Thesis (MCur)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: Motivation. Homeostasis is a dynamic and balanced process that must be maintained in order to for health to be sustained (Scales & Pilsworth, 2008:50-57). In critically illness, homeostasis is disrupted and along with inadequate tissue perfusion potentially leads to multiple organ failure (Elliot, Aitken & Chaboyer, 2007:437). The fluid balance of a patient is essential for preserving homeostasis and to maintain optimal tissue perfusion, thus monitoring fluid balance plays an important role in the managing a critically ill patient. Current literature and best nursing practice emphasise the importance of accurate and correct fluid balance monitoring in critically ill patients including recording fluid intake and output on a purpose designed fluid balance sheet. Research has shown that the patient’s outcome after critical illness is influenced by the fluid balance management including fluid balance monitoring (Vincent, Sakr, Sprung, Ranieri, Reinhart, Gerlach, Moreno, Carlet, Le Gall & Payen, 2006:344-353), while several studies have questioned accuracy of fluid balance calculation in various acute care settings (Johnson & Monkhouse, 2009:291; Smith, Fraser, Plowright, Dennington, Seymour, Oliver & MacLellan, 2008:28-29). In an informal audit performed in a local critical care unit, seven out of ten fluid balances were incorrectly calculated. Clinical experience of nurses’ inattention to fluid balance monitoring, together with the informal audit data, reveals that fluid balance monitoring is generally not performed correctly or accurately by nurses working in critical care units. The aim of the study was to describe the perspectives and practices of registered nurses in critical care units with regard to fluid balance monitoring. Methods. A quantitative approach in the form of an audit was applied to establish the current practice of fluid balance monitoring. A survey was conducted among registered nurses to gain insight into their perspectives and knowledge of fluid balance monitoring. The sample for the audit was drawn from fluid balance records, which met the study inclusion criteria. The survey was conducted with a sample of participants from registered nurses in critical care units from a particular hospital group, in compliance with the inclusion criteria. The researcher collected the data using a purpose designed audit tool and questionnaire. Results. The audit revealed that 90 % of the sampled fluid balance records were inaccurate (tolerated deviation 0-10ml) and 79% were inaccurate if a deviation of 50ml would be tolerated. Furthermore the inaccuracy in calculation was larger in patients whoreceived diuretics. The questionnaire data revealed that registered nurses considered fluid balance monitoring as an important part of patient nursing care and were aware that inaccuracy can pose a risk to the patient. The nurses feel responsible for performing fluid balance monitoring. In addition the nurses gave recommendations for the practice. Discussion. The results of this study are similar to other studies done internationally. The nurses are aware of the importance of the fluid balance, and recognise the inaccuracies. With our limited resources, both financial and in terms of nursing staff, the solutions have to be very basic and practical. Key words: fluid balance, critical care, accuracy and auditing, best practice / AFRIKAANSE OPSOMMING: Motivering. Homeostase is ’n dinamiese en gebalanseerde proses wat onderhou moet word vir gesondheid om handhaaf te word (Scales & Pilsworth, 2008:50-57). Onder toestande van kritieke siekte, word homeostase onderbreek en kan dit saam met onvoldoende weefselperfusie moontlik tot veelvuldige orgaanmislukking lei (Elliot, Aitken & Chaboyer, 2007:437). Die vloeistofbalans van ’n pasiënt is van die uiterste belang vir die preservering van homeostase en om optimale weefselperfusie te onderhou, en dus speel die monitering van vloeistofbalans ’n belangrike rol in die bestuur van die pasiënt wat kritiek siek is. Die huidige literatuur en beste verpleegkundige praktyk beklemtoon die belangrikheid van akkurate en korrekte vloeistofbalansmonitering in pasiënte wat kritiek siek is, insluitend die aantekening van vloeistofinname en -afskeiding op ’n vorm wat vir die doel pasgemaak is. Navorsing het getoon dat die pasiënt se uitkoms ná kritiese siekte deur vloeistofbalansbestuur, insluitend