Orientador: José Roberto Fioretto / Resumo: A cateterização venosa central é procedimento indispensável para monitorização e tratamento de crianças internadas em unidades de tratamento intensivo. Apesar de disseminada, a utilização de cateteres venosos centrais (CVCs) não é destituída de complicações no momento da inserção e durante sua manutenção. Os objetivos do estudo foram: identificar e quantificar as complicações da cateterização venosa central em crianças internadas em Unidade de Terapia Intensiva Pediátrica (UTIP); identificar os fatores de risco para complicações de inserção e de manutenção e avaliar a necessidade do emprego de medidas de prevenção de complicações e, se necessário, propor modificação das normas e rotinas dos cuidados de enfermagem vigentes. Analisou-se prospectivamente todas as crianças e adolescentes (1 mês a 18 anos de idade) internados na UTIP no período de um ano e que foram submetidos a punção venosa central, no ambiente da unidade. No período, 120 CVCs foram inseridos em 83 crianças. Os residentes (R3) inseriram 84,2% dos CVCs e não houve correlação entre complicações de inserção e manutenção e o profissional que realizou o procedimento.A taxa de sucesso de punção foi alta. A veia mais puncionada foi a jugular interna (79,2%), observando-se que sete tentativas de punção foram mal sucedidas (5,8%). As complicações de inserção mais freqüentes foram mal posicionamento do cateter (14,1%) e punção arterial (10,9%). Mais de três tentativas de punção foi significante para o aparecimento de intercorrências de inserção dos CVCs (p=0,004). Quanto as complicações de manutenção, houve correlação significante para troca do cateter realizada com fio guia (p=0,008), utilização de ventilação mecânica (p=0,025) e tempo de permanência do cateter por mais de sete dias (p=0,001). Sinais flogísticos ocorreram em 68,2% dos locais de inserção... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Central Venous Catheters (CVCs) are considered indispensable in the current medical practice. The aim of this study was to identify and to analyze the complications of the venous catheterization in children admitted in the Pediatric Intensive Care Unit (PICU) - UNESP, and to identify the risk factors for insertion and maintenance of CVCs. Also we aim to evaluate the necessity from prevention measures of complications and if it is necessary to change nursing care routine. During one year we analyzed prospectively 120 CVCs inserted in 83 children aged between 1 month and 18 years. Residents (R3) inserted 84.2% CVCs and no differences were observed between insertion and maintenance complications and the professional responsible for the procedure. Success punction rate was level. Internal jugular vein was the most punctioned vein (79,2%), and only 7 attempts failure (5,8%). Insertion complications more frequent were catheter bad positioned (14,1%) and arterial punction (10,9%). More than three attempts were statistical significant to insertion complication (p=0.004) and CVCs changed with guidewire were significant (p=0.008) to maintenance complications, as well as mechanical ventilation and indwelling time more than 7 days. Local infection was diagnosed in 68,2% and there were two cases of bloodstream-catheter-related infection. Constant observation of the nursing techniques, have showed that 82.3% of the nursing personal did not wash their hands before dressing, verifying association between no washing hands and appearing local infection catheter (p=0,005). Coagulase-negative Staphylococcus was the most common microorganism isolated from the catheters. Results aim the necessity to achieve training and continuing education about nursing care in the maintenance of central venous catheters. Results make clear the necessity to achieve training and continuing education about nursing care in the maintenance of central venous catheters. / Mestre

