Bakgrund: På intensivvårdsavdelningar finns olika rutiner kring huruvida endotrakealtubens position hos intuberade skall skiftas eller bibehållas i samma mungipa, då sidbyten kan leda till allvarliga komplikationer. Rutinen vid CIVA har varit att byta endotrakealtubens position på alla intuberade patienter en gång per dygn. Varken rutinen med skifte samt bibehållen position har utvärderats. Syftet med studien är att undersöka oralt intuberade patienters munhälsa vid bibehållen position av endotrakealtub under vårdtiden. Metod: Studien är en kvantitativ deskriptiv tvärsnittsstudie. Ett protokoll utformades för att undersöka hur stor andel av patienterna som får tryckskador i munnen med bibehållen tublägesposition. Resultat: Av totalt 85 oralt intuberade patienter utvecklade 10 rodnad och 7 sår medan 68 hade helt intakt slemhinna. Flest nyupptäckta sår uppkom efter 3-4 dagars intubering medan rodnader var jämnt fördelat. Slutsats: Endast ett fåtal patienter utvecklade tryckskador. Rutinen att bibehålla endotrakealtuben i samma position lämpar sig på patientkategorin på CIVA eftersom medelvårdtiden för intuberade är 3,2 dagar och flertalet extuberas under de 3 första dagarna. Klinisk betydelse: Studien ligger till grund för CIVA:s ändrade rutin att bibehålla endotrakealtubspositionen i samma mungipa och skulle på sikt kunna bidra till att minska samhällskostnaderna genom att reducera förekomsten av VAP och därmed patientvårdtiden / Background: Intensive care units have different routines whether the endotracheal tube position should be shifted or maintained in the same corner of the mouth. Repositioning of the tube can lead to serious complications. The routine at CIVA has been to change the endotracheal tube position in all intubated patients once per day. None of the routines have been evaluated. The objective of this study is to examine the oral health of intubated patients with maintained tube position. Method: The study is a quantitative descriptive cross-sectional study. A protocol was designed to examine the proportion of patients receiving pressure sores in the mouth. Results: Of a total of 85 orally intubated patients, 10 developed redness and 7 wounds while 68 had intact mucosa. The majority of the newly discovered sores occurred after 3-4 days of intubation. Conclusion: Only a few patients developed pressure sores. The routine to maintain the endotracheal tube in the same position is suitable for the patient category at CIVA since the average length of stay for intubated is 3.2 days and the majority were extubated during the first 3 days . Clinical significance: This study is the basis for CIVA's changed routine to maintain the endotracheal tube position in the same corner of the mouth and could eventually help to reduce the costs for society by reducing the incidence of VAP and thus patient care period.

No description available.

