Oavsiktlig hypotermi är ett ämne som hamnat i skymundan i den hektiska intraoperativa fasen för anestesisjuksköterskan. Patientens nedkylning påbörjas redan vid de preoperativa förberedelserna. En salstemperatur under 22˚C är den vanligaste orsaken till hypotermi hos patienterna och deras kroppstemperatur bör inte understiga 36,5˚C. Förebyggande åtgärder som att använda värmefiltar, salstemperatur på 22˚C-23˚C, varma infusioner i blodvärmare, inte exponera mer hud än nödvändigt samt postoperativt använda sig av värmetak. Kroppstemperaturen bör övervakas vid operationer längre än 30 minuter. Genom ökat fokus på kroppstemperaturen i den intraoperativa fasen kan postoperativa komplikationer minskas samt förkorta vårdtiden. Kan påverkbara faktorer under den intraoperativa fasen påverka och minska risken för oavsiktlig hypotermi? Fokus ligger på utvärdering av metod och mätinstrument. Syftet med den randomiserade pilotstudien är att undersöka patienter som drabbas av oavsiktlig hypotermi som genomgår hysterektomi med generell anestesi. Metoden är en kvantitativ pilotstudie med randomiserat urval samt en litteraturgranskning för förbättring av instrumentutveckling. Antalet deltagare i studien var 15 stycken, inga generella slutsatser kan dras. Mild hypotermi har 60 % av deltagarna redan innan operationsstart. Tio av 15 patienter uppnår ej 37°C under de första 30 minuterna oavsett bair hugger eller ej. Temperaturtagning 30 minuter efter ankomst till postoperativaavdelningen är mellan 35,4°C-37,2˚C. För att få ett heltäckande formulär om den perioperativa vården utförs en instrumentutveckling inför kommande primärstudie. Anestesisjuksköterskan är ansvarig för att förebygga och åtgärda hypotermi i enlighet med vad som är bäst för patienten. Vårdtagaren ska alltid stå i centrum och hypotermi är något som lätt kan åtgärdas bara medvetandet inom kunskapsområdet ökar. / Program: Specialistsjuksköterskeutbildning med inriktning mot anestesisjukvård

Patientens liggkomfort under ambulanstransport är en viktig faktor i omvårdnaden i ambulanssjukvård. Vi tror att en ökad komfort kan minska patientens lidande. Det är flera faktorer som påverkar komforten i en ambulans, hur fordonet framförs, hur vårdaren agerar, patientens tillstånd mm. När det kommer till liggkomforten är personalen begränsad av det material som finns att tillgå. I syfte att förbättra komforten har vi haft möjlighet att prova en säck, att transportera patienter i och jämföra den med det gamla sättet, med lakan och filtar. Kan ett nytt sätt att bädda ner patienten kunna förbättra komforten under ambulanstransport?Studiens syfte var att undersöka patienters upplevelse vid användandet av två olika metoder för bäddning på ambulansbåren. Studien är kvantitativ randomiserad interventionsstudie för att jämföra patientens upplevda komfort vid två olika bäddmetoder. Datainsamlingen har bestått av enkäter där patienter besvarat frågor angående den upplevda komforten under ambulanstransport. Patienterna fick besvara sex påstående angående komfort, temperatur, trygghet och integritet. Enkäten besvarades av 94 patienter. Hälften av dessa har transporterats med lakan och filtar och resten med patientsäckar.Studien visar att vid samtliga påstående har patienterna i patientsäcksgruppen varit mer positiva, men skillnaderna har inte varit signifikanta.Denna studie omfattar ett relativt litet antal patienter, ett större material behövs för att generalisera eventuella skillnader mellan grupperna. Resultaten pekar ändå på att patienterna som transporterades i patientsäcken upplevde en större komfort. / <p>Program: Fristående kurs</p><p>Uppsatsnivå: C</p>