Bakgrund: Förekomsten av venösa bensår hos den vuxna befolkningen i EU-länderna uppskattas vara mellan 490 000 upp till 1,3 miljoner personer. Den viktigaste behandlingen för att förebygga recidiverande bensår är kompressionsstrumpor. Hos de patienter som inte använder kompressionsstrumpor har risken att få recidiv beräknats vara 100% och hos de som använder strumporna 16%. Patientens livskvalitet påverkas av att det oftast krävs lång vårdtid och behandling av bensåret och att det vanligtvis är ett återkommande problem. Syfte: Att beskriva faktorer som påverkar patientens följsamhet till kompressionsbehandling för att förebygga och behandla venösa bensår. Metod: Studien har genomförts som en litteraturöversikt. Datainsamling har skett genom sökningar i databaserna CINAHL och PubMed. Resultat: Sammanfattningsvis så visar resultatet att det finns flera faktorer som påverkade patientens följsamhet. Patienternas följsamhet minskade till följd av smärtan som orsakades av kompressionsbandaget eller vid såromläggningen. Hos nya oerfarna sjuksköterskor fanns bristande kunskap i hur kompressionsbandaget ska appliceras, hos ett flertal patienter fanns bristande kunskap och förståelse varför kompressionsbehandling var viktigt för att förhindra nya venösa bensår. Appliceringssvårigheter med att ta av och på kompressionsstrumporna, tillit till sjuksköterskan och utseendet på kompressionsstrumporna/bandaget var andra faktorer som påverkade följsamheten. Slutsats: Patientens följsamhet till kompressionsbehandling påverkas av både hämmande och främjande faktorer. Det som sjuksköterskan bland annat kan göra för att påverka patientens följsamhet till kompressionsbehandling är att informera om hur kompressionsbehandling hjälper till med läkningen och egenvårdsråd för att förhindra recidiv. / Background: The incidence of venous leg ulcers in the adult population in the EU countries are estimated to be between 490,000 and 1.3 million. The main treatment for the prevention of recurrent leg ulcers is compression stockings. For those patients who don´t use compression stockings, the recurrence has been calculated to be 100% and for those who used the socks 16%. Patient's quality of life is affected by the fact that it is usually required long care and treatment of the leg and that it is usually a recurring problem. Aim : To describe factors that affect patient compliance with compression therapy to prevent and treat venous leg ulcers. Methods: The study has been carried out as a litterature review. Data collection has been done through searches in the CINAHL and PubMed databases. Results: In summary, the result shows that there are several factors that affected the patient's compliance. Patient compliance decreased as a result of the pain caused by the compression bandage or by the wound dressing. At new inexperienced nurses were lacking in knowledge of how the compression bandage should be applied, in several patients there was a lack of knowledge and understanding why compression treatment was important to prevent new venous leg ulcers. Difficulty in applying and removing the compression socks, trust in the nurse and the appearance of the compression socks / bandage were other factors that affected compliance. Conclusion: The patient's adherence to compression treatment is affected by both inhibitory and promotional factors. What the nurse can do, among other things to influence the patient's adherence to compression therapy is to inform about how compression treatment helps with the healing and self-care advice to prevent recurrence.

Neste estudo, avaliamos e caracterizamos o efeito de Ang II em leito venular mesentérico (LVM) e anéis de veia porta (AVP) de wistar e SHR. A reatividade vascular para Ang II foi estudada na presença e ausência de diferentes antagonistas para elucidar os mecanismos envolvidos na venoconstrição induzida por Ang II. Nossos resultados sugerem que a Ang II induz venoconstrição através da ativação de receptores AT1 e AT2 em Wistar e receptor AT1 em SHR. Essa venoconstrição parece ser contrabalanceada pelo receptor B2 em ambas as espécies. NO contribue para este efeito em wistar e metabólitos da COX em SHR. Há redução da venoconstrição induzida por Ang II em AVP de SHR que pode estar relacionado a redução da expressão protéica de receptores AT2. Esses resultados indicam diferentes mecanismos de regulação do tônus venoso de ratos wistar e SHR em resposta a Ang II que podem ter relevância no controle do retorno venoso e débito cardíaco. / In this study we have evaluated and characterized the effect of Ang II in the isolated perfused mesenteric venular bed (MVB) and portal vein rings (PVR) of SHR and wistar rats. Vascular reactivity to Ang II was studied in the absence and presence of different antagonists to elucidate the mechanisms involved in Ang II-induced venoconstriction. Our results suggest that Ang II induces venoconstriction by activation of AT1 and AT2 receptors in wistar and AT1 receptor in SHR. These venoconstriction seems to be counterbalanced by B2 receptor in both species. NO might contribute to this effect in wistar and COX metabolites in SHR. There is a decrease in Ang II induced venoconstriction in PVR of SHR that might be related to the decrease of protein expression of AT2 receptor. These results indicate different mechanisms of regulation of venous tonus of the SHR and wistar rats induced by Ang II that can be relevant in the control of the venous return and cardiac output.

