Orientador: Leandro Gobbo Braz / Resumo: Introdução: A incidência de parada cardíaca (PC) pode ser utilizada como um indicador de qualidade para promover melhorias quanto à segurança do paciente no período perioperatório. Até o momento, não há na literatura mundial nenhuma revisão sistemática com meta-análise de PC relacionada à anestesia. Este estudo buscou analisar dados globais de PC perioperatória e relacionada à anestesia de acordo com o Índice de Desenvolvimento Humano (IDH) e com a variável tempo. Além disso, comparou-se as incidências de PC perioperatória e relacionada à anestesia dos países com baixo e elevado IDH em 2 períodos de tempo. Método: Uma revisão sistemática foi realizada por meio de plataformas eletrônicas de busca para identificar estudos em que pacientes submetidos à anestesia tenham apresentado PC perioperatória e/ou relacionada à anestesia. A meta-análise proporcional e análise de metarregressão foram realizadas utilizando um intervalo de confiança (IC) de 95% para avaliar os dados globais de PC perioperatória e relacionada à anestesia de acordo com o IDH e tempo, e para comparar suas incidências de acordo com o IDH (baixo versus elevado IDH) dos países e de acordo com período (pré 1990 versus período de 1990 - 2014), respectivamente. Resultados: Cinquenta e três estudos provenientes de 21 países, abrangendo 11,9 milhões de anestesias foram incluídos. A meta-análise proporcional demonstrada na proporção de n eventos para 10.000 anestesias apresentaram declínio na incidência de PC perioperató... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Background: The anesthesia-related cardiac arrest (CA) rate is a quality indicator to improve patient safety in the perioperative period. A systematic review with meta-analysis of the worldwide literature related to anesthesiarelated CA rate has not yet been performed. This study aimed to analyze global data on perioperative and anesthesia-related CA rates according to country’s Human Development Index (HDI) and by time. Additionally, we compared the perioperative and anesthesia-related CA rates in low- and high-income countries in two time periods. Methods: A systematic review was performed using electronic databases to identify studies in which patients underwent anesthesia with perioperative and/or anesthesia-related CA rates. Proportional meta-analysis and metaregression were performed with 95% confidence intervals (CI) to compare the perioperative and anesthesia-related CA rates by country’s HDI status (low-HDI versus high-HDI) and by time period (pre-1990s versus 1990s-2010s), and to evaluate global data on perioperative and anesthesia-related CA rates according to country’s HDI and by time, respectively. Results: Fifty-three studies from 21 countries assessing 11.9 million anesthetic administrations were included. Meta-analysis showed per 10,000 anesthetics that perioperative and anesthesia-related CA rates declined in high-HDI (8.1 [95% CI: 5.1-11.9] before the 1990s to 6.2 [95% CI: 5.1-7.4] in the 1990s-2010s, P<0.001, and 2.3 [95% CI: 1.2-3.7] before the 1990s to 0.... (Complete abstract click electronic access below) / Doutor

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 Physical activity with regular physical exercise (PE) has long been advocated because it lowers morbidity and mortality. However, there have been concerns about a transiently increased risk of adverse cardiac events such as sudden cardiac death (SCD) during PE. Our aim was to identify risk factors related to SCD during PE and clarify the effect of PE on cardiovascular well-being in the general population. In study I we found out that male gender as well as coronary artery disease (CAD), cardiac hypertrophy and myocardial scarring as autopsy-findings were