vloeistofbalansmonitering, beïnvloed word (Vincent, Sakr, Sprung, Ranieri, Reinhart, Gerlach, Moreno, Carlet, Le Gall & Payen, 2006:344-353), terwyl verskeie studies die akkuraatheid van die vloeistofbalansberekening in ’n verskeidenheid kritiekesorgeenhede bevraagteken het (Johnson & Monkhouse, 2009:291; Smith, Fraser, Plowright, Dennington, Seymour, Oliver & MacLellan, 2008:28-29). In ’n informele oudit wat in ’n plaaslike kritiekesorgeenheid uitgevoer is, is daar gevind dat sewe uit tien vloeistofbalanse verkeerdelik bereken is. Kliniese ervaring van verpleërs se agtelosigheid met betrekking tot vloeistofbalansmonitering, tesame met die data vanuit die informele oudit, wys dat vloeistofbalansmonitering oor die algemeen nie korrek of akkuraat deur verpleërs in die kritiekesorgeenheid uitgevoer word nie. Die doelwit van hierdie studie was om die perspektiewe en praktyke van geregistreerde verpleërs in kritiekesorgeenhede met betrekking tot vloeistofbalansmonitering te beskryf. Metodes. ’n Kwantitatiewe benadering in die vorm van ’n oudit is gebruik om die huidige praktyk van vloeistofbalansmonitering te bepaal. ’n Opname is onder geregistreerde verpleërs gedoen om insig te bekom oor hulle perspektiewe oor en kennis van vloeistofbalansmonitering. Die steekproef vir die oudit is geneem uit vloeistofbalansrekords wat aan die studiekriteria voldoen het. Die opname is gedoen onder ’n steekproef van geregistreerde verpleërs in ’n kritiekesorgeenheid van ’n spesifieke hospitaalgroep, in ooreenstemming met die insluitingskriteria. Die navorser het die data met ’n pasgemaakte ouditinstrument en vraelys versamel. Resultate. Die oudit het gewys dat 90% van die vloeistofbalansrekords in die steekproef onakkuraat was (toleransie verskil 0-50ml) en 79% was onakkuraat als een verskil van 50 ml was tolereer. Verder was die onakkuraatheid in die berekenings groter in pasiënte wat urineermiddels ontvang het. Die data vanaf die vraelys het gewys dat geregistreerde verpleërs vloeistofbalansmonitering as ’n belangrike deel van die verpleging van ’n pasiënt beskou en daarvan bewus is dat onakkuraatheid ’n risiko vir die pasiënt kan inhou. Die verpleërs voel daarvoor verantwoordelik om die vloeistofbalansmonitering uit te voer. Hulle het ook aanbevelings vir die praktyk gemaak. Bespreking. Die resultate van hierdie studie is baie soortgelyk aan dié van ander internasionale studies. Die verpleërs is bewus van die belangrikheid van die vloeistofbalans en is bewus van die onakkuraathede. Met ons beperkte hulpbronne, beide finansieel en in terme van verpleegpersoneel, is dit noodsaaklik dat die oplossings baie basies en prakties is. Sleutelwoorde: vloeistofbalans, kritieke sorg, akkuraatheid en ouditering, beste praktyk

Background: When the patient is critically ill the family is in a vulnerable position. The nurse's role is to support and help the family to find meaning in the difficult situation and to provide realistic hope. Balancing between the patient's and the family's needs is difficult. Knowledge about how nurses experience difficulties in the interaction with family is required in order to grant good care too critically ill patients and their family-members. Aim: To describe nurses' perceived difficulties in the interaction with family-members of critically ill patients. Method: The study is a qualitative literature-based study based on qualitative research. Results: The analysis resulted in four main themes; difficult disunion, environmental constraints, interpersonal difficulties and communicative difficulties. Conflicts, disagreement and expectations in the interaction with family-members are difficult. There are environmental constraints in the form of family's presence, lack of space and time constraints. Nurses find it difficult to manage their emotions, family who get to close and to support the family. Information, comprehension, knowledge, language barriers and cultural differences represents communicative difficulties. Conclusion: There is a lack of knowledge among nurses about how to handle difficult situations where family is involved. Doctors and nurses need to collaborate more. Conflicts, disagreements and expectations can put severe pressure on the nurse. It is difficult for the nurse to strike a balance between being professional and being personal. Environmental constraints are an organizational problem which creates difficulties for the nurse in the interaction with family.

