This dissertation introduces a new problem in the delivery of healthcare, which could result in lower cost and a higher quality of medical care as compared to the current healthcare practice. In particular, a framework is developed for sedation and cardiopulmonary management for patients in the intensive care unit. A method is introduced to automatically detect pain and agitation in nonverbal patients, specifically in sedated patients in the intensive care unit, using their facial expressions. Furthermore, deterministic as well as probabilistic expert systems are developed to suggest the appropriate drug dose based on patient sedation level. This framework can be used to automatically control the level of sedation in the intensive care unit patients via a closed-loop control system. Specifically, video and other physiological variables of a patient can be constantly monitored by a computer and used as a feedback signal in a closed-loop control architecture. In addition, the expert system selects the appropriate drug dose based on the patient's sedation level. In clinical intensive care unit practice sedative/analgesic agents are titrated to achieve a specific level of sedation. The level of sedation is currently based on clinical scoring systems. In general, the goal of the clinician is to find the drug dose that maintains the patient at a sedation score corresponding to a moderately sedated state. This is typically done empirically, administering a drug dose that usually is in the effective range for most patients, observing the patient's response, and then adjusting the dose accordingly. However, the response of patients to any drug dose is a reflection of the pharmacokinetic and pharmacodynamic properties of the drug and the specific patient. In this research, we use pharmacokinetic and pharmacodynamic modeling to find an optimal drug dosing control policy to drive the patient to a desired sedation score.

Professional research project (Au.D.)--University of South Florida, 2003. / Title from PDF of title page. / Document formatted into pages; contains 20 pages. / Includes bibliographical references. / Text (Electronic thesis) in PDF format. / ABSTRACT: The purpose of this study was to determine the effects of an atypical pattern of early acoustic stimulation on auditory development. Previous human research suggests that the acoustic environment of pre-term human infants in the Neonatal Intensive Care Unit (NICU) negatively affects some aspects of auditory development. Animal research suggests that premature auditory stimulation interrupts auditory development. Because mice are born before their auditory systems are developed, they make an excellent model for research on fetal and postnatal plasticity of the auditory system. The premature auditory state of newborn mice is similar to that of the NICU pre-term infant, albeit, natural for mice C57 mouse pups were exposed to an augmented acoustic environment (AAE) of a nightly 12-hour regiment of 70 dB SPL noise burst, beginning before age 12 days (onset of hearing) and lasting for one month. / ABSTRACT: The prepulse inhibition (PPI) of mice exposed to the AAE was compared to that of non-exposed mice to observe short-term and long-term effects. Results showed that the prepulse inhibition of the AAE exposed mice did not differ significantly from that of the non-exposed mice. However, it is possible that the measurement used, PPI, may not have been appropriate or that the AAE may not have been an appropriate simulation of the NICU environment. / System requirements: World Wide Web browser and PDF reader. / Mode of access: World Wide Web.

Rationnel : La pandémie de grippe A(H1N1)pdm09 a induit un grand nombre d’hospitalisation d’enfants en soins intensifs pédiatriques (SIP). L’objectif de cette étude a été de comparer l’incidence et la mortalité des enfants admis en SIP durant l’automne 2009 entre le Canada et la France, deux pays qui diffèrent essentiellement par l’immunisation de la population contre ce virus (première vague en été et taux de couverture vaccinale supérieur à 50% au Canada ; pas de vague estivale et couverture vaccinale de 18% en France). Méthodes : Nous avons comparé deux cohortes nationales qui ont inclue tous les patients avec une infection A(H1N1)pdm09 documentée, admis en SIP au Canada et en France entre le 1er Octobre 2009 et le 31 janvier 2010. Résultats : Au Canada, 160 enfants (incidence=2,63/100000 enfants) en 6 semaines ont été hospitalisés en SIP comparé aux 125 enfants (incidence=1,15/100000 enfants) en 11 semaines