunskap inom lagar, riktlinjer och etik. / Background Healthcare professionals deal with ethical considerations and standpoints on a daily basis. Decision-making about when life-sustaining treatment should be continued or terminated is a complex position that requires several considerations. The doctor has the full responsibility regarding the standpoint to discontinue life sustaining treatment. The nurse often possesses important knowledge and understandings of the patient´s needs, which can provide important information in the decision making. Aim The aim of the study was to illustrate nurse´s experience of participation and communication regarding the ethical decision-making to terminate or refrain from patients life-sustaining treatment. Method Descriptive litterature review of ten qualitative research articles. Results The study resulted in two themes; participation and lack of knowledge. The results show that nurses considered their participation in the stance of maintaining or sustaining treatment as inadequate. The nurses felt that the cooperation with the physician in the decision-making did not work and felt a frustration related to not being listened to. Additional barriers to nurse’s participation in the decision-making appeared by nurse’s lack of knowledge regarding laws, guidelines and nursing ethics, as well as lack of work experience and confidence. Conclusion The nurse’s participation in the caring team about the stance of maintaining or sustaining life support care is inadequate. The study also highlight the nurses need for increased knowledge of laws, guidelines and ethics. / <p>Röda Korsets sjuksköterskeförening stipendium 2017</p>

Résumé : Les réanimateurs ont recours à des interventions à la fois médicales et chirurgicales en contexte de choc traumatique. Le rôle des vasopresseurs dans cette prise en charge est controversé. Alors que les lignes directrices américaines considèrent que les vasopresseurs sont contre-indiqués, certains experts européens en encouragent l’utilisation pour diminuer le recours aux liquides intraveineux. Avant d’élaborer un essai clinique, il importe de comprendre la pratique actuelle à laquelle se comparera une intervention expérimentale, ainsi que de connaître le niveau d’incertitude dans la littérature entourant la question de recherche. Le Chapitre 2 de ce travail présente une étude observationnelle effectuée dans un centre régional de traumatologie québécois. Cette étude documente les pratiques de réanimation adoptées par les équipes de traumatologie en 2013, particulièrement le recours aux liquides intraveineux et aux vasopresseurs. Les résultats démontrent que les vasopresseurs ont été utilisés chez plus de 40% des patients, particulièrement les victimes de traumatismes crâniens (RC 10.2, IC 95% 2.7-38.5). De plus, les vasopresseurs ont été administrés dans les phases précoces de la réanimation, soit avant l’administration d’un volume important de liquides. Le Chapitre 3 présente une revue systématique portant sur l’utilisation précoce de vasopresseurs en traumatologie. Les bases de données MEDLINE, EMBASE, CENTRAL et ClinicalTrials.gov ont été interrogées, ainsi que les abrégés présentés dans les conférences majeures en traumatologie depuis 2005. La sélection des études et l’extraction des données ont été effectuées en duplicata. Aucune donnée interprétable n’a pu être extraite des études observationnelles et le seul essai clinique identifié n’avait pas une puissance suffisante (RR de mortalité avec vasopresseurs 1.24, IC 95 % 0.64-2.43). Cette synthèse met en lumière l’incertitude scientifique sur le rôle des vasopresseurs en traumatologie. Les vasopresseurs ont des bénéfices potentiels importants, puisqu’ils permettent entre autres de supporter étroitement l’hémodynamie des patients. En revanche, ils présentent aussi un fort potentiel de dangerosité. Ils sont utilisés fréquemment, malgré l’absence de données sur leurs risques et bénéfices. Ces trouvailles établissent clairement la pertinence clinique et le bien-fondé éthique d’un essai clinique sur le rôle des vasopresseurs dans la prise en charge précoce des victimes de traumatismes. / Abstract : Trauma teams often make use of both medical and surgical interventions in the early management of traumatic shock. Vasopressors have an important clinical potential, namely because they allow fluid restriction and narrow hemodynamic support. However, they also have the potential for significant harm. The role of vasopressors in this early phase of care is controversial. Although North American guidelines consider that vasopressors are contraindicated in this clinical setting, some European experts encourage their use in the hopes of reducing intravenous fluid administration and its inherent risks. Before designing an adequate clinical trial on vasopressor use, a number of vital questions must be answered. First, current accepted practice must be described in order to determine how it will compare with an eventual experimental intervention. Second, relevant knowledge gaps in the scientific literature must be identified in order to establish equipoise and refine the research question. Chapter 2 of this document presents an observational study conducted in a regional trauma centre in the province of Québec. This retrospective study documents current practice patterns adopted by trauma teams over the course of 2013, with particular emphasis on vasopressor and intravenous fluid use. Over this timeframe, more than 40 % of patients received vasopressors, most often in the presence of traumatic brain injury (OR 10.2, 95% CI 2.7-38.5). Moreover, these vasopressors were often administered in the very early phases of trauma care, before any significant intravenous fluid loading. Chapter 3 consists of a systematic review on the early use of vasopressors in the management of traumatic shock. MEDLINE, EMBASE, CENTRAL and ClinicalTrials.gov were searched, as well as conference proceedings from major trauma meetings since 2005. Independent reviewers completed study selection and data extraction in duplicate. Observational studies yielded no interpretable data, and the only clinical trial addressing the research question had insufficient power to inform clinical practice (RR of death with vasopressor use 1.24, 95% CI 0.64-2.43). This knowledge synthesis highlights the uncertainty surrounding the role of vasopressors in trauma. Trauma teams routinely make use of vasopressors despite the absence of data on their risks and benefits. These findings clearly establish both the clinical impetus and ethical justification for a clinical trial focusing on the early use of vasopressors in the management of traumatic shock.

