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Perifer vaskulär insufficiens innebär arteriell och/eller venös cirkulationssvikt i nedre extremiteter, vilket kan förorsaka bensår. Vaskulär insufficiens i benen är ett ökande hälsoproblem som ofta är ett mycket smärtsamt tillstånd och kan ha stora konsekvenser för den drabbade i dennes dagliga liv. Litteraturöversikt valdes som metod för att besvara syftet; att beskriva forskning om patienters upplevelser av hur perifer vaskulär insufficiens i de nedre extremiteterna påverkar det dagliga livet. Detta utifrån Carnevalis omvårdnadsteori om dagligt liv funktionellt hälsotillstånd. Stora inskränkningar i dagligt liv på grund av sjukdomen identifierades i litteraturen. Smärtan spelade en central roll i flertalet begränsningar respondenterna mötte. Den sänkte deras mobilitet, vilket medförde social isolering och begränsningar i vardagliga aktiviteter och förändrad självbild. Smärtan orsakade även sömnrubbningar och förändrade sinnesstämningar. Flera respondenter upplevde rädslor, de med arteriell insufficiens för amputation och för tidig död, och de med venös insufficiens för situationer som kunde medföra nya sår. Ett annat återkommande fynd var brist på kunskap, smärtlindring och brister i relationen med vårdpersonal. / Peripheral vascular insufficiency entails arterial and / or venous circulatory failure in the lower extremities, which can cause ulcers. Vascular insufficiency in the legs is an increasing health problem which often is a very painful condition and can have a major impact on the patient's daily life. Literature review was chosen as a method to answer the study aim; to describe research on patients' experiences of peripheral vascular insufficiency in the lower limbs and how it affects everyday life. This according to Carnevali’s theory on daily life functional health status. Major limitations in daily life because of the disease were identified in the literature. The pain was a central part of the restrictions all respondents met. It lowered mobility, leading to social isolation, limitations in activities in daily life and change in self-image. The pain also caused sleep disorders and altered moods. Several respondents experienced fears, those with arterial insufficiency of amputation and premature death, and those with venous insufficiency of situations that could cause new ulcers. Another frequent finding was a lack of knowledge, pain relief and trustful relationships with health professionals.

京都大学 / 新制・論文博士 / 博士(医学) / 乙第13553号 / 論医博第2282号 / 新制||医||1067(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 齋藤 潤, 教授 万代 昌紀, 教授 長尾 美紀 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

Umbilical flow velocity waveforms (FVW' s) can be measured non-invasively using Doppler ultrasound. Changes in the FVW's occur long before the warning signs from other conventional monitoring methods. Correct interpretation of the changes in the FVW has the potential of providing the clinician with an early warning of foetal distress. A number of indices have been described in the literature to characterise the FVW including the Pulsatility Index (PI), the Resistance Index (RI) and more recently, the High Resistance State Index (HRSI). Researchers have shown a dependence of the FVW, and thus the indices which describe it, on factors such as the placental resistance (Muijsers et al 1990a) blood pressure pulsatility (Mulders et al 1986), and the foetal heart rate (Downing et al 1991). In order to model the foetal circulation, the dimensions of the foetal vessels were required. These were taken from the literature when available, but had to be supplemented by measurements on post mortem specimens. This information, together with blood pressures and flow rates taken from the literature, was used to design electrical analogous models of the foetal arterial circulation (model 1 and model 2), which were implemented using PSpice, which is an electronic circuit simulator package. The Flow Velocity Waveforms (FVW's) simulated were stored and then analyzed using MATLAB, which is a mathematical package to calculate the waveform indices and both the blood pressure and percentage blood flow to the different anatomical regions of the foetus. Model 1 is a simple model of the umbilical placental unit only, which assumes a rectified sine wave with a D.C. offset as an input waveform while Model 2 is a distributed element model of the complete foetal arterial system, including a realistic representation of the foetal heart. AIM: Simulations of the FVW were used to examine the effects of placental obliteration (raised placental resistance), placental size, foetal heart rate (FHR), blood pressure pulsatility (BPPI), mean blood pressure (BP), and site of measurement of the FVW along the umbilical artery and thus on the waveform indices which are used to describe it (RI, PI and HRSI). RESULTS/ DISCUSSION: The investigations using models 1 and 2 showed that the indices were significantly dependent on the placental resistance, the size of the placenta and the type of placental obliteration. Model 1 was also used to investigate the effect of FHR variations on the indices under the original assumption that the input waveform to the umbilical/placental unit was a rectified sinusoid offset by a constant voltage (D.C.) (Thompson and Trudinger 1990). The result obtained, that is, the FHR does not affect the indices (in particular the PI) needed further investigation because the assumption for the input waveform is not true under all conditions. For this reason, the simulations were repeated using model 2, with the interesting result that there is a difference between short term FHR variations and long-term FHR variation. Short term FHR variations had a pronounced effect on the indices. The blood pressure pulsatility and the indices concerned varied by large amounts in this case, which indicated a link between the blood pressure pulsatility and all the indices. Long term FHR variations had an inconsistent but small effect on the blood pressure pulsatility and in turn had a small effect on the RI and PI. The mean blood pressure in these simulations decreased with increasing FHR which resulted in a pronounced increase in the HRSI which indicated the dependency of this index on the mean blood pressure rather than on the blood pressure pulsatility. It was found that the HRSI is a good index of placental resistance and may be particularly useful in evaluating high placental resistance in cases of absent flow during diastole, since, in these cases it is only slightly affected by the FHR. A value of greater than 34 percent is the recommended HRSI value to indicate severe foetal distress. The results also indicate that the FVW shape varies along the umbilical artery and is far more pulsatile at the aortic (proximal) end than the placental end. This is reflected in the indices which thus have worst case values at the placental end. It is thus recommended that, where possible, the indices are measured at the placental end of the umbilical artery.

Interscalene nerve blocks are common procedures performed before upper extremity surgeries in order to provide post-op pain relief and improve recovery time. Here we present two cases of patients who underwent a unilateral supraclavicular and bilateral interscalene nerve block, respectively. The first patient had no risk factors but the second presented with a body mass index of 45.5 and a history of symptoms consistent with obstructive sleep apnea but never diagnosed. Both patients experienced some form of respiratory distress diagnosed via changes in chest x-ray and clinical presentation. The mechanism of injury that occurs in these procedures is typically from inadvertent damage to the phrenic nerve. Mild adverse effects in interscalene nerve block are relatively common. However, there is minimal data in regards to performing bilateral interscalene nerve blocks. The purpose of this study is to highlight that severe complication in both high and low-risk patients can occur but may be reduced with a safer approach and more effective communication among multidisciplinary team members.

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