Diss. (sammanfattning) Stockholm : Karol. inst. / Härtill 5 uppsatser.

No description available.

No description available.

Survivors of critical illness suffer from a range of problems affecting physical, psychological and social well-being (Needham et al 2011). Weakness, fatigue and malnutrition are highly prevalent during the months following a critical illness. Few studies have systematically and comprehensively explored the factors that influence nutritional recovery or ways to overcome them. The aim of this study was to provide a comprehensive understanding of the factors influencing nutritional recovery, and the relationship between them, in post intensive care (ICU) patients. A model of care was then developed to improve current management of nutrition for patients recovering from critical illness. Grounded theory methodology was used with a mixed method research design. Nutritional status and intake were assessed on discharge from ICU and at three months post ICU discharge. The process of nutritional recovery during the first three months post ICU discharge was explored from a patient perspective and at the level of ward organisation of care, through observation of practice and interviewing patients and staff. Seventeen patients, who had required greater than 48 hours ventilation, were recruited on discharge from the ICU. On transfer to the ward 9 of the 17 patients were assessed as well-nourished and 8 were malnourished using Subjective Global Assessment. At three months post ICU discharge 14 patients were followed up (1 lost to follow up, 1 incapacitated following illness and 1 went overseas). Seven of these were classified as well-nourished and the other 7 were malnourished. Patients universally failed to meet their nutritional targets during their ward stay and although intakes had improved by three months post ICU discharge, the majority of patients were still not achieving their nutritional requirements. Qualitative data revealed that patients' nutritional intake was influenced by interrelated system breakdowns during the recovery process; this emerged as the overarching core theme. Three sub-themes were ‘experiencing a dysfunctional body’, ‘experiencing socio-cultural changes in relation to eating and ‘encountering organisational nutritional care delivery failures’. This study identified connections and interrelations between these concepts and provided new insights into the factors that influence the nutritional care of post ICU patients. In order to optimise nutritional rehabilitation in this patient group a model of care has been developed which addresses the identified organisational and patient related factors that were shown to influence the nutritional recovery of patients after critical illness. This nutritional strategy will need to be evaluated in clinical trials or quality improvement programmes.

Abstract Mortality of patients requiring intensive care treatment for greater than 5 days has been shown to be about 20% worldwide. Hyperglycaemia is common in critically ill patients. Strict glucose control with insulin in critically ill patients was shown to reduce mortality and morbidity significantly. Several interrelated mechanisms are involved in the development of “stress hyperglycaemia” in critically ill patients. These include dextrose containing intravenous infusions and total parenteral nutrition; the counter regulatory hormones (catecholamines, cortisol, glucagon and growth hormone) which oppose the effects of insulin; nervous system signaling; increased insulin clearance; and excess production of cytokines that interfere with intracellular insulin signaling pathways. Aim of study: To determine if the cytokines TNFα, IL-6 and adiponectin are significant determinants of insulin resistance in critically ill patients. Methods: The study was a prospective observational study conducted in the intensive care unit (ICU) at the Chris Hani Baragwanath hospital. Forty sequential adult ICU admissions that met with the inclusion criteria were enrolled. Blood specimens were drawn for adiponectin, TNF, and IL-6 at the time of ICU admission, on day 3, day 7 and on discharge from the ICU. Demographic data and clinical data were recorded, and body mass index (BMI) and APACHE II scores were calculated on admission. Blood glucose was measured every 2 to 4 hours, recorded and a mean value was calculated over the 24 hour period. Insulin infusions were started when the blood glucose values exceeded 6.0mmol/l. Administration of insulin was according to a fixed sliding scale. The total amount of insulin administered intravenously over that 24 hour period was recorded. Other factors known to be related to insulin sensitivity, such as inflammation (as indicated by C-reactive protein), vii triglycerides, insulin, C-peptide and cortisol levels were also drawn in addition to the blood drawn for routine investigations. Results: Duration of stay in ICU correlated with severity of illness as assessed by the APACHE II score (r = 0.44, p = 0.004). There was no significant difference in the mean 24 hour plasma glucose concentration throughout the duration of stay in ICU, there were however significant differences in the amount of insulin administered to maintain normoglycaemia. The amount of administered insulin required was found to peak on day 3 and decline thereafter. The main determinant of insulin administered was mean glucose (r = 0.79, p < 0.00001). The measured insulin concentrations on admission correlated with mean plasma glucose (r = 0.41, p = 0.009) and C-peptide (r = 0.45, p = 0.004) levels. The main determinants of mean plasma glucose levels on admission were BMI (r = 0.38, p = 0.013) and serum cortisol (r = 0.41, p = 0.008) levels. Serum triglycerides levels showed a significant difference from admission to discharge, with values increasing from admission levels. Adiponectin levels showed a significant increase from admission to discharge. IL-6 levels showed a significant decrease. TNFα levels did not show statistically significant changes. No statistically significant correlations were found between the levels of TNFα or IL-6 and administered insulin. Adiponectin concentrations showed a negative correlation with amount of administered insulin on discharge (r = -0.457, p = 0.0049). There were significant gender differences in BMI, administered insulin on admission, serum cortisol and C-peptide concentrations, with females having higher values than males. BMI was shown to account for the gender differences in administered insulin and C-peptide levels. viii There were significant differences in IL-6 and TNFα concentrations between the survivors and nonsurvivors, with higher levels being seen in non-survivors. Adiponectin levels were lower in nonsurvivors, but this did not reach statistical significance. Conclusion: Although there was a demonstrable change in insulin sensitivity during the stay in ICU, there was no statistically significant association between the cytokines TNFα or IL-6 and insulin administration. There was a negative correlation between adiponectin concentrations and administered insulin on discharge. This data also demonstrates that mortality is associated with increased levels of proinflammatory cytokines.