Zielstellung: Die optimale Ernährung kritisch kranker internistischer Patienten ist noch immer Gegenstand von Diskussionen. Es ist unklar, welche Energiemenge in Bezug auf den Krankheitsverlauf und den klinischen Ausgang günstig ist. Das Anliegen der vorliegenden Arbeit bestand darin, während der ersten sieben Tage der akuten Krankheitsphase eine normokalorische mit einer nur 50% des ermittelten Energiebedarfes abdeckenden künstlichen Ernährung bezüglich klinischer und metabolischer Parameter zu vergleichen. Methode: Es wurden kritisch kranke internistische Patienten, die länger als drei Tage eine künstliche Ernährung benötigten, innerhalb der ersten 24 Stunden nach Aufnahme auf der Intensivstation in die Studie eingeschlossen und in zwei Studienarme randomisiert. Die Patienten der Gruppe 1 erhielten 100%; Patienten der Gruppe 2 nur 50% des ermittelten täglichen Energiebedarfes. Ergebnisse: Insgesamt wurden 100 Patienten eingeschlossen (54 in Gruppe 1 und 46 in Gruppe 2). Es waren 66 Männer und 34 Frauen mit einem durchschnittlichen Alter von 65,8±11,6 Jahren. In der hypokalorisch ernährten Gruppe befanden sich signifikant mehr Diabetiker, jedoch war der Insulinbedarf in der normokalorisch ernährten Gruppe signifikant höher. Die gastrointestinale Toleranz war in der hypokalorisch ernährten Gruppe signifikant besser als in der normokalorischen Gruppe. In der hypokalorischen Gruppe wurden nosokomiale Infektionen häufiger beobachtet als in der normokalorischen Gruppe. Bezüglich des Überlebens auf der Intensivstation, im Krankenhaus und am Tag 28 ergaben sich keine signifikanten Unterschiede zwischen den Ernährungsregimen. Es gab keine Korrelation zwischen Energie- und Proteinzufuhr und klinischem Ausgang. Schlussfolgerungen: Während der ersten sieben Tage ist eine hypokalorische Ernährung bei kritisch kranken internistischen Patienten mit einem geringeren Insulinbedarf und einer besseren gastrointestinalen Verträglichkeit verbunden. Die Rate an nosokomialen Infektionen war allerdings unter hypokalorischer Ernährung höher, wobei in Bezug auf den klinischen Ausgang kein Unterschied zwischen den Gruppen beobachtet wurde. Die vorliegende Studie sollte allerdings aufgrund der relativ geringen Fallzahl als eine Pilotstudie angesehen werden.

Bakgrund: Mötet med medicinskt svåra situationer förekommer dagligen för ambulanssjuksköterskan. Det finns flera komponenter som påverkar hur situationen upplevs. Ambulanssjuksköterskan ska ha adekvat utbildning för det arbetet de utför.  Syfte: Syftet var att undersöka ambulanssjuksköterskans upplevelse av att vårda svårt sjuka patienter.  Metod: Studien genomfördes som en allmän litteraturöversikt med induktiv ansats. Resultatet baserades på åtta vetenskapliga artiklar. Resultat: Fem kategorier framkom: Ambulanssjuksköterskans upplevelse av att förbereda sig; Ambulanssjuksköterskans upplevelse av kommunikation; Ambulanssjuksköterskans upplevelse av att omhänderta en patient på plats och under transport; Ambulanssjuksköterskan copingstrategier och Ambulanssjuksköterskans upplevelse av kunskap och erfarenhet. Ambulanssjuksköterskan upplevde vikten av förberedelser inför patientmötet för att optimera mötet med patienten. Reflektion efter patientmötet var viktigt, för den självständiga utvecklingen där konstruktiv kritik framfördes. Ambulanssjuksköterskan nyttjade flertalet olika copingstrategier för att bearbeta upplevelserna av att vårda en svårt sjuk patient.   Konklusion: Litteraturstudien påvisar olika faktorer som påverkar ambulanssjuksköterskorna i den pre-hospitala vården. Ambulanssjuksköterskorna möter oväntade situationer och måste vara förberedda på omhändertagandet av svårt sjuka patienter. Säkerheten upplevs ökas då arbetet sker med utbildad och erfaren personal. Kommunikationen riskerar att fallera vid olika vårdsituationer. Ständig reflektion och återkoppling inom arbetsgruppen upplevdes / Background: The encounter with medically difficult situations occurs daily for the ambulance nurse. There are several components that affect how the situation is experienced. The ambulance nurse shall have adequate training for the work they have performed.  Aim: The aim was to examine the ambulance nurse's experience of caring for seriously ill patients.  Method: The study was conducted through a general literature review with an inductive approach. The results were based on eight scientific articles.  