en France (p<0,001). Le taux de vaccination avant l’admission était inférieur à 25% parmi les enfants en situation critique dans les deux pays. La gravité à l’admission en SIP et le taux de mortalité ont été similaires au Canada et en France (4,4% en France vs 6,5% au Canada, p=0,45, respectivement). Au Canada, la vaccination contre le virus H1N1pdm09 a été associée avec une diminution du recours à la ventilation invasive (Odd Ratio 0.30, intervalle de confiance à 95% [0,11-0,83], p=0,02). Au Canada comparé à la France, les durées médianes de séjour en SIP et de ventilation invasive ont été plus courtes (2,9 vs 3 jours, p=0,03 et 4 vs 6 jours, p=0,02, respectivement). Conclusion : Les enfants canadiens et français critiquement malades ont été beaucoup moins nombreux à recevoir le vaccin contre le virus influenza A (H1N1)pdm09 en comparaison avec l’ensemble des enfants dans ces deux populations. Au Canada, où la couverture vaccinale a été élevée, le risque d’avoir une détresse respiratoire sévère était moins important parmi les enfants en situation critique ayant été vaccinés avant l’admission. / Background: The pandemic influenza A (H1N1)pdm09 resulted in a large number of admissions to pediatric intensive care units (PICUs). The objective of the study was to compare the incidence and mortality rate of children admitted to PICU in autumn 2009 between France and Canada, two countries that essentially differed by their population immunization to this virus (first pandemic wave in summer and vaccine coverage >50% in Canada; no wave in summer and vaccine coverage of 18% in France). Methods: We compared two national cohorts that included all patients with documented H1N1pdm09 infection, admitted to a PICU in Canada and in France between October 1st 2009 and January 31st 2010. Results: In Canada, 160 children (incidence=2.63/100,000 children) in 6 weeks were hospitalized in PICU compared to 125 children (incidence=1.15/100,000) in 11 weeks in France (p<0.001). Prior vaccination was under 25% among critically ill children in both countries. Severity of illness at PICU admission and mortality rates were similar in Canada and France (6.5%, vs 4.4 p=0.45, respectively). In Canada, H1N1pdm09 vaccination was associated with a decreased risk of requiring invasive ventilation (Odd Ratio 0.30, 95%Confidence Interval 0.11-0.83, p=0.02). In Canada as compared to France, median PICU length of stay and invasive ventilation durations were shorter (2.9 vs 3 days, p=0.03 and 4 vs 6 days, p=0.02, respectively). Conclusion: Critically ill Canadian and French children were much less likely to have received prior vaccination against influenza A (H1N1) pdm09 in comparison to all children in the populations. In Canada, where vaccination rate was higher, the risk of severe respiratory failure was less among those critically ill children receiving prior vaccination.

Rationnelle. La ventilation mécanique invasive (VI) s’accompagne lorsqu’elle se prolonge, d’une augmentation de la morbimortalité. Jusqu’à 64% des enfants hospitalisés aux soins intensifs sont ventilés et peu de données épidémiologiques existent afin d’estimer précocement la durée du support ventilatoire. Objectifs. Déterminer l’incidence et les facteurs de risque précoces de ventilation mécanique invasive prolongée aux soins intensifs pédiatriques. Méthode. Nous avons conduit une étude descriptive rétroélective sur un an. Tous les épisodes de VI aux soins intensifs du Centre hospitalier universitaire Sainte Justine de Montréal ont été inclus. Les facteurs de risque de VI prolongée (≥ 96 heures) ont été déterminés par régression logistique. Résultats. Parmi les 360 épisodes de VI, 36% ont duré ≥ 96 heures. Les facteurs de risques de ventilation prolongée en analyse multivariée sont : âge <12 mois, score de PRISM ≥ 15 à l’admission, pression moyenne dans les voies aériennes ≥13 cm H2O au jour 1 de ventilation, utilisation de la sédation intraveineuse continue au jour 1 de ventilation et ventilation non invasive avant intubation. Conclusion. La VI prolongée survient chez environ un tiers des patients ventilés. Les patients de moins de 12 mois semblent être plus à risque que les enfants plus âgés et devraient bénéficier de stratégies différentes pour diminuer leur durée de ventilation mécanique. La sévérité de la maladie, l’agressivité du support ventilatoire, l’utilisation d’une sédation continue au premier jour de ventilation sont également des facteurs à considérer dans les études visant à diminuer la durée de support ventilatoire. / Rationale. Invasive