Thesis (Ph. D.)--University of Washington, 1999. / Vita. Includes bibliographical references (leaves 167-179).

Thesis (M.A.)--Boston University, 2012. / PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / Recent evidence has suggested that vitamin D may modulate innate immune function. We performed a prospective, observational investigation to assess the prevalence of vitamin D deficiency in adult critically ill patients with sepsis. Subjects were categorized by baseline 25-hydroxyvitamin D [25(0H)D]: Deficient: < 20 ng/ml, Insufficient: 21-29 ng/ml, or Normal: > 29 ng/ml. A total of 39 subjects were enrolled in the study. 25(0H)D deficiency is common with 23/39 (59%) of subjects either deficient or insufficient. In-hospital mortality was 15% (6/39) and 5/6 (83%) of the subjects who expired were 25(0H)D insufficient. There were modest differences in severity of illness across 25(0H)D categories (SAPS 3: p = 0.01) and statistically significant inverse associations between 25(0H)D and markers of inflammation (IL-6: p = 0.04; TN F-a: p = 0.03) and vascular endothelial dysfunction (E-selectin: p = 0.05). There is a high prevalence of vitamin D deficiency or insufficiency in critically ill patients with sepsis and an inverse association between vitamin D and inflammation and vascular endothelial dysfunction. Future studies should assess the causal relationship between vitamin D and inflammation and outcomes from sepsis. / 2031-01-02