clearly more common among exercise-related SCD. Typical northern activities in skiing and snow shoveling were among the three most common types of PE alongside cycling. In study II we analyzed the previously recorded electrocardiograms (ECG) of victims of SCD. Fragmented QRS complex (fQRS) in anterior leads was a common finding among subjects who died during exercise, especially among subjects with a prior diagnosis of CAD. In study III, we collected retrospectively out-of-hospital sudden cardiac arrest (SCA) data in Northern Ostrobothnia between the years 2007 and 2012. The subjects who suffered SCA in relation to PE were younger and previously healthier, and they had more often a shockable rhythm as the initial rhythm. There was a markedly better prognosis for hospital discharge when SCA occurred during PE. In study IV, we noticed a decrease in cardiac mortality in subjects who were physically active or became active during follow-up in a population of 1,746 stable CAD patients. A similar effect could be seen affecting SCD mortality. No increase in cardiac mortality could be seen among those with the highest levels of habitual PE. In conclusion, ischemic heart disease and male gender, especially when fQRS is present in anterior leads, are characteristics related to exercise-related SCD. On the other hand, when SCA takes place during PE, the prognosis is markedly better compared to SCA occurring at rest. An active lifestyle is also linked to decreased cardiac mortality. / Tiivistelmä Säännöllinen aktiivinen elämäntapa on yhteydessä pienempään fyysisten ja psyykkisten sairauksien riskiin. Tutkimuksissa on kuitenkin havaittu raskaampaan liikuntaan liittyvä väliaikaisesti lisääntynyt akuutin sydäntapahtuman, kuten äkkikuoleman, riski. Väitöskirjatutkimuksessa tutkitaan rasitukseen liittyvän sydänperäisen äkkikuoleman erityispiirteitä ja fyysisen aktiivisuuden merkitystä hyvinvoinnille. Ensimmäisessä osajulkaisussa havaittiin, että rasitukseen liittyvissä kuolemissa oli ruumiinavauslöydöksenä merkittävästi enemmän sepelvaltimotautia, sydänlihaksen arpeutumista ja sydänlihaksen liikakasvua verrattuna äkkikuolemiin levossa. Miessukupuoli oli selkeästi yliedustettuna rasituspopulaatiossa, sillä peräti 94 % oli miehiä. Yleisimmät rasitusmuodot olivat hiihto, pyöräily ja lumenluonti. Toisessa osatutkimuksessa tutkittiin edeltävien EKG-muutosten yhteyttä rasitusperäisiin äkkikuolemiin. Havaitsimme, että QRS-kompleksin pirstoutuminen etuseinäkytkennöissä oli selkeästi yleisempi löydös rasitusryhmässä. Tämä löydös oli erityisen merkittävä sepelvaltimotautipotilailla. Kolmas julkaisu sisältää tiedot sairaalan ulkopuolisista sydänpysähdyksistä Pohjois-Pohjanmaalla vuosina 2007–2012. Tässä aineistossa havaitsimme, että rasitukseen liittyvän sydänpysähdyksen alkurytmi oli useammin defibrilloitava, potilaat olivat nuorempia ja terveempiä, ja maallikkoelvytys aloitettiin useammin. Rasituksessa elottomaksi menneillä oli suhteellisen hyvä selviämisennuste. Neljännessä tutkimuksessa havaitsimme selkeästi paremman ennusteen niillä stabiilia sepelvaltimotautia sairastaneilla, jotka olivat liikunnallisesti aktiivisia. Sydänperäinen kuolleisuus oli pienempi myös niillä potilailla, jotka onnistuivat lisäämään liikunnallista aktiivisuuttaan. Samankaltainen tulos todettiin sydänperäisten äkkikuolemien osalta. Sepelvaltimotauti ja miessukupuoli ovat hyvin yleisiä löydöksiä, kun sydänperäinen äkkikuolema tapahtuu rasituksessa. Myös QRS-kompleksin pirstoutuminen etuseinäkytkennöissä liittyi rasitusperäisiin kuolemiin. Toisaalta potilaan ennuste selvitä on selkeästi parempi sydänpysähdyksen tapahtuessa rasituksessa. Osoitimme myös, että liikunnallinen aktiivisuus ja sen pienikin lisäys parantavat sepelvaltimotautipotilaiden ennustetta.