Abstract Hypothermia deaths pose a difficult challenge from the medico-legal point of view because no specific traces are left on the cadaver to be examined post-mortem. The concentrations of urinary catecholamines, adrenaline and noradrenaline increase in various stressful situations including cold stress, and high levels have been considered to be suggestive of lethal hypothermia. There is, however, a need for a better hypothermia indicator. A potential candidate could be thrombomodulin (TM), an endothelially expressed protein whose plasma concentration has been shown to elevate in response to hypothermia. TM and catecholamine levels were studied in short-term cold exposure (human subjects, n = 7), in mild and severe hypothermia with or without rewarming (rats, n = 96) and in hypothermia deaths compared with deaths from cardiovascular diseases, traumas and other causes (autopsy cases, total n = 552). Myocardial thrombomodulin transcript expression was increased in severely hypothermic rats, but was lower in hypothermia deaths than in other causes. The circulating TM level was transiently reduced in severe hypothermia. The myocardial and urinary TM protein levels were reduced in lethal hypothermia compared with other causes of death. TM and catecholamine levels correlated significantly in blood and urine both in living subjects and post-mortem examination. In severely hypothermic rats, there was an inverse relationship between plasma adrenaline concentration and myocardial thrombomodulin transcript level. The results suggest that TM expression and secretion are altered by hypothermia, possibly linked to the actions of catecholamines. Analysing the post-mortem catecholamine and TM levels provides evidence of ante-mortem cold stress in suspected hypothermia deaths. Further studies should be conducted in order to reveal the exact mechanisms behind the regulation of TM on cell level. / Tiivistelmä Paleltumiskuolemat ovat oikeuslääketieteellisesti haastavia, koska vainajaan ei jää paleltumiseen viittaavia yksiselitteisiä löydöksiä. Virtsan katekoliamiinien, adrenaliinin ja noradrenaliinin, pitoisuudet kasvavat stressitilanteissa kuten kylmäaltistuksessa. Korkeita pitoisuuksia on pidetty paleltumiseen viittaavana tekijänä. Paremmalle paleltumista osoittavalle merkkiaineelle on kuitenkin selkeä tarve. Eräs mahdollinen merkkiaine voisi olla trombomoduliini (TM), joka on endoteelisolujen tuottama proteiini. Sen plasmapitoisuuden on aiemmin osoitettu nousevan alilämpöisyystilassa. TM- ja katekoliamiinitasoja tutkittiin lyhyessä kylmäaltistuksessa (koehenkilöt, n = 7) sekä lievässä ja vaikeassa alilämpöisyystilassa joko lämmityksen jälkeen tai ilman lämmitystä (rotat, n = 96). Lisäksi verrattiin paleltumisen, sydän- ja verisuonitautien, vammojen sekä muiden syiden aiheuttamia kuolemia (ruumiinavausaineisto, n = 552). Sydänlihaksen trombomoduliini-transkriptin taso oli kohonnut vaikeasti alilämpöisillä rotilla, mutta se oli matalampi paleltumiskuolemissa kuin muissa kuolemissa. Veren TM-taso oli hetkellisesti alentunut vaikeassa alilämpöisyystilassa. Sydänlihaksen ja virtsan TM-proteiinipitoisuudet olivat matalampia paleltumiskuolemissa kuin muissa kuolemansyissä. TM- ja katekoliamiinitasot korreloivat merkittävästi veressä ja virtsassa sekä koehenkilöillä ja -eläimillä että vainaja-aineistossa. Vaikeasti alilämpöisillä rotilla todettiin käänteinen suhde plasman adrenaliinipitoisuuden ja sydänlihaksen trombomoduliini-transkriptitason välillä. Tulosten perusteella alilämpöisyystila muuttaa TM:n ekspressiota ja erittymistä, mikä voi liittyä katekoliamiinien vaikutuksiin. Kuolemanjälkeisten TM- ja katekoliamiinitasojen määritys tuo lisänäyttöä kuolemaa edeltäneestä kylmävaikutuksesta epäiltäessä paleltumiskuolemaa. Lisätutkimuksia tarvitaan TM:n solutason säätelymekanismien selvittämiseksi.