Results: Five categories emerged: the ambulance nurse's experience of preparing; The ambulance nurse's experience of communication; The ambulance nurse's experience of caring for a patient on site and during transport; The Ambulance Nurse coping strategies and the Ambulance Nurse experience of knowledge and experience. The ambulance nurse experienced the importance of preparing for the patient meeting to optimize the meeting with the patient. Reflection after the patient meeting was important, for the independent development where constructive criticism was presented. The ambulance nurse used several different coping strategies to process the experiences of caring for a seriously ill patient. Conclusion: The literature study demonstrates various factors that affect the ambulance nurses in pre-hospital care. The ambulance nurses face unexpected situations and must be prepared for the care of seriously ill patients. The safety is perceived to increase as the work takes place with trained and experienced staff. Communication risks failing in different care situations. Constant reflection and feedback within the working group was felt to strengthen

The critical illness/injury of a family member warranting an admission to an A&E unit can predispose a family to psychological and physiological needs. The patient-centred-care approach rendered in an A&E unit focuses on the patient as a priority, resulting in the family’s needs being neglected during a crisis situation. Based on the Family Resilience Framework, the aim of this study was to assess the needs of the families of the critically ill/injured patients in an A&E unit. Based on the identified needs, recommendations were made with regard to a family-centred-care approach as a relevant resilience-based strategy suitable to these families. The research adopted a quantitative, non-experimental, exploratory and descriptive design. A purposive convenience sample of 100 participants was recruited over a period of four months. The data were collected by means of a structured interview schedule. The study revealed that the five main domains of family needs identified by the respondents as very important was, in order of priority, the need for communication, support, meaning, comfort and proximity. The findings supported the need to initiate and foster a family-centred-care approach in the A&E unit, which could guide the nurse practitioners in supporting the affected families, which in turn could enable these families to become resilient. Copyright / Dissertation (MCur)--University of Pretoria, 2010. / Nursing Science / unrestricted

Zielstellung: Die optimale Ernährung kritisch kranker internistischer Patienten ist noch immer Gegenstand von Diskussionen. Es ist unklar, welche Energiemenge in Bezug auf den Krankheitsverlauf und den klinischen Ausgang günstig ist. Das Anliegen der vorliegenden Arbeit bestand darin, während der ersten sieben Tage der akuten Krankheitsphase eine normokalorische mit einer nur 50% des ermittelten Energiebedarfes abdeckenden künstlichen Ernährung bezüglich klinischer und metabolischer Parameter zu vergleichen. Methode: Es wurden kritisch kranke internistische Patienten, die länger als drei Tage eine künstliche Ernährung benötigten, innerhalb der ersten 24 Stunden nach Aufnahme auf der Intensivstation in die Studie eingeschlossen und in zwei Studienarme randomisiert. Die Patienten der Gruppe 1 erhielten 100%; Patienten der Gruppe 2 nur 50% des ermittelten täglichen Energiebedarfes. Ergebnisse: Insgesamt wurden 100 Patienten eingeschlossen (54 in Gruppe 1 und 46 in Gruppe 2). Es waren 66 Männer und 34 Frauen mit einem durchschnittlichen Alter von 65,8±11,6 Jahren. In der hypokalorisch ernährten Gruppe befanden sich signifikant mehr Diabetiker, jedoch war der Insulinbedarf in der normokalorisch ernährten Gruppe signifikant höher. Die gastrointestinale Toleranz war in der hypokalorisch ernährten Gruppe signifikant besser als in der normokalorischen Gruppe. In der hypokalorischen Gruppe wurden nosokomiale Infektionen häufiger beobachtet als in der normokalorischen Gruppe. Bezüglich des Überlebens auf der Intensivstation, im Krankenhaus und am Tag 28 ergaben sich keine signifikanten Unterschiede zwischen den Ernährungsregimen. Es gab keine Korrelation zwischen Energie- und Proteinzufuhr und klinischem Ausgang. Schlussfolgerungen: Während der ersten sieben Tage ist eine hypokalorische Ernährung bei kritisch kranken internistischen Patienten mit einem geringeren Insulinbedarf und einer besseren gastrointestinalen Verträglichkeit verbunden. Die Rate an nosokomialen Infektionen war allerdings unter hypokalorischer Ernährung höher, wobei in Bezug auf den klinischen Ausgang kein Unterschied zwischen den Gruppen beobachtet wurde. Die vorliegende Studie sollte allerdings aufgrund der relativ geringen Fallzahl als eine Pilotstudie angesehen werden.