Orientador: Marcone Lima Sobreira / Resumo: As úlceras venosas ativas afetam 0.2-1% da população total e geralmente têm um curso prolongado de cura e recidivas frequentes. Devido a sua natureza recorrente e ao longo tempo entre a abertura e a cura, as úlceras venosas apresentam um grande impacto econômico e social com uma influência negativa na qualidade de vida do paciente. Além disso, sabe-se que ansiedade e depressão são recorrentes em pacientes com úlcera venosa. Objetivo: comparar a qualidade de vida e os sintomas ansiosos e depressivos antes e após diferentes tipos de tratamentos minimamente invasivos para a úlcera venosa. Método: Ensaio clínico randomizado que teve como intervenções a terapia endovenosa a laser, a ablação endovascular por radiofrequência e a escleroterapia com microespuma em comparação ao grupo controle. A amostra foi composta por 124 indivíduos. Os instrumentos utilizados para avaliação da qualidade de vida e dos aspectos psicológicos foram o Venous Leg Ulcer Quality of Life Questionnaire (VLU-QoL) e a Escala de Ansiedade e Depressão (HADS). A interação técnicas versus momentos foi feita através da Análise de variância, seguida do teste de Tukey ajustado para o delineamento em medidas repetidas. A associação entre momentos e categorias dos escores da HADS foi avaliada pelo teste Qui-quadrado de tendência. Para as correlações foi usado o teste de Pearson. Resultados: Todas as técnicas refletiram melhora da qualidade de vida ao longo do tempo de avaliação, porém a ablação endovascular por radiofr... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Active venous ulcers affect 0.2-1% of total population and usually have extended curing period and frequent recurrences. Due to their recurrent nature and to the long period between their ocurrence and cure, venous ulcers have significant economic and social impact, with negative influence on the patient’s quality of life. Moreover, it is known that anxiety and depression are recurrent in patients with venous ulcer. Objective: To compare quality of life and symptoms of anxiety and depression before and after different types of minimally invasive treatments for venous ulcer. Method: Randomized clinical trial with interventions: endovenous laser therapy, endovascular radiofrequency ablation and microfoam sclerotherapy comparing to control group. Sampling comprised 124 individuals. The instruments used for assessment of life quality and of psychological aspects were the Venous Leg Ulcer Quality of Life Questionnaire (VLU-QoL) and the Hospital Anxiety and Depression Scale (HADS). The interaction Techniques versus Moments was done by analysis of variance, followed by Tukey test adjusted for delineation in repeated measures. Association between moments and HADS score categories was assessed by chi-square test for trend. Person test was used for correlations. Results: All techniques reflected better quality of life along assessment period, however radiofrequency ablation had greater impact over quality of life. Elastic compression (control group) was the technique with less impact, ... (Complete abstract click electronic access below) / Mestre

Central-line-associated bloodstream infections (CLABSIs) occur during the insertion or change of the dressing of the central venous catheter (CVC) and are reportable healthcare-associated infections at the state and the national level. The purpose of this systematic review of the literature was to evaluate and synthesize available evidence to establish the effectiveness of using an adhesive transparent chlorohexidine gluconate (CHG) Tegaderm™ gel dressing for CVC in the prevention of CLABSIs. The logic model was used as a framework to guide the review of the literature to establish how an intervention that is not currently practiced can contribute to CVC prevention of infection. The practice question focused on gathering evidence to support the effects of CHG Tegaderm™ gel central-line dressing compared with the Biopatch® dressing. A total of 373 articles were retrieved and 16 met the inclusion for review and were graded according to the Melnyk and Fineout-Overholt hierarchy level of evidence and evidence synthesis broken down into the reduction of CLABSI, the cost-effectiveness and ease of use of the CHG Tegaderm™ gel. Findings from the systematic review supported the use of CHG gel dressing as a CLABSI preventative measure. The findings from the project support positive social change by reducing CLABSI and associated illnesses and saving the increased cost, mortality, and morbidity associated with CLABSIs.