Submitted by FERNANDO AKIRA KOGA null (koga_fernando@yahoo.com.br) on 2016-02-19T20:58:18Z No. of bitstreams: 1 Fernando Koga (Doutorado) TESE ARQUIVADA.pdf: 1966237 bytes, checksum: 7170273f830c678c8ddafb8c2f2301eb (MD5) / Approved for entry into archive by Juliano Benedito Ferreira (julianoferreira@reitoria.unesp.br) on 2016-02-22T20:11:57Z (GMT) No. of bitstreams: 1 koga_fa_dr_botu.pdf: 1966237 bytes, checksum: 7170273f830c678c8ddafb8c2f2301eb (MD5) / Made available in DSpace on 2016-02-22T20:11:57Z (GMT). No. of bitstreams: 1 koga_fa_dr_botu.pdf: 1966237 bytes, checksum: 7170273f830c678c8ddafb8c2f2301eb (MD5) Previous issue date: 2016-02-15 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / Pró-Reitoria de Pesquisa (PROPe UNESP) / Introdução: A incidência de parada cardíaca (PC) pode ser utilizada como um indicador de qualidade para promover melhorias quanto à segurança do paciente no período perioperatório. Até o momento, não há na literatura mundial nenhuma revisão sistemática com meta-análise de PC relacionada à anestesia. Este estudo buscou analisar dados globais de PC perioperatória e relacionada à anestesia de acordo com o Índice de Desenvolvimento Humano (IDH) e com a variável tempo. Além disso, comparou-se as incidências de PC perioperatória e relacionada à anestesia dos países com baixo e elevado IDH em 2 períodos de tempo. Método: Uma revisão sistemática foi realizada por meio de plataformas eletrônicas de busca para identificar estudos em que pacientes submetidos à anestesia tenham apresentado PC perioperatória e/ou relacionada à anestesia. A meta-análise proporcional e análise de metarregressão foram realizadas utilizando um intervalo de confiança (IC) de 95% para avaliar os dados globais de PC perioperatória e relacionada à anestesia de acordo com o IDH e tempo, e para comparar suas incidências de acordo com o IDH (baixo versus elevado IDH) dos países e de acordo com período (pré 1990 versus período de 1990 - 2014), respectivamente. Resultados: Cinquenta e três estudos provenientes de 21 países, abrangendo 11,9 milhões de anestesias foram incluídos. A meta-análise proporcional demonstrada na proporção de n eventos para 10.000 anestesias apresentaram declínio na incidência de PC perioperatória e relacionada à anestesia em países com elevado IDH (de 8,1 [IC 95%: 5,1-11,9] pré 1990 para 6,2 [IC 95%: 5,1-7,4] no período de 1990-2014, p<0,001, e 2,3 [IC 95%: 1,2-3,7] pré 1990 para 0,7 [IC 95%: 0,5-1,0] no período de 1990-2014, p<0,001; respectivamente). Os países com baixo IDH apresentaram aumento significativo na incidência de PC perioperatória (de 16,4 [IC 95%: 1,5-47,1] pré 1990 para 19,9 [IC 95%: 10,9-31,7] no período de 1990-2014, p=0,03) diferentemente da incidência de PC relacionada à anestesia, que não apresentou alteração significativa (9,2 [IC 95%: 2,0-21,7] pré 1990, para 4,5 [IC 95%: 2,4-7,2] no período de 1990-2014, p=0,14). A metarregressão demonstrou que as incidências de PC perioperatória (slope: -2,4071; IC 95%: -4,0482 a -0,7659; p=0,005) e relacionada à anestesia (slope: -3,5729; IC 95%: -6,6306 a -0,5152; p=0,024) decresceram com o aumento do IDH, mas não com o tempo. Conclusão: Existe uma redução clara e consistente na incidência de PC perioperatória e relacionada à anestesia nos países com elevado IDH, mas um aumento na incidência de PC perioperatória sem alteração significativa na incidência de PC relacionada à anestesia nos países com baixo IDH comparando esses dois períodos de tempo. As incidências de PC perioperatória e relacionada à anestesia reduziram com o aumento do IDH dos países, mas não ao longo do tempo. / Background: The anesthesia-related cardiac arrest (CA) rate is a quality indicator to improve patient safety in the perioperative period. A systematic review with meta-analysis of the worldwide literature related to anesthesiarelated CA rate has not yet been