There are many studies about problematic of sleep connected with shift work. However, only few studies devoted to the conditions for good rest and sleep in patients hospitalized in intensive care units. Insufficient or poor quality sleep and relaxation are the most common problems reported by patients that were hospitalized at intensive care units (ICU). Sleep is one of the basic biological needs of human. Sleep deficit can lead to psychical and psychological dysfunction that can affect the healing process. The diploma thesis is dealing with sleeping issues of patients hospitalized especially at intensive care units. The aim of the study is to determining the opinions of nurses that work at intensive care units on meeting the needs relating with sleep and rest of hospitalized patients and mapping, what interventions they use to prevent of occurrence of difficulties in this area. The theoretical part at first describes physiology of sleep and biological rhythms, then sleep disorders, then factors affecting sleep along with the consequences of the lack of sleep and last nursing process for patients with sleep disorder. The empirical part presents the results of questionnaire survey and then results of executed statistical analysis. Established hypothesis not have been assumed in results of survey...

A crescente demanda por serviços de saúde, juntamente com a necessidade de proporcionar um cuidado com qualidade e com segurança, trazem desafios para as instituições que trabalham nessa área. Buscando-se soluções para esse problema, hospitais vêm aderindo a filosofia Lean Healthcare (LH), contudo é necessário ressaltar a dificuldade que essas aplicações podem ter, em longo prazo, por ser uma abordagem distinta da gestão tradicional e não levar em consideração a natureza complexa da saúde. Esse estudo buscou em desenvolver um Framework para análise e intervenção em Sistemas Complexos (SC), por meio da integração entre princípios de gestão de sistemas enxutos e princípios da ciência da complexidade. Para isso, lançou-se mão de métodos, como mapeamento de fluxo de valor, mapeamento de processos e Functional Resonance Analysis Method (FRAM). O Framework proposto estruturou-se em 6 etapas, sendo construído por meio da Design Science Research. O estudo aplicado ocorreu em um hospital universitário na análise do fluxo do paciente grave do Serviço de Emergência para a Unidade de Terapia Intensiva. Como resultado dessa aplicação, foi possível identificar 16 problemas nesse fluxo, propondo-se um plano de ação para um dos problemas e simulando os potenciais impactos por meio da utilização do FRAM. Concluiu-se que é possível unificar as visões de LH e de SC, gerandose uma visão aprofundada dos problemas enfrentados no cotidiano dos serviços da saúde, criando meios para intervenções mais seguras e que proporcionem maior qualidade no cuidado prestado ao paciente. / The increasing demand for healthcare, altogether with the necessity to provide quality and secure care, bring challenges for institutions in this domain. Pursuing solutions for this problem, hospitals are implementing Lean Healthcare (LH) philosophy, although, it is important to consider difficulties that this application might have in a long term. This is due to the fact LH differs from a tradition approach and does not take in consideration the complex nature of healthcare systems. This study sought to develop a Framework for analysis and intervention in Complex Systems (CS) through integration of principals from Lean Production Management and Complex Science. In this way, methods such as Value Stream Mapping, Process Mapping, and Functional Resonance Analysis Method (FRAM) were used. The proposed Framework had six stages, been based in Design Science Research. The Framework application took place in an university hospital, focusing in the critically ill patients flow from the emergency service to the intensive therapy unit. As a result, it was possible to identify 16 problems in the flow and an action plan was proposed for one problem using FRAM for potential impacts simulation. In conclusion, the integration of LH and CS was possible, generating a deeper understanding of day-by-day problems in healthcare, creating means for secure interventions and allowing more quality in patient care.