The increased survival of high-risk preterm infant has required a great number of studies about his/her quality of life and integration during development process with the need for a greater improvement and specialization in the other areas who cares of these children. Many premature infants need to receive mechanical ventilation and it may represent a risk factor for the development of the stomatognathic system causing difficulties in the introduction of oral feeding. This paper aims to evaluate the effects of the endotracheal tube used for mechanical ventilation on the oral skills and feeding performance of preterm infants. Forty-five preterm infants were selected in the Neonatal Intensive Care Unit (NICU) at the University Hospital of Santa Maria (HUSM) from February 2012 to February 2013. The babies were enrolled at the time to begin oral feeding, after parent s consent was obtained. Children who presented head or neck malformation, genetic syndromes, heart problems, perinatal asphyxia, intracranial haemorrhage grades III and IV and bilirubin encephalopathy were exclude. Participants were divided in two groups according the use or not of endotracheal tube. The oral skills were evaluated at the time to begin oral feeding through two distinct protocols: Fujinaga et al. (2005) and Lau and Smith (2011). The data were analyzed using software Stata 10, being considered as significant the p value < 0.05. We concluded that the use of endotracheal tube during neonatal hospitalization negatively influenced the feeding performance and prolonged the time to acquisition full oral feeding in preterm infants. However, it seems have no influence on oral skills according the protocols. The protocol proposed by Fujinaga seems better discriminate the oral skills when compared to the Lau and Smith s protocol. / O aumento na sobrevida do recém-nascido pré-termo (RNPT) de alto risco tem exigido um grande número de estudos acerca da qualidade de vida e da integração da criança prematura ao longo da sua trajetória de desenvolvimento. Para isso, houve necessidade de um aperfeiçoamento e especialização das demais áreas que prestam assistência a estas crianças. Muitos prematuros necessitam da utilização de ventilação mecânica, o que pode representar um fator de risco ao desenvolvimento do sistema estomatognático e, conseqüentemente, dificultar a introdução da alimentação por via oral nesse grupo de crianças. O objetivo deste estudo foi o de avaliar os efeitos da utilização do tubo orotraqueal, durante a ventilação mecânica, sobre as habilidades orais e a performance alimentar do RNPT, na liberação da via oral. Para isso, foram avaliados 45 RNPT na Unidade de Terapia Intensiva Neonatal (UTIN) do Hospital Universitário de Santa Maria (HUSM), na cidade de Santa Maria RS, no período compreendido Fevereiro de 2012 e Fevereiro de 2013. Foram selecionados recém-nascidos pré-termo, de ambos os sexos, no momento da liberação médica para início da alimentação por via oral, cujos pais autorizaram a participação na pesquisa, após assinatura do Termo de Consentimento Livre e Esclarecido. Não foram incluídas crianças com malformações de cabeça e pescoço, síndromes genéticas, complicações cardíacas, asfixia perinatal (Apgar no 5º minuto ≤ 5), hemorragias intracranianas grau III e IV e encefalopatia bilirrubínica. Os participantes foram distribuídos em dois grupos segundo o uso ou não do tubo orotraqueal e submetidos à avaliação das habilidades orais, no momento da liberação para início da via oral, através de dois distintos protocolos ((Fujinaga (2005) e Lau e Smith (2011)). Os dados foram analisados através do software Stata 10, sendo considerado como significativo um valor de p<0,05. Os resultados obtidos, permitiram concluir que a utilização de tubo orotraqueal, durante a internação neonatal, influenciou negativamente a performance alimentar de RNPT, no momento da liberação para a via oral, dificultando a aquisição da via oral plena. No entanto, não houve diferença significativa, entre os grupos, na avaliação das habilidades orais. O protocolo de avaliação de Fujinaga et al.(2005) pareceu discriminar melhor as habilidades orais de RNPT,quando comparado ao de Lau e Smith (2011).

Bakgrund: Syrgas används liberalt hos vuxna endotrakealt intuberade patienter peroperativt för att ge en skyddande marginal mot livshotande hypoxi. Ett överskott av syrgas kan dock öka risken för allvarliga biverkningar med en potentiellt negativ påverkan på både morbiditet och mortalitet. Vilken mängd syrgas som skall användas peroperativt är en omdiskuterad fråga i forskningsvärlden där RCT och metaanalys-studier kommer med motstridiga uppgifter om vad som faktiskt är det optimala oxygenmålet peroperativt. Motiv: Det finns meningsskiljaktigheter kring peroperativ oxygenering där nuvarande forskning om vad som är det optimala för patienten skiljer sig från studie till studie. Författarna av denna studie anser att det behövs en djupare förståelse av den ansvariga anestesisjuksköterskans erfarenheter och tankar kring peroperativ oxygenering, framförallt då det saknas evidens att luta sig mot. Syfte: Att beskriva anestesisjuksköterskors tankar och erfarenheter av peroperativ oxygenering hos vuxna endotrakealt intuberade patienter. Metod: Individuella semi-strukturerade intervjuer genomfördes med anestesisjuksköterskor (n=10) på två olika sjukhus i mellansverige. En kvalitativ innehållsanalys användes för att bearbeta och analysera datan. Resultat: Analysen genererade tre huvudkategorier; En snäv balansgång - Att undvika hypoxi och hyperoxi, Upprätthållande av en patientsäker ventilation är ett mål och Vad är den optimala FiO2-nivån? En vilja om att arbeta evidensbaserat. Konklusion: Det är en pågående debatt internationell om vad den optimala målnivån av peroperativ FiO2 är. Med anledning av det oklara evidensläget visade det sig att anestesisjuksköterskorna arbetar efter beprövad erfarenhet när peroperativ FiO2 ställs in till patienten. De målnivåer av FiO2 som anestesisjuksköterskorna använder innehåller en säkerhetsmarginal för hypoxi och hänsyn tas till patientens sjuklighet. Rutinmässig hyperoxi förekommer inte och höga nivåer FiO2 likställs med ökad risk för komplikationer. Vidare forskning inom ämnet behövs som stöttning för patientansvarig anestesisjuksköterska i dess dagliga arbete. / Background: Oxygen is used liberally in adult endotracheal intubated patients intraoperative to provide a protective margin against life-threatening hypoxia. A surplus of oxygen can however increase the risk of serious side effects with a potentially increased long-term mortality. The use of oxygen intraoperative is a highly debated question in the scientific community, where RCT and metaanalysis studies are producing contradictory results about what the optimal oxygenation target intraoperative really is. Motive: There is a disagreement about intraoperative oxygenation where the current evidence about what the optimal target for the patient really is; this varies from study to study. The authors of this study thereby consider that there is a need for a deeper understanding of the responsible nurse anesthetist’s experiences and thoughts on intraoperative oxygenation; above all when there is no definitive evidence to lean on. Aim: The aim of this study was to describe nurse anesthetists’ thoughts and experiences of intraoperative oxygenation at adult patients who are endotracheal intubated. Methods: Individual semi-structured interviews were conducted with nurse anesthetists (n=10) at two different hospitals in the middle of Sweden. Qualitative content analysis was used to process the data. Result: The analysis generated three main categories; A narrow balancing act – To avoid hypoxia and hyperoxia, Maintaining patient-safe ventilation is a goal and What is the optimal level of FiO2? A desire to work evidence-based. Conclusion: There is an ongoing debate internationally about what the optimal target level of intraoperative FiO2 is. Due to the unclear state of evidence, it turned out that the nurse anesthetists work after proven experience when intraoperative FiO2 is set for the patient. The target levels of FiO2 used by the nurse anesthetists contain a margin of safety for hypoxia and the patient's morbidity is taken into account. Routine hyperoxia does not occur and high levels of FiO2 are equated with an increased risk of complications. Further research is needed in the subject to support the nurse anesthetists responsible for the patient in their daily work.