Most in-hospital deaths secondary to infections in under-five deaths within sub-Saharan Africa (SSA) occur in the initial 24 hours of admission and shock has been identified as a major risk factor for the early deaths. However, controversies exist on the appropriate clinical diagnosis of shock, choice of ideal fluid for resuscitation (crystalloid or colloid), and safety of fluid resuscitation in severe malnutrition or severe malaria. This thesis investigates these aspects and also reviews the evidence base of current paediatric fluid resuscitation guidelines for children (aged >60 days and ≤12 years) with severe febrile illnesses. Capillary refill time >2 seconds, weak pulse volume, or bradycardia, in the presence of abnormal temperature and severe disease are predictive of impaired perfusion (defined by lactic acidosis) and death. Tachycardia and temperature gradient are neither associated with increased risk of death nor predictive of hypoperfusion. Existing international definitions of shock have low sensitivities (FEAST=44%, WHO=2%, and ACCM=59%) and high specificities (FEAST=82%, WHO=100%, and ACCM=66%) for diagnosis of impaired perfusion. Clinical criteria derived (called derived shock) had a sensitivity of 30% and specificity of 93%. Shock in children with severe febrile illnesses in Kilifi has a complex presentation but mainly presents with hyperdynamic circulation (high cardiac index) and vasodilatation. Cases with low cardiac index (myocardial dysfunction) are relatively rare but increase the risk of mortality when present. Synthetic colloids (gelofusine, hydroxyethyl starch 130/0.4 (HES), and dextran 70) are safe for use in fluid resuscitation in children with severe malaria. However, HES is the most promising compared to other synthetic colloids concerns still remain about its renal safety. However, further evaluation of synthetic colloids for treatment of shock is not warranted due to the findings of FEAST trial. A Pilot trial shows that bolus isotonic fluids are safe, have better efficacy, and produce faster resolution of shock compared to low-sodium solutions at volumes and rates recommended by WHO in children with severe malnutrition. Evidence available from all ten the trials in children with sepsis show that fluid resuscitation using crystalloids and colloids result in similar survival. However, fluid bolus resuscitation results in increased mortality compared to no bolus (control) in children in SSA. This finding excludes children with gastroenteritis, trauma, burns, and malnutrition. Colloids are better than crystalloids for severe dengue shock but both have similar efficacy in moderate dengue shock.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal.