mechanical ventilation is associated, if prolonged, with higher morbidity and mortality. Up to 64% of children hospitalized in pediatric intensive care units (PICU) require invasive ventilation but little epidemiological data are available on children requiring prolonged acute invasive mechanical ventilation. Objectives. To determine the incidence rate and early risk factors for prolonged acute invasive mechanical ventilation in children. Methods. We conducted a retrolective longitudinal cohort study over a one-year period. All consecutive episodes of invasive mechanical ventilation in the PICU of Sainte-Justine Hospital were included. Risk factors for prolonged (≥ 96 hours) versus short (< 96 hours) ventilation were determined by logistic regression. Results. Among the 360 episodes of invasive ventilation, 36% had a length ≥ 96 hours. Following multivariate analysis, significant risk factors for prolonged acute invasive mechanical ventilation were: age <12 months, PRISM score ≥ 15 at admission, mean airway pressure ≥13 cm H2O on day one, use of continuous intravenous sedation on day one and use of non-invasive ventilation prior to intubation. Conclusion. Prolonged acute mechanical ventilation occurs in approximately one third of ventilated children. Younger children (aged <12 months) may be different from older patients and may require different strategies to decrease the duration of mechanical ventilation. Severity of illness, the aggressiveness of ventilatory support required and the use of continuous intravenous sedation on the first day of ventilation are also risk factors to consider in trials aimed at reducing mechanical ventilation duration.

Disertacijoje tiriant ligonių, ilgai gydytų intensyviosios terapijos skyriuje, su sveikata susijusios gyvenimo kokybės skirtumus iki gydymo ir praėjus 6 mėnesiams po gydymo vertinamos gyvenimo kokybės pablogėjimo priežastys bei gyvenimo kokybės ir mirštamumo po iškėlimo iš intensyviosios terapijos skyriaus ryšys. Jau anksčiau nustatyta, kad gyvenimo kokybė po gydymo intensyviosios terapijos skyriuje pablogėja. Tačiau neaišku, kokie veiksniai turi didžiausios įtakos intensyviosios terapijos skyriaus ligonių gyvenimo kokybei. Ypač mažai duomenų apie ligonių, ilgai gydytų intensyviosios terapijos skyriuje, gyvenimo kokybę po iškėlimo iš intensyviosios terapijos skyriaus. Tyrimo rezultatai patvirtino, kad ilgas gydymas intensyviosios terapijos skyriuje turi didžiausios įtakos fizinėms su sveikata susijusioms gyvenimo kokybės sritims. Tyrimo rezultatai įrodo, kad būklės sunkumas pirmą gydymo intensyviosios terapijos skyriuje parą, terapinių intervencijų skaičius iškėlimo iš intensyviosios terapijos skyriaus metu ir sunkus kritinių būklių neuroraumeninis pažeidimas susiję su pablogėjusia gyvenimo kokybe, o dirbtinės plaučių ventiliacijos trukmė – veiksnys turintis didžiausią įtaką gyvenimo kokybės blogėjimui. Taip pat nustatyta, kad įprastos sistemos būklės sunkumui įvertinti netinka numatyti ligonių mirštamumui po gydymo intensyviosios terapijos skyriuje, o nustačius fizinį aktyvumą iki gydymo intensyviosios terapijos skyriuje tai galima atlikti. / The doctoral dissertation investigates changes in health-related quality of life for long-term intensive care patients prior to ICU admission and 6 months after ICU discharge, exploring into the causes of impaired quality of life and the relationship between the quality of life and post-ICU mortality. It has already been established that the quality of life decreases after treatment in the intensive care unit. However, factors that have the strongest effect on the quality of life in ICU patients have not been identified. Information on post-ICU quality of life in long-term intensive care patients is particularly scarce. The findings of our research confirmed that long term treatment in the intensive care unit has major implications for the physical domains of health-related quality of life. The findings evidence that severity of illness on the first day in the ICU, number of therapeutic interventions upon ICU discharge and severe critical illness neuromuscular abnormalities are associated with impaired quality of life, while duration of mechanical ventilation is the factor with the strongest effect on reduced quality of life. Likewise, the findings demonstrate that usual systems for identification of severity of illness are not useful for predicting mortality in patients after discharge from the intensive care unit. Yet, identification of pre-ICU physical activity allows predicting post-ICU mortality.