Chronic kidney disease (CKD) affects more than 30 million adults in the U.S. and is strongly associated with cardiovascular events and mortality. Venous thromboembolism (VTE) is the third leading vascular disease, affects up to 900,000 Americans each year and contributes to as many as 100,000 deaths annually. The relationship of CKD and VTE has been described in patients receiving dialysis, kidney transplants recipients and in nephrotic syndrome, however, data supporting the association of VTE in mild to moderate CKD is conflicted. The overall goal of this research was to study the association of CKD and VTE and to understand the mechanisms of this association. To accomplish this goal we studied participants of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study, a nationally representative cohort of 30,239 blacks and whites in the U.S.. The first chapter provides a review of the state-of-the science on CKD and VTE and potential mechanisms for this association. We focus on factor VIII as a potential mediator of VTE risk in CKD by reviewing the biochemistry and epidemiology linking factor VIII and CKD. In Chapter 2, we use a cohort study design and a competing risk analysis to determine the risk of VTE with albuminuria (ACR) and with various equations for estimated glomerular filtration rate (eGFR). There was no association of ACR and VTE and the risk of VTE was similar among eGFR equations. Compared to a normal eGFR (>90 ml/min/1.73m2), eGFR < 45 ml/min/1.73m2 was associated with a two-fold risk of VTE. The association of eGFR and unprovoked VTE was similar to the association with provoked VTE. The population attributable fraction of CKD (eGFR<60 ml/min/1.73m2) was modest at 5%. In Chapter 3, we utilize a case-cohort study to determine if biomarkers of inflammation (C-reactive protein) and procoagulation (Factor VIII and D-dimer) attenuate the risk of VTE in CKD. These biomarkers were higher in lower kidney function and were also strongly associated with VTE. Adjustment for factor VIII fully attenuated the risk of VTE in CKD, thus factor VIII is a potential mediator of the association of CKD and VTE. We assessed whether lifestyle factors and medications mitigate the risk of VTE in those with and without CKD. Exercise frequency and use of statins were associated with reduced risk of VTE in the presence and absence of CKD, but normal BMI was associated with reduced VTE risk only in those without CKD. We conclude that CKD is a risk factor for VTE, and findings shed light on the mechanisms of this association. Interventions that might lower VTE risk in CKD patients include exercise and statin therapy, but not weight loss. Factor VIII is a potential mediator of VTE in CKD and deserves further study. We suggest several avenues for future research to explore the relationship of Factor VIII and CKD.

This study addressed an increasing number of peripheral intravenous catheter infiltrations within hospitals, leading to problems such as phlebitis and cellulitis, which may result in a longer length of hospital stay. The purpose of this project was to determine how to reduce infiltrations in order to increase the longevity of the catheter. A quantitative, description design was used, guided by Abdellah's classification framework for identifying nursing problems. The target population was 50 patients experiencing incidents of peripheral intravenous catheter infiltration, identified in a patient safety event log used across a 252-bed hospital. Each incident was assessed for several risk factors, such as age, diagnosis, length of time of catheter use, co-morbidities, size of catheter used for insertion, and how many medications were being administrated intravenously. Using descriptive statistics, the combination of patient co-morbidities had a direct correlation with increased probability of infiltration before 96 hours. Among 82% of patients, co-morbidities included hypertension in 56% of subjects, advancing age, and placement of the catheter in the upper arm. Data play a significant role in decisions to change clinical practice and protocols. Findings from this study related to peripheral intravenous catheter insertions, and their maintenance can drive changes across a healthcare organization.