performed. This study aimed to analyze global data on perioperative and anesthesia-related CA rates according to country’s Human Development Index (HDI) and by time. Additionally, we compared the perioperative and anesthesia-related CA rates in low- and high-income countries in two time periods. Methods: A systematic review was performed using electronic databases to identify studies in which patients underwent anesthesia with perioperative and/or anesthesia-related CA rates. Proportional meta-analysis and metaregression were performed with 95% confidence intervals (CI) to compare the perioperative and anesthesia-related CA rates by country’s HDI status (low-HDI versus high-HDI) and by time period (pre-1990s versus 1990s-2010s), and to evaluate global data on perioperative and anesthesia-related CA rates according to country’s HDI and by time, respectively. Results: Fifty-three studies from 21 countries assessing 11.9 million anesthetic administrations were included. Meta-analysis showed per 10,000 anesthetics that perioperative and anesthesia-related CA rates declined in high-HDI (8.1 [95% CI: 5.1-11.9] before the 1990s to 6.2 [95% CI: 5.1-7.4] in the 1990s-2010s, P<0.001, and 2.3 [95% CI: 1.2-3.7] before the 1990s to 0.7 [95% CI: 0.5- 1.0] in the 1990s-2010s, P<0.001; respectively). In low-HDI countries, perioperative CA rates increased significantly (16.4 [95% CI: 1.5-47.1] before the 1990s to 19.9 [95% CI: 10.9-31.7] in the 1990s-2010s, P=0.03) while anesthesia-related CA rates did not alter significantly (9.2 [95% CI: 2.0-21.7] before the 1990s to 4.5 [95% CI: 2.4-7.2] in the 1990s-2010s, P=0.14). Metaregression showed that perioperative (slope: -2.4071; 95% CI: -4.0482 to -0.7659; P=0.005) and anesthesia-related (slope: -3.5729; 95% CI: -6.6306 to -0.5152; P=0.024) CA rates decreased with increasing HDI, but not with time. Conclusions: There is a clear and consistent reduction in perioperative and anesthesia-related CA rates in high-HDI countries, but an increase in perioperative CA rates without significant alteration in the anesthesia-related CA rates in low-HDI countries comparing the two time periods. Both perioperative and anesthesia-related CA rates decrease with increasing HDI but not with time by meta-regression. / FAPESP: 2013/11006-7 / PROPe: 0143/004/13

Bakgrund: Hjärtsjukdom är en av de vanligaste dödsorsakerna i västvärlden. I Sverige drabbas årligen ca. 8000 personer av oväntat hjärtstopp och majoriteten av dessa sker i hemmet vilket leder till att närstående ofta är närvarande. Närstående upplever ofta en känsla av overklighet, kaos, rädsla och osäkerhet i samband med detta. Syfte: Syftet med denna studie var att beskriva närståendes upplevelse av att bevittna hjärtstopp prehospitalt. Metod: Studien genomfördes med kvalitativ design och data samlades in genom åtta semistrukturerade intervjuer med närstående till personer som hade fått hjärtstopp. Dataanalys genomfördes med kvalitativ innehållsanalys med induktiv insats. Resultat: Analysen resulterade i fem kategorier: förändrad tidsuppfattning, personalens närvaro gav trygghet och lugn, att pendla mellan hopp och hopplöshet, kaotisk situation och att uppskatta tydlighet. Närstående beskrev att de upplevde hjärtstoppet som traumatiskt med känslor av kaos, osäkerhet och overklighet, men också trygghet, lugn och lättnad när hjälpen kom. Det framkom även en känsla av tacksamhet över ambulanspersonalens insats. Behovet av tydlig information framgick också. Konklusion: Närstående var i överlag nöjda med den vård som gavs men det framgick även att deltagarna hade ett behov av att få prata med någon om sina upplevelser av hjärtstoppet och även att få feedback efteråt. Ytterligare forskning om närståendes situation vid oväntat hjärtstopp i hemmet är av stor betydelse för utvecklingen av ambulanspersonalens tillvägagångssätt vid vård av närstående.