The doctoral dissertation investigates changes in health-related quality of life for long-term intensive care patients prior to ICU admission and 6 months after ICU discharge, exploring into the causes of impaired quality of life and the relationship between the quality of life and post-ICU mortality. It has already been established that the quality of life decreases after treatment in the intensive care unit. However, factors that have the strongest effect on the quality of life in ICU patients have not been identified. Information on post-ICU quality of life in long-term intensive care patients is particularly scarce. The findings of our research confirmed that long term treatment in the intensive care unit has major implications for the physical domains of health-related quality of life. The findings evidence that severity of illness on the first day in the ICU, number of therapeutic interventions upon ICU discharge and severe critical illness neuromuscular abnormalities are associated with impaired quality of life, while duration of mechanical ventilation is the factor with the strongest effect on reduced quality of life. Likewise, the findings demonstrate that usual systems for identification of severity of illness are not useful for predicting mortality in patients after discharge from the intensive care unit. Yet, identification of pre-ICU physical activity allows predicting post-ICU mortality. / Disertacijoje tiriant ligonių, ilgai gydytų intensyviosios terapijos skyriuje, su sveikata susijusios gyvenimo kokybės skirtumus iki gydymo ir praėjus 6 mėnesiams po gydymo vertinamos gyvenimo kokybės pablogėjimo priežastys bei gyvenimo kokybės ir mirštamumo po iškėlimo iš intensyviosios terapijos skyriaus ryšys. Jau anksčiau nustatyta, kad gyvenimo kokybė po gydymo intensyviosios terapijos skyriuje pablogėja. Tačiau neaišku, kokie veiksniai turi didžiausios įtakos intensyviosios terapijos skyriaus ligonių gyvenimo kokybei. Ypač mažai duomenų apie ligonių, ilgai gydytų intensyviosios terapijos skyriuje, gyvenimo kokybę po iškėlimo iš intensyviosios terapijos skyriaus. Tyrimo rezultatai patvirtino, kad ilgas gydymas intensyviosios terapijos skyriuje turi didžiausios įtakos fizinėms su sveikata susijusioms gyvenimo kokybės sritims. Tyrimo rezultatai įrodo, kad būklės sunkumas pirmą gydymo intensyviosios terapijos skyriuje parą, terapinių intervencijų skaičius iškėlimo iš intensyviosios terapijos skyriaus metu ir sunkus kritinių būklių neuroraumeninis pažeidimas susiję su pablogėjusia gyvenimo kokybe, o dirbtinės plaučių ventiliacijos trukmė – veiksnys turintis didžiausią įtaką gyvenimo kokybės blogėjimui. Taip pat nustatyta, kad įprastos sistemos būklės sunkumui įvertinti netinka numatyti ligonių mirštamumui po gydymo intensyviosios terapijos skyriuje, o nustačius fizinį aktyvumą iki gydymo intensyviosios terapijos skyriuje tai galima atlikti.

Le but de cette étude est d’adopter une intervention systémique visant à faciliter la communication entre les infirmières1 et les familles2 dans un contexte de soins intensifs (SI) en traumatologie. Cette recherche prend en compte la réalité et les besoins du milieu à l’étude grâce au devis participatif retenu. Le cadre de référence est composé de l’approche systémique familiale de Wright et Leahey (2005) ainsi que de la théorie du caring de Jean Watson (1979). La collecte des données a été inspirée du parcours de recherche en spirale de Lehoux, Levy et Rodrigue (1995). Cinq entrevues ont été menées auprès de membres de familles ainsi que trois groupes de discussion (focus groups) auprès d’infirmières. L’analyse des données a été effectuée selon le Modèle de Huberman et Miles (2003) qui préconise une démarche analytique continue et interactive. Les résultats obtenus révèlent un changement de pratique selon dix interventions systémiques infirmières spécifiques permettant de faciliter la communication avec les familles aux soins intensifs en traumatologie et soulignent l’importance d’agir sur le plan du contexte, de la relation et du contenu liés au processus de communication. De plus, ils permettent de démontrer un réel changement de pratique dans le milieu retenu pour l’étude. / Abstract The purpose on this study was to adopt systemic nursing interventions to enhance communication with families in a context of traumatology intensive cares. This participative study has the benefit of reflecting the real needs expressed by the persons concerned. The terms of reference for this study comprised the conceptual model as well as Wright and Leahey’s (2005) family systems nursing approach and the caring theory of Jean Watson (1979). The data collection was inspired by Lehoux, Levy and Rodrigue (1995) over five family interviews and three nurses’ meetings. The data collection was performed over a period of seven months. All of the interviews and meetings were recorded on audio tape and the verbatim’s were fully transcripted. The data analysis was done according to Huberman and Miles’ (2003) model, where analytical activities and data collection establish a continuous and interactive approach. The results obtained revealed ten specific systemic nursing interventions to enhance communication with families in this context and revealed the importance of the three levels of communication: cognitive, affective and behavioral. Moreover, the results are used to identify well-established interventions and recommend those who have to be improved.