Introdução: A lesão renal aguda (LRA) ocorre em unidades de terapia intensiva (UTI), com incidência de 30%, enquanto que a incidência hospitalar é 3-5%. A mortalidade nestes pacientes, inalterada nas últimas décadas, varia entre 50 e 70%. O padrão clínico para diagnóstico da LRA é a dosagem da creatinina sérica, que é um método pouco sensível, tardio e incapaz de discriminar a gravidade da lesão. Esse fato compromete o uso de terapias efetivas em tempo hábil e não permite vislumbrar a evolução pós LRA. O reconhecimento da lesão renal precoce contribui para a prevenção de danos renais maiores. O NGAL, proteína presente no sangue e na urina proveniente da lesão de células tubulares renais, é capaz de detectar a LRA antes do aumento da creatinina, estabelece medidas de prevenção e tratamento logo após o insulto, indica o grau de severidade da lesão e sugere o início da terapia de substituição renal (TSR). Objetivo: Esse estudo visa caracterizar a evolução da função renal de pacientes com LRA baseados na classificação AKIN (Acute Kidney Injury Network) e no NGAL. Material e método: Estudo de coorte prospectivo consistindo de 83 pacientes internados em UTI, avaliados em relação ao fluxo urinário, creatinina plasmática e NGAL. Resultados: Um total de 65 pacientes desenvolveram LRA, 28 a adquiriram durante a internação na UTI e 37 já apresentavam LRA na admissão. Dos pacientes com LRA, trinta e três (50,8%) apresentaram AKIN estágio 1, treze (20,0%) apresentaram AKIN estágio 2 e dezenove (29,2%) AKIN estágio 3. Os pacientes classificados em AKIN estágio 3 apresentaram valor significativamente maior de NGAL do que o grupo com AKIN estágio 1. Níveis de NGAL significativamente menores (p< 0,05) foram encontrados em pacientes que não desenvolveram LRA. Dentre os fatores associados ao óbito, destacamos a presença de doença de Chagas, LRA e Sepse; a baixa fração de ejeção (FE); o uso de drogas vasoativas (DVA), ventilação mecânica (VM) e balão intra-aórtico (BIA); maior pontuação no escore SOFA; necessidade de hemodiálise; redução da diurese e elevações da creatinina e NGAL. Observamos que somente as variáveis: presença de BIA (p=0,013), balanço hídrico positivo positivo (p< 0,001) e necessidade de hemodiálise (p< 0,001) foram preditores de óbito. Somente a presença de sepse, distúrbios do sódio e fluxo urinário foram preditores de diálise Conclusão: Níveis de NGAL colhidos nas primeiras 24 horas de admissão na UTI contribuíram para predizer o desenvolvimento da LRA além de corresponder ao aumento da severidade da LRA. / Introduction: The incidence of AKI varies from 3-5% in hospitalized patients to 30% in patients in intensive care units (ICU). Over the last decades, mortality rates have remained unchanged for adult patients, at 50-70%. The clinical standard for AKI diagnosis is the serum creatinine levels, which have low sensitivity, are incapable of differentiating the lesions severity, and lead to the late diagnosis in the injury process. These facts compromise the timely use of effective therapies and the assessing of the lesions evolution. NGAL, a protein present in the blood, in the urine and provenient from kidney tubule cells damage, is capable of detecting AKI before serum cretinine levels rise, allowing treatmen to be undertaken right after the injury; it also reflects injury severity and may forecast the need of renal replacement therapy. Objective: this study aims to assess the evolution of kidney function of AKI patients, based on the AKIN (Acute Kidney Injury Network) classification and on NGAL levels. Material and methods: Coorte prospective study consisting of 83 intensive care patients, who had their serum creatinine, NGAL and urine output evaluated. Results: a total of 65 patients developed AKI, 28 developed it during their hospital stay, and 37 already demonstrated it at ICU admission. Of the AKI patients, 33 (50,8%) were classified as AKIN stage 1, 13 (20,0%) as AKIN stage 2 and 19 (29,2%), as AKIN stage 