<p>Evaluating respiratory mechanics during dynamic conditions without interrupting ongoing ventilation and flow, adds to the information obtained from the mechanics derived from static (= no flow) conditions, i.e., the flow signal has the potential to provide information on the properties of the respiratory system (including the tubing system). Hence monitoring the changes in the flow signal during ongoing mechanical ventilation would give information about the dynamic mechanics of the respiratory system. Any change in the mechanics of the respiratory system including the endotracheal tube (ETT) and the ventilatory circuit would affect the shape of the flow signal. </p><p>Knowledge of the airway pressure distal to the ETT at the carina level (= tracheal pressure) is required for calculating the extra resistive load exerted by the endotracheal tube in order to compensate for it. In a porcine model, the flow signal was used to non-invasively calculate tracheal pressure. There was good agreement between calculated and measured tracheal pressure with different modes of ventilation. However, calculation of tracheal pressure assumes that the inner diameter of the ETT is known, and this assumption is not met if the inner diameter is narrowed by secretions. Flow that passes a narrowed tube is decelerated and this is most pronounced with the high flow of early expiration, yielding a typical time constant over expiratory volume pattern that is easy to recognize during mechanical ventilation. This pattern reliably detected partial endotracheal obstruction during volume and pressure controlled mechanical ventilation. </p><p>A change in compliance of the respiratory system modifies the elastic recoil and this also affects the rate of the expiratory flow and the shape of its signal. In a porcine model, lung volume gains on the flow signal generated by the heartbeats (cardiogenic oscillations) provided information about the compliance of the respiratory system during ongoing mechanical ventilation</p><p>In conclusion analyzing the flow signal during ongoing ventilation can be a cheap, non-invasive and reliable tool to monitor the elastic and resistive properties of the respiratory system including the endotracheal tube.</p>