Die Critical-lllness-Polyneuropathie (CIP), eine Erkrankung des peripheren Nervensystems nach einer schweren intensivmedizinisch behandlungspflichtigen Erkrankung, ist bereits seit dem 19. Jahrhundert bekannt und lässt sich nur sehr schwer von einer Critical-Illness- Myopathie, die im gleichen Kontext auftreten kann, unterscheiden. Erschwert wird die Situation dadurch, dass beide Funktionsstörungen kombiniert auftreten können. Auf Grund der Weiterentwicklung in der Medizin ist in den letzten 2 Jahrzehnten eine Häufigkeitssteigerung zu verzeichnen mit der Forderung geeignete Maßnahmen zu finden, die häufig schwerwiegenden Folgeerscheinungen zu mindern. Mit Entwicklung eines bestimmten neurorehabilitativen Behandlungsregimes ergeben sich die Fragen, welche CIP Patienten profitieren, ergeben sich prognoserelevante Faktoren und welche Art und Dauer der Neurorehabilitation vorgehalten werden muss. In der vorliegenden Arbeit wurden retrospektiv die Entlassungsbriefe der Patienten mit einer CIP der Abteilung für neurologisch-neurochirurgisch Frührehabilitation der Jahre 2004-2008 ausgewertet. Die Beurteilung der Fähigkeitsstörungen erfolgte mit dem Frührehabilitations-Barthel-Index nach Schönle, dem Barthel-Index sowie dem FIM und das Handicap wurde mit der 8-stufigen Glasgow-Outcome-Scale bewertet. Zusätzliche Parameter waren das Alter und Geschlecht, die Ursache der CIP, die Zeit von Erkrankungsbeginn bis zur Aufnahme, die Behandlungsdauer, Komplikationen sowie die Entlassungsart. 200 Patienten, 67,5% Männer und 32,5% Frauen konnten ausgewertet werden. Eine Häufung des Erkrankungsbildes fand sich bei Patienten ab dem 60. Lebensjahr. Eine Ursachenpräferenz fand sich nicht, wobei im Wesentlichen kardiale, respiratorische und gastrointestinale Erkrankungen vorgefunden worden waren. Alle Patienten konnten, nach einer durchschnittlichen Behandlungsdauer von 40 Tagen, von der Frührehabilitationsbehandlung profitieren. So konnten 34% in weiterführende rehabilitative Behandlungsstufen und 17,5% der Patienten gebessert nach Hause entlassen werden. Die Sterblichkeit mit 11% muss der besonderen Schwere des Krankheitsbildes angelastet werden. Dies wird durch die Feststellung gestützt, dass die Komplikationsrate mit über 60% während der rehabilitativen Behandlung sehr hoch lag. Hervorzuheben ist, dass sich herausarbeiten ließ, dass sich eine längere Behandlung positiv auf die Behandlungsergebnisse, auch bei schwer Betroffenen auswirkte. Die auslösende Ursache scheint keinen wesentlichen Einfluss auf das outcome zu haben. Männer profitieren bei der Wiedererlangung motorischer Fähigkeiten etwas besser als Frauen. Die älteren Patienten zeigen gute Verbesserungen bei körperlichen Funktionsstörungen. Bezogen auf die kognitiven Fähigkeiten muss aber das Alter als negativer Prädiktor angesehen werden. Der Grad der Behinderung hat einen deutlichen Einfluss auf die Behandlungsdauer und Behandlungsergebnisse. Demgegenüber stellt eine primäre Intensivpflicht einen negativen Prädiktor, auch wenn auch diese Patienten von der Rehabilitation profitieren. / The Critical-lllness-Polyneuropathie (CIP) is an illness of the peripheral nervous system after a severe illness with intensive care treatment. It is known since the 19th century and cannot be distinguished easyly from the Critical Illness Myopathie which can appear in the same context. The situation is complicated by the fact that both dysfunctions can appear combined. Because of the advances in the medicine the frequency of the CIP has increased in the last 2 decades. The question is which patients profits from a certain neurorehabilitativen treatment, which factors are relevant for the prognosis and which kind and duration of the neurorehabilitation must be reproached.