Purpose. To systematically develop and field test an intervention to engage families and healthcare teams in the decision-making process about life support for critically ill patients in the Intensive Care Unit (ICU). Setting. Adult medical-surgical ICU at a Canadian academic teaching hospital. Methods. The International Patient Decision Aid Standards (IPDAS) criteria and the Interprofessional Shared Decision Making (SDM) model guided the study of families facing decisions about life support for their relative in ICU that involved:1) systematic review; 2) qualitative descriptive study; 3) mixed methods field test of a novel patient decision aid (DA). Systematic review findings. Of 3162 citations, four trials evaluated interventions to improve communication between health professionals and patients/families. One intervention met eight of nine criteria for SDM but did not evaluate its effect on the benefit to communication. Qualitative study findings. Six family members and nine health professionals identified two options (life support or comfort care) and values associated with these options. Values included maintaining quality of life, surviving critical illness, minimizing pain and suffering, not being attached to machines, giving the family enough time to adapt emotionally to the patient’s health situation, and the judicious use of healthcare resources. Families were unlikely to become engaged without healthcare professionals making the decision explicit and minimizing other barriers across the decision-making process. Field test findings. Family members and health professionals for eight patients indicated that the DA was feasible to use, acceptable to users, had the potential to do what was intended, and did not seem to present adverse consequences to users. An enhanced delivery strategy is needed for future evaluation of its effect on facilitating patient/family involvement in decisions. Conclusions. Limited involvement of families in the process of decision-making about life support in the ICU reinforced the need for effective interventions to facilitate SDM. These studies validated the operationalization of the IPDAS criteria, as part of a systematic process for developing and field testing DAs. However, IPDAS criteria stop short of elements necessary to consider when implementing the DA in the processes of care.

Critical illness associated muscle weakness and muscle dysfunction in intensive care unit (ICU) patients lead to severe morbidity and mortality as well as significant adverse effect on quality of life. Immobilization, mechanical ventilation, neuromuscular blocking agents, corticosteroids, and sepsis have been implicated as important risk factors, but the underlying molecular and cellular mechanisms remain unclear.  A unique porcine ICU model was employed to investigate the effect of these risk factors on the expression profiles, gene expression and contractile properties of limb and diaphragm muscle, in the early phase of ICU stay. This project has focused on unraveling the underlying molecular and cellular pathways or networks in response to ICU and critical illness interventions. Upregulation of heat shock proteins indicated to play a protective role despite number of differentially transcribed gene groups that would otherwise have a negative effect on muscle fiber structure and function in response to immobilization and mechanical ventilation.  Mechanical ventilation appears to play a critical role in development of diaphragmatic dysfunction. Impaired autophagy, chaperone expression and protein synthesis are indicated to play a pivotal role in exacerbating muscle weakness in response to the combined effect of risk factors in ICU. These results may be of therapeutic importance in alleviating critical illness associated muscle weakness.