INTRODUÇAO: O uso da epinefrina na ressuscitação cardiopulmonar (RCP) tem sido questionado devido aos efeitos adversos como dano miocárdico e cerebral. Fármacos como azul de metileno têm sido estudados como adjuvantes, objetivando reduzir essas lesões. OBJETIVOS: Neste estudo objetivou-se avaliar o efeito da administração do azul de metileno em bôlus durante a RCP, na lesão miocárdica e cerebral. MÉTODO: Quarenta e nove ratos Wistar machos submetidos a parada cardíaca por fibrilação ventricular foram distribuídos aleatoriamente em quatro grupos com 11 animais: azul de metileno (GA, 2mg/kg), solução salina (GC, salina 0,9% 0,1ml), epinefrina (GE, 20mcg/kg), epinefrina + azul de metileno (GM), além do grupo sham com 5 animais. A fibrilação ventricular foi induzida por estimulação elétrica direto no ventrículo direito por 3 minutos, sendo mantidos por mais 2 minutos em anóxia. As manobras de RCP foram iniciadas com o fármaco correspondente de cada grupo, massagem torácica, ventilação e desfibrilação. Após retorno a circulação espontânea (RCE), os animais foram observados durante quatro horas. Foram coletados sangue para gasometria e troponina, tecido cardíaco e cerebral para análise histológica, marcação de TUNEL, marcadores inflamatórios e de estresse oxidativo. Os grupos foram comparados por meio do teste não paramétrico de Kruskal-Wallis, com o teste de comparação múltipla com correção de Bonferroni quando adequado. RESULTADOS: Animais do grupo GE apresentaram 63% de RCE, enquanto o GC e GM obtiveram 40% e 45%, respectivamente, sem diferença estatística entre os grupos (p= 0,672). O grupo GA apresentou apenas 18% de RCE e foi excluído da análise. O tempo de RCP do GC foi maior comparado aos grupos GE e GM, mas sem diferença estatisticamente significativa. Os animais do grupo GM apresentaram PAM maior comparado ao grupo GC, no momento imediatamente após a RCE (P=0,007). Em todos os grupos os animais apresentaram acidose, queda da PaO2 e aumento do lactato após PCR e RCP. A mediana da troponina sérica foi maior no GC (130ng/ml) comparada ao grupo GE (3,8ng/ml), e GM (43,7ng/ml), porém sem diferença estatística. O grupo GC apresentou aumento significativo na expressão proteica dos marcadores BAX e TLR4. Não houve diferença estatística em relação a histologia e marcação de TUNEL entre os grupos submetidos a PCR. CONCLUSÃO: A utilização de azul de metileno em bolus na RCP de forma isolada apresentou resultados negativos em relação ao retorno da circulação espontânea. A utilização de azul de metileno associada a epinefrina não diminuiu a presença de lesões no cérebro e no coração decorrentes da parada cardíaca / INTRODUCTION: The use of epinephrine in cardiopulmonary resuscitation (CPR) has been questioned due to adverse effects such as myocardial and cerebral damage. Drugs such as methylene blue have been studied as adjuvants in order to reduce lesions. OBJECTIVES: The aim of this study was to evaluate the effect of methylene blue administration during CPR on myocardial and cerebral lesion. METHOD: Forty nine Wistar male rats submitted to ventricular fibrillation cardiac arrest (CA) were randomly assigned to four principal groups with 11 cases each one: methylene blue (MB, 2mg/kg), control (CTRL, 0.1ml saline 0.9%), epinephrine (EPI, 20?g/kg), epinephrine plus methylene blue (EPI+MB), and a sham group, wich have 5 cases. Ventricular fibrillation was induced by direct electrical stimulation in the right ventricle for 3 minutes and anoxia was maintained until a total of 5 minutes. CPR was initiated using the group drug, ventilation, chest compressions and defibrillation. The animals were observed for four hours after return of spontaneous circulation (ROSC). Blood samples were collected for blood gas and troponin measurements. Heart and brain tissues were harvested for the evaluation of oxidative stress, inflamation, histological and TUNEL staining. Groups were compared using the non-parametric Kruskal-Wallis test and Bonferroni post test. RESULTS: ROSC was achieved in 63% of the cases in EPI, 40% in CTRL, and 45% in EPI+MB (P=0.672). MB was excluded from analysis because of its low ROSC rate (18%). CPR duration was longer in CTRL compared to EPI and