Evaluating respiratory mechanics during dynamic conditions without interrupting ongoing ventilation and flow, adds to the information obtained from the mechanics derived from static (= no flow) conditions, i.e., the flow signal has the potential to provide information on the properties of the respiratory system (including the tubing system). Hence monitoring the changes in the flow signal during ongoing mechanical ventilation would give information about the dynamic mechanics of the respiratory system. Any change in the mechanics of the respiratory system including the endotracheal tube (ETT) and the ventilatory circuit would affect the shape of the flow signal. Knowledge of the airway pressure distal to the ETT at the carina level (= tracheal pressure) is required for calculating the extra resistive load exerted by the endotracheal tube in order to compensate for it. In a porcine model, the flow signal was used to non-invasively calculate tracheal pressure. There was good agreement between calculated and measured tracheal pressure with different modes of ventilation. However, calculation of tracheal pressure assumes that the inner diameter of the ETT is known, and this assumption is not met if the inner diameter is narrowed by secretions. Flow that passes a narrowed tube is decelerated and this is most pronounced with the high flow of early expiration, yielding a typical time constant over expiratory volume pattern that is easy to recognize during mechanical ventilation. This pattern reliably detected partial endotracheal obstruction during volume and pressure controlled mechanical ventilation. A change in compliance of the respiratory system modifies the elastic recoil and this also affects the rate of the expiratory flow and the shape of its signal. In a porcine model, lung volume gains on the flow signal generated by the heartbeats (cardiogenic oscillations) provided information about the compliance of the respiratory system during ongoing mechanical ventilation In conclusion analyzing the flow signal during ongoing ventilation can be a cheap, non-invasive and reliable tool to monitor the elastic and resistive properties of the respiratory system including the endotracheal tube.

Introduktion: Anestesisjuksköterskor arbetar inom flera olika delar av sjukvården. Tack vare deras kunskaper om luftvägar och omhändertagande av kritiskt sjuka patienter så anställs anestesisjuksköterskor inom olika prehospitala verksamheter så som exempelvis resursenheter. Vid plötsliga hjärtstopp är upprättandet av en fri luftväg kritiskt. Detta görs vanligen genom användandet av olika medicintekniska hjälpmedel som larynxmask eller endotrachealtub. De respektive hjälpmedlen har olika styrkor och svagheter som är väl studerade, men upplevelser av att använda dessa metoder finns det lite forskning om. Syfte: Syftet med studien var att studera anestesisjuksköterskans upplevelser av att använda larynxmask och endotrachealtub vid plötsliga hjärtstopp utanför sjukhuset. Metod: En kvalitativ induktiv enkätstudie med öppna semistrukturerade frågor genomfördes för att fånga användarnas upplevelser av skillnader mellan dessa metoder av luftvägshantering. 14 anestesisjuksköterskor med minst två års erfarenhet samt erfarenhet av att arbeta prehospitalt deltog i studien. Deltagarna arbetar i tre regioner vilka har stora skillnader i resurser och arbetsrutiner. Resultat: Larynxmask var mest använt, trots att nästan alla deltagare föredrog att ha patienten intuberad. Orsaken till att laynxmasken användes trots att deltagarna föredrog att patienten skulle ha en endotrachealtub varierade något men hade flera gemensamma faktorer så som tidsåtgång och enkel användning. / Introduction: Nurse anesthesias work in different parts of healthcare. In various prehospital activities and different resource units these specialist nurses are often hired for their knowledge of the airways and critical patients. In case of sudden cardiac arrest, the establishment of a free airway is critical. This is usually done using various medical aids such as a laryngeal mask or endotracheal tube. These have their different strengths and weaknesses that are well studied, but there is little research on experiences of using these methods. Aim: The aim of the study was to study anesthesia nurses' experiences of using a laryngeal mask and endotracheal tube in sudden cardiac arrest outside the hospital. Method: A qualitative inductive survey with open semistructural questions, was done to capture the users’ experiences of the differences between these methods of airway management. This study included 14 nurse anesthetists, with at least 2 years of experience and experience of working in a prehospital setting. Participants from three regions participated, those regions differ in resources and ways of working routines. Result: The laryngeal mask is most commonly used, even though almost all participants prefer to have an intubated patient. The reasons for that varies between the participants but have several common factors such as time of application and ease of use.