Night work is inherent in working processes in hospitals and may have repercussions on the health of workers. Among these, stands out for the nursing care practice uninterrupted. Thus, beyond the specific implications of the process of nursing care, night service workers are exposed to typical repercussions of this shift. This study had as its object: the effects of night work in nursing and guiding question: what are the effects of night work for workers of Nursing intensive care units? In this sense, aimed to know the effects of night work for workers of these units. This is a qualitative, descriptive. The study included thirteen nursing workers of adult intensive care units and cardiology in a public hospital in the state of Rio Grande do Sul was used as a tool to semistructured data collection interview, which took place from October to November 2013. Data were analyzed according to thematic content analysis proposed by Minayo. It is reiterated that the ethical aspects of Resolution Nº 466/2012 of the National Health Council. As results were seen three categories emerged: Perceptions of nursing about the night work in the Intensive Care Unit; Physical, psychological and social effects of night work on Unit and Intensive Care; Strategies used by shift workers in Intensive Care Units in response to suffering. It was found in the statements of these workers that night work can promote both experiences of pleasure and satisfaction as dissatisfaction and suffering. This study reveals corroborating previous researches that night work reflected both in health and in social, family and emotional life of nursing workers. However, despite realize these effects, participants prefer to stay in this shift, due to personal, family and financial needs. It was evident that the workers, in most cases, they use individual and collective strategies in order to stay healthy in the workplace, even though they often do not perceive them. It is considered, based on the findings of this study, it is essential that hospitals develop health prevention and promotion of quality of life of workers nocturnal Nursing programs, as well as moments of integration between management, workers and institutional directions, promoting dialogue and sharing of knowledge and experiences in order that this employee feels valued and welcomed at it on your desktop. / O trabalho noturno é inerente ao processo laboral em instituições hospitalares e pode apresentar repercussões na saúde dos trabalhadores. Dentre esses, destaca-se os da Enfermagem pela prática assistencial ininterrupta. Com isso, além das implicações específicas do processo assistencial da Enfermagem, os trabalhadores do serviço noturno ficam expostos a repercussões típicas desse turno de trabalho. Este estudo teve como objeto: as repercussões do trabalho noturno na Enfermagem e como questão norteadora: quais as repercussões do trabalho noturno para trabalhadores de Enfermagem de Unidades de Cuidados Intensivos? Nesse sentido, objetivou conhecer as repercussões do trabalho noturno aos trabalhadores destas unidades. Trata-se de uma pesquisa qualitativa, de caráter analítico e descritivo. Participaram do estudo treze trabalhadores de Enfermagem das Unidades de Cuidados Intensivos Adulto e Cardiológica de um hospital público do interior do estado do Rio Grande do Sul. Utilizou-se a entrevista semiestruturada como instrumento de coleta de dados, a qual ocorreu no período de outubro a novembro de 2013. Os dados foram analisados segundo a análise de conteúdo temática proposta por Minayo. Reitera-se que foram atendidos os aspectos éticos da Resolução Nº 466/2012 do Conselho Nacional de Saúde. Como resultados emergiram três categorias: Percepções dos trabalhadores de Enfermagem acerca do trabalho noturno em Unidade de Cuidados Intensivos; Repercussões físicas, psíquicas e sociais do trabalho noturno em Unidade de Cuidados Intensivos e Estratégias utilizadas pelos trabalhadores noturnos de Unidades de Cuidados Intensivos frente ao sofrimento. Constatou-se nos depoimentos destes trabalhadores que o trabalho noturno pode promover tanto vivências de prazer e satisfação quanto de insatisfação e sofrimento. Este estudo revela que o trabalho noturno repercute tanto na saúde, como na vida social, familiar e emocional dos trabalhadores de Enfermagem. No entanto, apesar de perceberem estas repercussões, os participantes preferem permanecer neste turno de trabalho, em função de suas necessidades pessoais, familiares e financeiras. Evidenciou-se que os trabalhadores, na maioria das vezes, utilizam-se de estratégias individuais e coletivas, no intuito de se manterem saudáveis no seu ambiente de trabalho, mesmo que muitas vezes, não as percebam. Considera-se, a partir dos achados deste estudo, ser fundamental que as instituições hospitalares desenvolvam programas de prevenção à saúde e promoção da qualidade de vida dos trabalhadores noturnos da Enfermagem, assim como, momentos de integração entre chefias, direções institucionais e trabalhadores, promovendo o diálogo e o compartilhar de conhecimentos e vivências, no intuito de que este trabalhador se sinta valorizado no que faz e acolhido no seu ambiente de trabalho.