3. The AKIN stage 3 patients showed to have significantly higher NGAL levels than AKIN stage 1 patients. Significantly lower NGAL levels (p<0,05) were found in patients that have not developed AKI. Among the factors associated to mortality, we highlight Chagas disease, AKI and sepsis, low ejection fraction, the use of vasoative drugs, mechanical ventilation, intra-aortic balloon pump use, higher SOFA score, need of renal replacement therapy, reduction in urine output, higher NGAL and serum creatinine levels. Only positive hydric balance (p>0,001), the use of intra-aortic balloon pump, and the need of renal replacement therapy were able to predict death. Also, only the urine output, the presence of sepsis or sodium disturbances were able to predict the need of renal replacement therapy. Conclusion: NGAL levels obtained in the fist 24 hours after admission to the intensive care unit contributed to the prediction of AKI development, and they were indicative of the injurys severity.

A crescente demanda por serviços de saúde, juntamente com a necessidade de proporcionar um cuidado com qualidade e com segurança, trazem desafios para as instituições que trabalham nessa área. Buscando-se soluções para esse problema, hospitais vêm aderindo a filosofia Lean Healthcare (LH), contudo é necessário ressaltar a dificuldade que essas aplicações podem ter, em longo prazo, por ser uma abordagem distinta da gestão tradicional e não levar em consideração a natureza complexa da saúde. Esse estudo buscou em desenvolver um Framework para análise e intervenção em Sistemas Complexos (SC), por meio da integração entre princípios de gestão de sistemas enxutos e princípios da ciência da complexidade. Para isso, lançou-se mão de métodos, como mapeamento de fluxo de valor, mapeamento de processos e Functional Resonance Analysis Method (FRAM). O Framework proposto estruturou-se em 6 etapas, sendo construído por meio da Design Science Research. O estudo aplicado ocorreu em um hospital universitário na análise do fluxo do paciente grave do Serviço de Emergência para a Unidade de Terapia Intensiva. Como resultado dessa aplicação, foi possível identificar 16 problemas nesse fluxo, propondo-se um plano de ação para um dos problemas e simulando os potenciais impactos por meio da utilização do FRAM. Concluiu-se que é possível unificar as visões de LH e de SC, gerandose uma visão aprofundada dos problemas enfrentados no cotidiano dos serviços da saúde, criando meios para intervenções mais seguras e que proporcionem maior qualidade no cuidado prestado ao paciente. / The increasing demand for healthcare, altogether with the necessity to provide quality and secure care, bring challenges for institutions in this domain. Pursuing solutions for this problem, hospitals are implementing Lean Healthcare (LH) philosophy, although, it is important to consider difficulties that this application might have in a long term. This is due to the fact LH differs from a tradition approach and does not take in consideration the complex nature of healthcare systems. This study sought to develop a Framework for analysis and intervention in Complex Systems (CS) through integration of principals from Lean Production Management and Complex Science. In this way, methods such as Value Stream Mapping, Process Mapping, and Functional Resonance Analysis Method (FRAM) were used. The proposed Framework had six stages, been based in Design Science Research. The Framework application took place in an university hospital, focusing in the critically ill patients flow from the emergency service to the intensive therapy unit. As a result, it was possible to identify 16 problems in the flow and an action plan was proposed for one problem using FRAM for potential impacts simulation. In conclusion, the integration of LH and CS was possible, generating a deeper understanding of day-by-day problems in healthcare, creating means for secure interventions and allowing more quality in patient care.