Support provided by non-professional family members is generally believed to be beneficial to the recovery of critically ill patients. Nursing researchers have conducted a number of studies about the experiences of critically ill patients and the needs of their families. However, few have investigated the experiences and interactions of both this group of patients and their main informal carers (principal lay support persons) simultaneously. This study has sought to rectify this situation by capturing and undertaking a theoretical analysis of the perceptions and experiences of both critically ill patients and their principal lay support persons. As a result a substantive theory has been developed through the use of grounded theory method in the Study. This theory identifies and explains the actions and interactions between critically ill patients and their principal lay support persons who participated in the Study, whom the researcher observed and interviewed during the data collection period. Data were collected during the critically ill participant¡¦s hospitalisation and three months following his/her discharge from hospital. Implications of the study concern nursing practice as well as outcomes of the Study as these are described and explained through the substantive theory developed from it. Testing of this theory in the context of critically ill patients and their lay support persons provides opportunities for further research, as does the overall phenomenon of lay person support for critically ill patients. Grounded theory was the method used in the Study. Data for the Study were collected by participant observation of, and face-to-face interviews with patients who had a critical illness and their principal lay support persons. Two interviews were conducted with each of these participants. Patients and their principal lay support persons were initially interviewed separately to obtain information about their individual perspectives of what support meant to them during an episode of critical illness. A second interview was conducted three months later to facilitate the researcher¡¦s understanding of both patients¡¦ and principal lay support persons¡¦ experiences during the recovery process. A total of sixteen (16) interviews were conducted in this study from eleven (11) participants before data saturation occurred. The data collected were analysed by constant comparative analysis integral to the grounded theory approach. Data analysis was also facilitated by a computer-aided qualitative data analysis software NUD*IST 4 (Non-numerical Unstructured Data Indexing, Searching, and Theorizing Version 4). This software aided the analysis to the extent that it provided an efficient data management system. Three categories, 1) being-there-with, 2) independing, and 3) coping were discovered from the data. Being-there-with is an essential and mutual need between the patients and their principal lay support persons during the episode of critical illness and later recovery. Independing on the other hand is the process through which these patients experiment with regaining their independence. It involves their experiences of making decisions and re-building confidence. Coping is the process whereby the principal lay support persons and patients manage their stress during the critical illness and later recovery. During the coping process, there is an uncertainty in principal lay support persons about their loved ones¡¦ situation. They experience ¡¥coping with each day as it comes¡¦ and ¡¥learn to adjust¡¦ to the stress arising from the changing and unpredictable condition of the patients. Being-there-with is also a major coping strategy for both the principal lay support persons and patients to manage their stress. The three categories of being-there-with, independing, and coping arising from this Study provided the basis from which to identify its core category, ¡¥mutually being-there-with each other¡¦, and to theorize the core process that represents the substantive theory about experiences and interactions of principal lay support persons and their loved ones during a critical illness situation. The core process that represents the developed substantive theory is ¡¥surviving a critical illness through mutually being-there-with each other¡¦. This theory explains the complex, dynamic, and interactive nature of principal lay person support which both patients and principal lay support persons experienced during an episode of critical illness and later recovery. An understanding of this dynamic, complex and interdependent relationship between patients and lay support persons will better enable nurses to consider both these parties as the focus of their care. Furthermore, because the substantive theory emerging from this Study captures the process of patients¡¦ and lay support persons¡¦ recovery from an episode of critical illness it provides a conceptual map of how this process may progress. In this Study the theory enables nurses to gauge both patients¡¦ and lay support persons¡¦ progress along the road to recovery and to consider this in their plan of care. Several implications for nursing practice emerged from this study. These relate to the needs of critically ill patients and their principal lay support persons during the process of being critically ill and recovering which they experienced together. Because this Study identified the importance to both patients and principal lay support persons being-there-with each other, a key implication of the study is the need for intensive care units to adopt flexible visiting hours to maximise opportunities for this to occur. Nevertheless, at the same time nurses need to be vigilant that flexible visiting does not prove onerous and overtire patients or their principal lay support persons. A further implication of the Study for nursing practice closely related to its finding of the importance of the core category ¡¥mutually being-there-with each other¡¦ to patients and their lay support persons in the context of critical illness and recovery, is the need for nurses (and other health professionals) to be willing to care for both parties as an inseparable dyadic unit. This Study also has implications relating to the care of critically ill patients following their discharge home. The experience of participants in this Study revealed the importance of careful discharge planning, post-ICU follow-up, and continuity of care in the community to enhance recovery of the patients and to address the special needs of their principal lay support persons. From a researcher¡¦s perspective the process of recruitment for this study demonstrated that recruitment of vulnerable populations (like ICU patients) is a challenge to the researcher in terms of ethical considerations, particularly when the researcher is attempting to meet the expectation of primary selection for theoretical sampling in grounded theory method. Suggestions are made in this thesis about how to tackle this challenge in future studies. At the conclusion of the Study, a number of suggestions for further research are made relating to the findings. These include the recommendation that the substantive theory developed in this Study be tested with a larger population. It is also suggested that a longitudinal follow-up study, which extends beyond a three months recovery period, be conducted to further understand the experiences and support needs of post-ICU patients and their principal lay support persons. In addition, more research is required to identify best practice regarding discharge planning, post-ICU follow-up care, and continuity of care in the community for critically ill patients and their principal lay carers. / PhD Doctorate

Thesis (M.S.)--University of Michigan, 1996. / Includes bibliographical references.