Objectifs: Les patients hospitalisés aux soins intensifs (SI) sont souvent victimes d’erreurs médicales. La nature interprofessionnelle des équipes de SI les rend vulnérables aux erreurs de communication. L’objectif primaire du projet est d’améliorer la communication dans une équipe interprofessionnelle de soins intensifs par une formation en simulation à haute fidélité. Méthodologie Une étude prospective randomisée contrôlée à double insu a été réalisée. Dix équipes de six professionnels de SI ont complété trois scénarios de simulations de réanimation. Le groupe intervention était débreffé sur des aspects de communication alors que le groupe contrôle était débreffé sur des aspects techniques de réanimation. Trois mois plus tard, les équipes réalisaient une quatrième simulation sans débreffage. Les simulations étaient toutes évaluées pour la qualité, l’efficacité de la communication et le partage des informations critiques par quatre évaluateurs. Résultats Pour l’issue primaire, il n’y a pas eu d’amélioration plus grande de la communication dans le groupe intervention en comparaison avec le groupe contrôle. Une amélioration de 16% de l’efficacité des communications a été notée dans les équipes de soins intensifs indépendamment du groupe étudié. Les infirmiers et les inhalothérapeutes ont amélioré significativement l’efficacité de la communication après trois sessions. L’effet observé ne s’est pas maintenu à trois mois. Conclusion Une formation sur simulateur à haute fidélité couplée à un débreffage peut améliorer à court terme l’efficacité des communications dans une équipe interprofessionnelle de SI. / Objective: Patient hospitalized in intensive care units (ICU) are often victims of medical errors. The interprofessional nature of ICU teams makes them particularly vulnerable to communication errors. The primary objective of this project is to improve interprofessional communication in an ICU team using a high fidelity simulation-based training. Method A prospective, double-blind, randomized controlled trial was conducted. Ten teams of six ICU workers completed three simulated scenarios of resuscitation. The intervention group was debriefed on communication skills, whereas the control group was debriefed on technical resuscitation skills. Three months later, teams completed a fourth simulation without debriefing. All simulation sessions were coded for quality, efficacy of communication and team information-sharing by four blinded observers. Results For our primary end-point, improvement in communication in intervention group wasn’t greater than in control group. A 16% increase in communication effectiveness was noted in ICU teams independently of the studied group. Nurses and respiratory therapists significantly increased their communication effectiveness after three sessions. The effect did not last to three months. Conclusion The combination of high-fidelity simulation training and communication-oriented debriefing can produce short-term gains in communication effectiveness of an interprofessional ICU team.

The work deals with the quality of student's knowledge of the second year master's degree Pedagogical Faculty of Charles University in Prague. These students as future teachers not only have to be experts in their field of study, but also shall be able to provide first aid if necessary. The theoretical part focuses on the integrated rescue system, the legislative definition of first aid, CPR adult and child, coma, shock, hemorrhage and resuscitation using an automatic defibrillator and allergic conditions. The aim of the practical part determine the level of student's knowledge of the second year master's degree Pedagogical Faculty of Charles University in Prague in first aid during an epileptic seizure, adult CPR, bleeding and knowledge of symptoms of hypoglycemia, meaning the recovery position and telephone numbers of the integrated rescue system. Quantitative research tool is a questionnaire survey. Finally, in the practical part there are suggestions that help to improve the quality of teachers and trainers in first aid. These ideas are incorporated in a didactic exit of the practical part, which is folded into a theme for the block education of first aid training of future teachers. KEYWORDS First aid, Integrated Rescue System, resuscitation, unconsciousness, knowledge of students

Providing emergency basic life support in life threatening situations is a duty of everyone. Adequate knowledge of all recommended procedures is a prerequisite for succesful management of a critical situation including identification of an emergency, activation of rescue system and provision of first help. Cardiac arrest is a significant socioeconomic burden. Survival of cardiac arrest victims depends on the underlying disease and lenght of cardiac arrest. Early CPR (cardiopulmonary resuscitation) is a most important factor of potential survival. However, effectivity of CPR for longterm survival reaches only around 10%. Therefore, ongoing education of general population in all techniques of CPR is justified and necessary. Just the initiation of CPRitself increases the chances for survival 2-3 fold. But, unfortunately, this emergency help is not provided always. This work is focused on evaluation of the quality of informations on recommended procedures and activities during acute setting and provision of lay person basic life support. In a theoretical introduction I describe the history of CPR and education of general population. Empirical part provides quantitative research based on a questionnaire with 100 respondents. Respondents are divided into two groups, persons who survived cardiac arrest...

Introduction: The dissertation of "The concept of basal stimulation from the point view of nurses working on Anaesthesiology and Resuscitation facility", discusses the matters of specifics and issues when it comes to providing a basal stimulation process within patient's hospitalization in a resuscitation unit. Patients in very complicated health conditions are hospitalized in a resuscitation unit, very often with symptoms of impaired consciousness. The concept of basal stimulation could very likely help patients' communication with other environment, with accepting and perceiving the actual situation as well as with recovering itself. The point of this dissertation is to chart the real and actual problematics of the basal stimulation used within resuscitation units, and also how nurses working in these units are bringing the concept to bear within their practice. Research methods and results: There are qualitative results posted within the empiric part of the research, as well as interviews with ten general educated nurses working in a resuscitation unit. All the results are collated and analysed in the final discussion after literal transcription of all the interviews. The result of which is, that the general educated nurses see the biggest issue when it comes to providing a basal stimulation...

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