EPI+MB, without statistical significance. EPI+MB animals presented higher arterial pressure compared to the CTRL group, immediately after ROSC (P=0.007). All animals presented acidosis, decreased PaO2 and increased lactate after CA and CPR. Serum troponin was higher in CTRL (130ng/ml) compared with EPI (3.8ng/ml) and EPI+MB (43.7ng/ml), without statistical significance. CTRL presented higher BAX and TLR4 expression. There was no difference in TUNEL staining and histology among CA groups. CONCLUSION: Methylene blue in bolus during CPR did not improve outcome. Methylene blue combined with epinephrine did not decrease CA-related myocardial and cerebral lesions

Bakgrund: När en patient drabbas av hjärtstopp ingår det i allmänsjuksköterskans uppgifter att påbörja HLR för att försöka rädda patientens liv. På allmän vårdavdelning används mer avancerad behandling, så kallad S-HLR. En hjärtstoppsituation kan upplevas skrämmande för sjuksköterskan eftersom hen sannolikt behöver gå från en mer lugn till en akut situation. Det kan kännas påfrestande men kunskap och erfarenhet hjälper hen att agera. Behandlingen av hjärtstopp utförs i team tillsammans med flera professioner vilket innebär att det är viktigt med ett väl fungerande teamarbete. Syfte: Syftet med studien var att undersöka allmänsjuksköterskors upplevelser av att vårda vid ett hjärtstopp på vårdavdelningar. Metod: Som metod valdes en kvalitativ intervjustudie där resultatet baserades på sju semistrukturerade intervjuer. Intervjuerna transkriberades och analyserades sedan med en kvalitativ innehållsanalys som besvarade syftet för studien. Resultat: Resultatet visade på att det fanns fyra kategorier som bidrog till upplevelsen av hjärtstopp; ”Kunskap om hjärtstopp” där vikten av utbildning, rutiner och erfarenhet påtalades. ”När hjärtstopp pågår” som innefattar första reaktionen, HLR-situationen och att avbryta HLR. ”Att arbeta i team” bestående av samarbete, trygghet och verktyg för teamet. Slutligen ”Bearbetning efter hjärtstopp” som handlade om debriefing, uppföljning och uppfattning om hjärtstopp. Alla dessa områden bildade tillsammans en uppfattning av hjärtstopp. Slutsats: Hjärtstoppsvård är en påfrestande situation som sjuksköterskan minns länge och det är därför viktigt att avdelningarna arbetar med samtliga kategorier som framkommit i resultatet för att stödja och underlätta för de sjuksköterskor som engageras vid ett hjärtstopp på en vårdavdelning. / Background: When a patient has a cardiac arrest, it is included in the RN's duties to start CPR in order to try to save the patient's life. In the general nursing ward, more advanced treatment, so-called hospital CPR, is used. A cardiac arrest can be daunting for the nurse because they probably need to shift from a calm situation to an emergency situation. It may feel stressful, but knowledge and experience helps the RN to act. The treatment of cardiac arrest is performed in teams with several professions which means that it is important to have a good teamwork. Aim: The aim of the study was to investigate the RN’s experiences of caring for a cardiac arrest occurring at nursing wards. Method: As a method, a qualitative interview study was chosen, based on seven semi- structured interviews. The interviews were transcribed and then analyzed with a qualitative content analysis that suited the aim of the study. Result: The result showed that there were four categories that contributed to the experience of cardiac arrest; "Knowledge of cardiac arrest", emphasizing the importance of education, routines and experience. "When cardiac arrest is in progress" that includes the first response, CPR situation, and termination of CPR. "Working in team" consisting of cooperation, safety and instruments for teamwork. Finally, "Processing after cardiac arrest" that involved debriefing, follow-up and perception of cardiac arrest. All of these areas together formed an idea of ​​cardiac arrest. Conclusion: Cardiac arrest is an urgent situation that the nurse remembers for a long time, and it is therefore important that the wards work with all categories identified in the results to support and facilitate the nurses engaged in a cardiac arrest in a nursing ward.