The continuous emergence of drug-resistance pathogens is a global concern. As a result, substantial effort is being expended to develop new therapeutics and mechanisms for controlling microbial growth to avoid entering a "post-antibiotic" era in which commonly used antibiotics are no longer effective in treating infections. In this work, we investigate the efficacy and application of ceragenins as non-peptide mimics of antimicrobial peptides (AMPs). First, this work examines the susceptibility of drug-resistant Gram-negative bacteria. The susceptibility of colistin-resistant clinical isolates of Klebsiella pneumoniae to ceragenins and AMPs suggests that there is little to no cross-resistance between colistin and ceragenins/AMPs. Furthermore, Lipid A modifications are found in bacteria with modest changes in susceptibility to ceragenins and with high levels of resistance to colistin. Next, we investigated the potential for cross resistance between chlorhexidine, colistin, AMPs and ceragenins as repeated exposure of bacteria to chlorhexidine might result in cross resistance with colistin, AMPs or ceragenins. Furthermore, a proteomics study on the chlorhexidine-resistant strains showed that chlorhexidine resistance is associated with upregulation of proteins involved in the assembly of LPS for outer membrane biogenesis and virulence factors in Pseudomonas aeruginosa.Second, this dissertation describes the antifungal activity of ceragenins against an emerging multidrug-resistant fungus, Candida auris. We found that lead ceragenins displayed activities comparable to known antifungal agents against C. auris isolates. We also found that fungal cell morphology was altered in response to ceragenin treatment, that ceragenins exhibited activity against sessile organisms in biofilms, and that gel and cream formulations including CSA-44 and CSA-131 resulted in a significant log reduction against established fungal infections in ex vivo mucosal tissues. Finally, a hydrogel film containing CSA-131 was generated on endotracheal tubes (ETTs). ETTs provide an abiotic surface on which bacteria and fungi form biofilms that cause serious infections. In this study, the eluting ceragenin prevented fungal and bacterial colonization of coated ETTs for extended periods while uncoated tubes were colonized by bacteria and fungi. Coated tubes were well tolerated in intubated pigs. The ability of ceragenins to eradicate established biofilms make them attractive potential therapeutics for persistent infections in the lung, including those associated with cystic fibrosis. In ex vivo studies, we initially found that this ceragenin, at concentrations necessary to eradicate established biofilms, also causes loss of cilia function. However, by formulating CSA-131 in poloxamer micelles, cilia damage was eliminated and antimicrobial activity was unaffected. These findings suggest that CSA-131, formulated in micelles, may act as a potential therapeutic for polymicrobial and biofilm-related infections in the lung and trachea.

<p>This thesis looks at two sides of the same coin: how to support the production and future development at a specialist medical technology department at Danderyd Hospital. The two sides are; a pilot study of a product management system (PDM) and an interview based study on the characteristics of the silent knowledge of the technicians. The department (National respiratory centre, NRC) is facing retirement of several key employees.</p><p>The technical study shows that the success of an implementation is largely dependent on the users’ prior knowledge and use of a 3D Computer aided design system (CAD).The system itself is shown to fulfill the Lifecycle requirement of tracking the products (mostly tracheostomy tubes) but without a CAD centered workflow, some substantial education and preferably some new recruits, an implementation of the PDM system will fail. The author recommends development of the current “low-tech” system of MS Excel and Access rather than redistribute the dependency from technician towards a complex, commercial software and its vendor.</p><p>The analysis of the technicians’ silent knowledge with the newly developed method, epithet for silent knowledge (ETK), shows that the longer employment time:</p><ul><li>the more differentiated technicians become in describing their work,</li><li>practical knowledge are regarded higher and</li><li>the social and collective problem solving factors of the work becomes more important.</li></ul><p>Typically, it is shown that a new employee should preferably enjoy problem solving, being pragmatic and social as well as having some prior education or work experience in a CAD and/or a PDM system.</p>

This thesis looks at two sides of the same coin: how to support the production and future development at a specialist medical technology department at Danderyd Hospital. The two sides are; a pilot study of a product management system (PDM) and an interview based study on the characteristics of the silent knowledge of the technicians. The department (National respiratory centre, NRC) is facing retirement of several key employees. The technical study shows that the success of an implementation is largely dependent on the users’ prior knowledge and use of a 3D Computer aided design system (CAD).The system itself is shown to fulfill the Lifecycle requirement of tracking the products (mostly tracheostomy tubes) but without a CAD centered workflow, some substantial education and preferably some new recruits, an implementation of the PDM system will fail. The author recommends development of the current “low-tech” system of MS Excel and Access rather than redistribute the dependency from technician towards a complex, commercial software and its vendor. The analysis of the technicians’ silent knowledge with the newly developed method, epithet for silent knowledge (ETK), shows that the longer employment time: the more differentiated technicians become in describing their work, practical knowledge are regarded higher and the social and collective problem solving factors of the work becomes more important. Typically, it is shown that a new employee should preferably enjoy problem solving, being pragmatic and social as well as having some prior education or work experience in a CAD and/or a PDM system.