Made available in DSpace on 2016-01-26T12:51:52Z (GMT). No. of bitstreams: 1 salomonrajas_tese.pdf: 1978465 bytes, checksum: ca15f774abde6ac24567685d49084f3a (MD5) Previous issue date: 2003-05-29 / Introduction: The surgical treatment of the aneurysm of descending thoracic and thoracoabdominal aorta are related with risk of spinal cord ischemic, as well as, coagulation and renal function disorders. Among the spinal cord protection methods, there are liquor drainage, temporary bypass, intercostal arteries implant, deep hypothermia, selective cooling of spinal cord and drugs. Objective: The goal of this paper is to show the viability of using extracorporeal circulation from left atrium to ascending aorta with deep hypotermia for surgical treatment of the thoracic and thoracoabdominal aneurysms. Material and Methods: From January 1994 to July 2001, thirty eight patients were operated, 26 male with mean age of 54.6±12.7. Twelve patients (31.6%) were submitted to correction of thoracoabdominal aneurysm and twenty six to correction of descending aorta aneurysm. The etiologies were: post-trauma in one patient, dilatation after correction of coarctation of the aorta in four patients, syphilitic aortite in two , atherosclerotic in ten patients and aortic dissection in twenty one patients. After extracorporeal circulation installed, the patients were cooled, the faryngeal temperature ranged from 15° and 25°C (20.6±3.2°C). The total circulatory arrest time from nine to thirty six minutes (21.3±6.7). The aortic diameter ranged from 4 to 10.5 cm (8.1±1.5 cm). Results: As neurological complications, paraplegia ocurred in two cases (5.3%) and in one of them there was stroke associated. One patient had paraparesis in inferior members and one, had seizure. The respiratory complications ocurred in twelve (31.6%) patients and tracheostomy was necessary in two cases por delayed ventilaroty support. Two patients from this group (16.7%) died. Two patients had transitory elevation of creatinine but dialysis was not necessary. Emergency operation was performed in two cases and both died. The overall mortality was seven patients (18.4%) and the causes were: bleeding in one patient, respiratory insufficiency in two patients, sudden death in two, heart failure in one and failure of weaning from extracorporeal circulation. Conclusion: Surgical correction of descending thoracic aorta and thoracoabdominal aneurysms during deep hypothermia using extracorporeal circulation with cannulation of left atrium and ascending aorta is a safe method, with low mortality. The complications such as neurologic, respiratory and renal were according to the literature. / O tratamento cirúrgico dos aneurismas da aorta torácica descendente e toracoabdominal estão associados com risco de isquemia medular, como também, a distúrbios de coagulação e alterações da função renal. Dentre os métodos de proteção medular estão, a drenagem do líquido cefalorraquidiano, o bypass temporário, o reimplante das artérias intercostais, a hipotermia profunda, o esfriamento seletivo da medula espinhal e o uso de agentes farmacológicos. Objetivo: O objetivo deste trabalho é demonstrar a viabilidade do uso da circulação extracorpórea (CEC) estabelecida entre o átrio esquerdo e aorta ascendente para indução da hipotermia profunda na correção dos aneurismas torácicos e/ou toracoabdominais. Casuística e Método: No período de janeiro de 1994 a julho de 2001, foram operados 38 pacientes, sendo 26 do sexo masculino, com média de idade 54,6±12,7 anos. Doze pacientes (31,6%) foram submetidos a correção de aneurisma toracoabdominal e 26, a aneurismas torácicos descendentes. O diagnóstico etiológico foi pós-trauma em um paciente; pós-coarctação da aorta (corrigida ou não) em quatro; aortite sifilítica em dois; aterosclerótico, dez pacientes e dissecção de aorta em 21 pacientes. Os pacientes foram induzidos a hipotermia profunda por meio de CEC, com temperatura faríngea variando entre 15 e 25°C (20,6±3,2°C). O tempo de parada circulatória variou de nove a trinta e seis minutos (21,3±6,1 minutos). O diâmetro da aorta dos pacientes variou de quatro a 10,5 cm (8,1±1,5 cm). Resultados: Dentre as complicações neurológicas, a paraplegia ocorreu em dois casos (5,3%), sendo que em um paciente houve quadro associado de acidente vascular cerebral. Um paciente evoluiu com paraparesia de membros inferiores e um, com quadro de convulsão. As complicações respiratórias estiveram presentes em 12 pacientes (31,6%), sendo que dois (5,3%) necessitaram de traqueostomia por necessidade de ventilação mecânica por tempo prolongado, com mortalidade de 16,7% (dois pacientes). Dois pacientes apresentaram elevação transitória nos níveis de creatinina, sem indicação de diálise. Dois pacientes foram operados em caráter de urgência, evoluindo para óbito. A mortalidade total da casuística foi de sete pacientes (18,4%), sendo um por sangramento, dois por complicações respiratórias, dois por morte súbita, um por insuficiência cardíaca e um por dificuldade de saída de CEC. Conclusão: A correção dos aneurismas da aorta torácica descendente e toracoabdominal com o emprego da hipotermia profunda de indução interna pela circulação extracorpórea estabelecida entre o átrio esquerdo e a aorta ascendente, demonstrou ser um método viável para o tratamento cirúrgico dos aneurismas torácicos e toracoabdominais apresentando: mortalidade, complicações neurológicas, renais e respiratórias compatíveis com os achados da literatura da época.