Central line-associated bloodstream infection (CLABSI) at the local healthcare setting exceeded the benchmark of 0 CLABSI. The Infection Prevention and Control (IPC) department determined that a role as CLABSI nurse champion would address the problem; however, no comprehensive education on CLABSI prevention and maintenance was available at the site. The purpose of this project was to develop a CLABSI prevention and maintenance education module using Knowles's adult learning theory and the chain of infection model. The practice-focused question asked whether a CLABSI educational module would provide the necessary information to educate nurse champions on CLABSI prevention and maintenance. The education module was presented to 9 local experts, composed of the Infection Prevention and Control (IPC) director, doctor of medicine, microbiologist, biomedical technologists, IPC nurses, and 2 staff nurses, who evaluated the CLABSI education module. An 11-question Likert-scale questionnaire that included an option for recommendations for improvement was used by the expert panel to evaluate the module. Of the 11 questions, only 3 were scored as strongly agree or agree, indicating a need to modify the module to raise the education level of the content and to include the clinical standards, objectives, and dressing-change procedures. After modifications, the education module was scored again, and 100% met the criteria and the recommendations of the expert panel. The project has the potential to promote positive social change by increasing the knowledge of the CLABSI nurse champions and by reducing the risk of CLABSI at the site.

<p>Treatment for varicose veins (VV) is insufficiently evidence based and recurrence rates are high. The aim of this thesis was to study the long-term results after VV surgery, risk factors for recurrences and the effect of preoperative duplex scanning on recurrence rate, quality of life (QoL) and costs.</p><p>In a follow-up study 89 patients with 100 legs operated on for VV 6–10 years earlier were re-examined with duplex, in 13 cases also with varicography. 57% had incompetent vessels in the groin visible with duplex, equally well defined by varicography. Residual branches could not be differentiated from new vessel formation. The recurrence rate did not correlate to the surgeon’s level of experience or perioperative difficulties at primary surgery. </p><p>In a prospective randomized study 293 patients (343 legs) were operated on for primary VV with or without preoperative duplex. Duplex was done postoperatively, at 2 months and 2 years. QoL was measured with SF-36 preoperatively, at 1 month, 1 year and 2 years. </p><p>After 2 years the number of reoperations were 2 in the group with preoperative duplex and 14 in the group without (p=0.002). Incompetent veins were seen in the saphenofemoral or saphenopopliteal junction in 19 and 53 legs respectively (p<0.001).</p><p>Preoperative QoL was worse in the VV patients compared to a reference population, and was normalised 2 years postoperatively. The improved surgical result in the duplex group was not reflected in a significantly higher QoL. </p><p>The lower costs for redo surgery in the duplex group did not offset the costs for duplex, partly due to more extensive primary surgery. </p><p>A significant proportion of recurrences after 2 years was new vessel formation and progression of disease. Preoperative perforating vein incompetence did not influence recurrence rate, and was abolished without specific interruption in 60% at 2 years postoperatively.</p>

Treatment for varicose veins (VV) is insufficiently evidence based and recurrence rates are high. The aim of this thesis was to study the long-term results after VV surgery, risk factors for recurrences and the effect of preoperative duplex scanning on recurrence rate, quality of life (QoL) and costs. In a follow-up study 89 patients with 100 legs operated on for VV 6–10 years earlier were re-examined with duplex, in 13 cases also with varicography. 57% had incompetent vessels in the groin visible with duplex, equally well defined by varicography. Residual branches could not be differentiated from new vessel formation. The recurrence rate did not correlate to the surgeon’s level of experience or perioperative difficulties at primary surgery. In a prospective randomized study 293 patients (343 legs) were operated on for primary VV with or without preoperative duplex. Duplex was done postoperatively, at 2 months and 2 years. QoL was measured with SF-36 preoperatively, at 1 month, 1 year and 2 years. After 2 years the number of reoperations were 2 in the group with preoperative duplex and 14 in the group without (p=0.002). Incompetent veins were seen in the saphenofemoral or saphenopopliteal junction in 19 and 53 legs respectively (p&lt;0.001). Preoperative QoL was worse in the VV patients compared to a reference population, and was normalised 2 years postoperatively. The improved surgical result in the duplex group was not reflected in a significantly higher QoL. The lower costs for redo surgery in the duplex group did not offset the costs for duplex, partly due to more extensive primary surgery. A significant proportion of recurrences after 2 years was new vessel formation and progression of disease. Preoperative perforating vein incompetence did not influence recurrence rate, and was abolished without specific interruption in 60% at 2 years postoperatively.