Abstract Coronary artery disease is the leading cause of death in the world. The outcome of patients at a very high operative risk undergoing coronary artery bypass surgery has not been thoroughly investigated. Cohorts of patients underwent coronary surgery between January 1997 and December 2013 at the Oulu University Hospital, Finland. Data was acquired from electronic patient records. Statistical analysis was performed on the collected data to evaluate outcome and identify predictors of adverse events. Very high-risk patients who underwent isolated coronary artery bypass surgery had a high 30-day mortality (16.2%), but their 5-year survival was satisfactory (66.8%). Survivors of out-of-hospital cardiac arrest were compared to a control group. Immediate postoperative mortality was slightly higher in out-of-hospital cardiac arrest patients (6.3% vs. 0%, p = 0.24), but the overall 5-year survival rates were similar (80.7% vs. 84.5%). Patients with preoperative stage 3 chronic kidney disease have a higher mortality than patients with stage 1-2 chronic kidney disease. Kidney function decline/year was predictive of all-cause mortality, cardiovascular mortality and also tended to predict fatal and non-fatal cardiovascular events. The E-CABG postoperative complication grading system was used to stratify the severity and prognostic impact of postoperative complications and was shown to predict early and late mortality for these patients. The outcome of emergency coronary artery bypass surgery was studied in a multi-center setting. Increasing emergency classes, left ventricular ejection fraction ≤30%, on-pump surgery, and participating centers were independent predictors of in-hospital mortality. Survival rates at 1, 3 and 5 years were 86.4%, 81.6%, and 76.1%. Despite the high preoperative risk of these patients, the long-term outcome for coronary surgery is satisfactory. Patients with stage 3 chronic kidney disease may experience a significant decline in kidney function and poor outcome. Early referral to a nephrologist may be beneficial for these patients. The E-CABG complication grading system seems to be a promising tool for stratifying the severity and prognostic impact of complications occurring after coronary surgery. / Tiivistelmä Sepelvaltimotauti on johtavia kuolinsyitä Maailmassa. Ohitusleikkauksen tuloksia ei ole täysin selvitetty erittäin korkean riskin potilailla. Potilaat leikattiin vuosina 1997-2013. Potilastiedot hankittiin sairauskertomuksista ja kuolinsyytiedot kansallisista rekistereistä. Erittäin korkean riskin potilaiden välitön kuolleisuus ohitusleikkauksen jälkeen on korkea (30 päivän kuolleisuus 16,2 %). Viiden vuoden kuluttua leikkauksesta elossa oli 66,8% leikatuista. Ohitusleikkausta edeltävästi elvytettyjä potilaita verrattiin kontrolliryhmään. Välittömät leikkauksen jälkeinen kuolleisuus oli 6,3% vs. 0% (p = 0,24). Viiden vuoden kuluttua leikkauksesta elossa oli tutkimusryhmästä 80,7% ja kontrolliryhmästä 80,7%. Leikkausta edeltävästi keskivaikean munuaisten vajaatoiminnan omaavilla potilailla on korkeampi kuolleisuus verrattuna potilaisiin, joiden munuaistoiminta on normaalia tai lievästi heikentynyt. Munuaisten vajaatoiminnan eteneminen ennusti kokonaiskuolleisuutta, sydän- ja verisuonikuolleisuutta ja enteili sydän- ja verisuonitapahtumia. E-CABG leikkauksen jälkeisten