Successfull cardiopulmonary resuscitation is an essential life-saving tool; nevertheless, general ischemia during cardiac arrest may trigger different pathways that could turn even into a fatal damage; this condition is called post-cardiac arrest syndrome. It has been repeatedly shown that oxidative stress (OS) plays one of the key roles in the development of ischemia-reperfusion injury. However, current evidence on the possible participation of OS in the pathogenesis of post-cardiac arrest syndrome is insufficient. We tested following hypotheses: (i) ischaemia-reperfusion injury after cardiac arrest is accompanied by OS and (ii) mild therapeutical hypothermia decreases OS cardiac arrest. In the experimental part of our work we studied the effects of hypothermia and normothermia on hemodynamic parameters, markers of organ damage and on the OS burden in porcine model of cardiac arrest. Furthermore, we compared the effects of hypothermia with ischaemic postconditioning and nitric oxide administration in the porcine model of extracorporeal cardiopulmonary resuscitation. We found protective effects of hypothermia on all major endpoints including OS in comparison with normothermia; moreover, hypothermia improved also selected variables compared to ischemic postconditioning and nitric oxide. In the...

Successfull cardiopulmonary resuscitation is an essential life-saving tool; nevertheless, general ischemia during cardiac arrest may trigger different pathways that could turn even into a fatal damage; this condition is called post-cardiac arrest syndrome. It has been repeatedly shown that oxidative stress (OS) plays one of the key roles in the development of ischemia-reperfusion injury. However, current evidence on the possible participation of OS in the pathogenesis of post-cardiac arrest syndrome is insufficient. We tested following hypotheses: (i) ischaemia-reperfusion injury after cardiac arrest is accompanied by OS and (ii) mild therapeutical hypothermia decreases OS cardiac arrest. In the experimental part of our work we studied the effects of hypothermia and normothermia on hemodynamic parameters, markers of organ damage and on the OS burden in porcine model of cardiac arrest. Furthermore, we compared the effects of hypothermia with ischaemic postconditioning and nitric oxide administration in the porcine model of extracorporeal cardiopulmonary resuscitation. We found protective effects of hypothermia on all major endpoints including OS in comparison with normothermia; moreover, hypothermia improved also selected variables compared to ischemic postconditioning and nitric oxide. In the...

Author's name: Bc. Irena Malá School: Charles university, Prague 1st Faculty of Medicine Institut of Theory and Practice of Nursing Vídeňská 800, 140 59 Prague 4 - Krč Program: Health Care Administration Title: Early postoperative care of the patient with the left ventricular assist device HeartMate II Diploma thesis supervisor: PhDr. Hocková Jana, PhD. Number of pages: 170 Number of attachments: 41 Year: 2013 Key words: early postoperative care, hypotermia, blood transfusion, fluid resuscitation, perioperative cardiovascular dysfunction, pharmacologic support, ventricular assist device HeartMateII, monitoration, device, cardiac arrhythmias, ventilation management, postoperative anticoagulation, glycemic kontrol, renal insufficiency, nutrition, nursing, complications, physiotherapy, psychological aspects The occurrence of the heart failure is similar to an epidemic with high mortality. This fact, together with stagnate or even decreasing number of suitable donors, led to a need of replacing the heart pump activity with an artificial one. Mechanical cardiac support systems are sophisticated devices that are able to support a certain period of time or completely replace the function of the heart as a pump. The indications implantation of mechanical cardiac support is significant symptomatic heart...