Representação social de morte e a formação médica: a importância da UTI / Social representation of death and medical education: the importance of ICU

Esta pesquisa identifica e analisa a representação social sobre a morte construída por médicos intensivistas, buscando compará-la aos resultados obtidos entre os médicos docentes da Clínica Médica. Realizaram-se entrevistas semiestruturadas com 27 médicos atuantes nas UTIs de um hospital universitário ligado a uma instituição de ensino superior federal do Brasil. Trabalhou-se com o conceito de Representação Social e a metodologia qualiquantitativa do discurso do sujeito coletivo (DSC). Os resultados mostraram que o contexto da UTI promove esforços de objetivação e naturalização da morte, mas não neutraliza os sentimentos vividos pelos médicos intensivistas. Estes reconhecem seu despreparo para lidar com situações que envolvem a morte e reivindicam o apoio de psicólogos e psicanalistas. Defendem, também, a UTI como espaço privilegiado para o contato e elaboração de atitudes pessoais e profissionais em relação à morte ao longo da graduação médica. Conclui-se que, pela especificidade do contexto da UTI, médicos e estudantes de Medicina podem testemunhar alcances e limites da atuação médica frente à inexorabilidade da morte humana e melhor elaborar suas percepções em relação a esse tema.

This study identifies and analyses the social representation of death according to a group of intensive care physicians, with the aim of comparing such representations with the results obtained from a clinic's medical staff. Semi-structured interviews were thus carried out with 27 physicians working at Intensive Care Units (ICUs) at a university hospital affiliated to a Brazilian federal higher education institution. The subject was further analysed based on the concept of Social Representations and on the Discourse of the Collective Subject (DCS) qualiquantitative methodology. Results demonstrate that the context of an ICU promotes efforts toward the naturalisation and objectification of death, although this does not neutralise feelings experienced by intensive care physicians. The latter acknowledge their lack of training on dealing with situations involving death, claiming assistance and support from psychologists and psychoanalysts. They defend the ICU as a privileged space for contact and the development of personal and professional behaviours regarding death, throughout the medical undergraduate course. Therefore, due to the uniqueness of the ICU context, physicians and medical students possess the ability to witness the reaches and limits of medical intervention in light of the inexorable nature of human death, and also to better formulate their opinions on the subject.

Treatment of early phase severe acute pancreatitis in intensive care units: a retrospective multicenter study / 中华肝胆外科杂志

Objective To analyse the experience and treatment of early phase severe acute pancreatitis (SAP) in intensive care units (ICU).Methods A multicenter retrospective study was done on patients with SAP treated in three major teaching hospitals (Beijing Hospital,Peking University First Hospital and Peking University Shenzhen Hospital) in China from Jan.2001 to Dec.2011.Results There were 188 patients who were enrolled in the study,including 121 males and 67 females.The age ranged from 19 to 104 (51.0±18.2) years.The mean APACHE Ⅱ score was (22.2±4.6).84.0％ of patients survived,the mortality was 10.1％ in the early phase and 5.9％ in the late phase.The most common systemic complications were acute renal injury (46.3 ％),acute respiratory distress syndrome (35.6％),and septic shock (17.6％).The local complication rate was 47.3％,which included acute peripancreatic fluid collections (32.8％),acute necrotic collection and walled-off necrosis (48.4 ％) and pseudocyst (18.8 ％).The conservative treatments included intensive care,fluid resuscitation,mechanical ventilation,continuous renal replacement therapy,antibiotics,glucose control,inhibition of pancreatic enzyme activity and secretion,and nutritional support.Surgical intervention included endoscopic retrospective cholangio-pancreatography and endoscopic sphincterectomy,B ultrasound or CT guided puncture and drainage,and surgical drainage and debridement of necrosis.Conclusions The early phase of SAP was characterized by systemic inflammatory response syndrome and multiple organ dysfunction syndrome which accounted for the first peak in mortality.Intensive care therapy and multi disciplinary comprehensive combined strategy were very important for these patients with systemic and local complications.ICU treatment in the early phase was preferred for patients with SAP.

Custo de pessoal na assistência direta de enfermagem em Unidade de Terapia Intensiva / Personnel cost in nursing direct care in an Intensive Care Unit