komplikaatioiden luokittelujärjestelmällä luokiteltiin leikkauksen jälkeisten komplikaatioiden vaikeusastetta ja ennusteellista vaikutusta. E-CABG luokat ja pisteytys ennustivat 1kk, 3kk kuolleisuutta ja kuolleisuutta pidemmällä aikavälillä. Päivystysohitusleikkauksen tuloksia tutkittiin monikeskusasetelmassa. Sairaalakuolleisuutta ennustivat päivystysleikkausluokitteluluokan vakavuus, vasemman kammion ejektiofraktio ≤30%, perfuusiossa tehty leikkaus ja leikkaava keskus. Potilaiden elossaololuvut olivat 1, 3 ja 5 vuoden kohdalla 86,4%, 81,6%, and 76,1%. Leikkaustulokset erittäin korkean riskin potilailla ohitusleikkauksesta ovat kohtuullisia leikkausta edeltävään riskiarvioon suhteutettuna. Näin ollen tämän potilasryhmän sepelvaltimotaudin hoito leikkaamalla on perusteltua. Keskivaikean munuaisten vajaatoiminnan omaavien potilaiden munuaissairauden etenemiseen seuranta-aikana liittyy kuolleisuutta ja sydän- ja verisuonitapahtumia. Aikaisessa vaiheessa tehty nefrolgin konsultaatio voi parantaa näiden potilaiden munuaisfunktiota. E-CABG komplikaatioiden luokittelujärjestelmä vaikuttaa lupaavalta työkalulta ohitusleikkauksen jälkeisten komplikaatioiden luokitteluun ja ennustevaikutuksien arviointiin.

Bakgrund: Dödligheten hos patienter som drabbats av hjärtstopp på vårdavdelningar är hög men med tidig hjärt-lungräddning (HLR) och tidig defibrillering så ökar chansen för överlevnad. Intensivvårdssjuksköterskan som ingår i akutteamet får ett larm om hjärtstopp och tillsammans med kollegor gör de en utryckning till patienten på avdelningen för att stötta och hjälpa till i den akuta situationen. Dessa situationer kan vara kaotiska och stressfyllda. Syfte: Syftet med studien var att beskriva intensivvårdssjuksköterskors upplevelser av hjärtstoppslarm och hjärtstopp på vårdavdelning som jobbat mindre än 5 år. Metod: En kvalitativ intervjustudie genomfördes på ett mindre länsdelssjukhus i norra Sverige. Data samlades in genom semistrukturerade intervjuer med nio intensivvårdssjuksköterskor med mindre än fem års yrkeserfarenhet som intensivvårdsjuksköterskor. Intervjuerna spelades in, transkriberades ordagrant och analyserades med kvalitativ innehållsanalys. Resultat: Analysen resulterade i fyra kategorier; Utmanande och spännande att bära hjärtstoppslarmet, Hjärtstoppslarm kräver planering och förberedelse, Övning och ett nära samarbete skapar trygghet och Stress påverkar handlingsförmågan. Resultatet visade att oerfarna intensivvårdssjuksköterskor upplever en viss form av stress men att de fann en trygghet i sina kollegor i akutteamet och att deras samarbete fungerar bra. Dock så kunde samarbetet med vårdavdelningens personal samt den medicinläkare som kommer till den patient som drabbats av hjärtstoppet fungera mindre bra och kommunikationen dålig. De upplevde ett behov av kontinuerlig HLR-träning dels med andra professioner samt mer scenarioövningar. Konklusion: Oerfarna intensivvårdssjuksköterskor kände sig trygga med hjärtstoppsteamet men upplevde otrygghet då de befann sig i en okänd miljö då en patient drabbats av hjärtstopp på vårdavdelning. Bristande rutiner och osäkerhet bland personalen kunde påverka den stress som uppstod negativt. Genom att utarbeta en gemensam rutin och träna tillsammans skulle arbetet kring hjärtstoppet kunna bli mindre stressfyllt och mer effektivt.

No description available.