Este trabalho teve por objetivo verificar o custo de pessoal na assistência direta de enfermagem em unidade de terapia intensiva (UTI). Para isso, identificou-se o tempo médio diário de assistência de enfermagem, por meio da aplicação do índice TISS-28 e calculou-se o custo médio da hora da equipe de enfermagem. Trata-se de um estudo exploratório descritivo na modalidade de estudo de caso, realizado na UTI de um Hospital Universitário do município de São Paulo. Para coleta de dados utilizou-se um sistema de classificação de pacientes segundo o grau de dependência da enfermagem (TISS-28), por 3 meses. Elaborou-se planilhas de: caracterização dos pacientes; banco de dados do índice TISS-28; custos unitários e diários da equipe de enfermagem; variabilidade dos custos diários; horas segundo a escala diária da equipe. Os resultados mostraram que na UTI da referida instituição, o TISS-28 unitário médio apresentado pelos pacientes durante o estudo foi de 31 pontos, variando de 10 a 58 pontos. O TISS-28 diário médio foi de 251 pontos, variando de 147 a 353 pontos. O custo direto das horas de assistência de enfermagem, dedicadas a um paciente/dia, foi em média R$ 298,69. O custo da assistência de enfermagem dedicada pela equipe ao grupo de pacientes/dia foi, em média, de R$ 2.531,13, oscilando de R$ 1.415,61 a R$ 3.438,07. O custo fixo da equipe para a instituição foi de R$ 4.144,94 ao dia. O custo da hora de trabalho da equipe como um todo foi de R$ 18,18, sendo compostos por 41,9% de enfermeiros e 58,1% pelos profissionais de nível médio. Cada ponto TISS-28 teve o valor de R$ 17,04. Discutiu-se, ainda, alguns aspectos críticos quanto à elaboração do orçamento de enfermagem por esta metodologia, visto que os dados do estudo evidenciaram que são necessárias estimativas paralelas ao se utilizar o TISS-28 como índice de gravidade para mensurar o custo da equipe de enfermagem, pois ele apresenta limitações como: ) a avaliação de pacientes hospitalizados com menos de 24 horas, grau de sensibilidade parcial ao medir as atividades da equipe de enfermagem, entre outros

This work aimed verifying the personnel cost in nursing direct care at an Intensive Care Unit (ICU). For that, it was identified the daily average time of nursing care, by applying the TISS-28 score and it was calculated the average cost of the nursing staff per hour. It refers to an exploratory descriptive study in the type of case study, which was done at an ICU in a university hospital in Sao Paulo city. It was used a patient classification system to collect data according to the level of nursing dependence (TISS-28) for 3 months. A table was elaborated by: patient characterization; database of TISS-28 score; unitary and daily costs of nursing staff; variability of daily costs; hours according to a staff daily schedule. The results showed that in the ICU aforementioned of that institution the average unitary TISS-28 presented by the patients during the study was 31 points, ranging from 10 to 58 points. The average daily TISS-28 was 251 points, ranging from 147 to 353 points. The direct cost of hours in nursing care devoted to a patient/day was in average R$ 298,69. The cost of nursing care dedicated by the staff to a group of patients/day was in average R$ 2.531,13, varying between R$ 1.415,61 and R$ 3.438,07. The staff fixed cost to the institution was R$ 4.144,94 per day. The cost of work hour by the staff on the whole was R$ 18,18, which was composed by 41.9% of nurses and 58.1% of professionals in technical level. Each TISS-28 point represented R$ 17,04. It was still discussed some critical aspects regarding to the elaboration of a nursing budget through this methodology, once the study data proved that parallel estimations are needed to use the TISS-28 as a gravity score to measure the cost of nursing staff, so it presents limitations, such as: the evaluation of inpatients with less than 24 hours, partial sensitivity degree to measure the activities of the nursing staff, among others

Síndrome pulmonar e cardiovascular por Hantavirus: aspectos epidemiológicos, clínicos, do diagnóstico laboratorial e do tratamento / Hantavirus pulmonary and cardiovascular syndrome: epidemiology, clinical presentation, laboratory diagnosis and treatment

The Hantavirus pulmonary and cardiovascular syndrome (HPCVS) is an emerging disease in Brazil. In this study, eight confirmed cases of HPCVS were studied. All the patients presented fever and dyspnea as well as thrombocytopenia and hypoxemia. Tachycardia, malaise, hypotension and lung rales occurred in 75 to 87.5% of the cases. Hemoconcentration, blood cell count increased and immature neutrophils, and high levels of creatinine were observed in 75 to 87.5%. Intravenous liquid infusion, the use of drugs for increasing systemic vascular resistance and inotropism, and mechanic ventilation were used for the patients. Mechanical ventilation and volume administration should be started precociously, preferable in intensive care units employing recommended universal and respiratory precautions. Careful volume administration should be limited if signs of pulmonary edema develop. Mortality (50%) is high and probably related to the severity of the disease as well as to a delayed attending of the patients for intensive management. It is important to report hantaviruses and HPCVS to the Brazilian medical community considering that many cases could be undiagnosed.

A síndrome pulmonar e cardiovascular por Hantavirus (SPCVH), é doença emergente com descrição crescente de casos no Brasil. Neste trabalho, estudou-se 8 casos confirmados da doença. Todos apresentaram febre e dispnéia. Taquicardia, astenia, hipotensão e estertoração pulmonar ocorreram em 75 a 87,5% dos casos. Plaquetopenia e hipoxemia ocorreram em 100% dos casos, hemoconcentração, leucocitose com desvio à esquerda e elevação de uréia e creatinina séricas em 75 a 87,5%. Assistência respiratória, hidratação endovenosa e utilização de aminas vasoativas foram as medidas utilizadas nos pacientes. Ressalta-se que o suporte ventilatório e cardiovascular deve ser precocemente instituído, preferencialmente em unidades de terapia intensiva, com precauções universais e respiratórias de isolamento. Deve-se ter cuidados com infusão excessiva de líquidos para não agravar o edema pulmonar. A mortalidade observada, de 50%, é elevada, deveu-se à gravidade da doença e ao comparecimento tardio para tratamento intensivo. Deve-se informar sobre a SPCVH aos profissionais de saúde, considerando que casos de SPCVH, provavelmente, vêm passando desapercebidos.