The effects of vasopressors with and without dobutamine on haemodynamics, metabolism and gut injury during endotoxic shock in rabbits. A controlled study.

INTRODUCTION: Vasopressors increase arterial pressure but they may have deleterious effects on mesenteric blood flow. We aimed to evaluate the response of gut biomarkers and superior mesenteric blood flow to different vasopressors with and without dobutamine. MATERIAL AND METHODS: Thirty New Zealand rabbits were included and randomly allocated to 5 groups: group A - sham group; group B - norepinephrine; group C - norepinephrine plus dobutamine; group D - vasopressin; and group E - vasopressin plus dobutamine. Mean arterial pressure (MAP) target was greater than 60 mmHg. Endotoxic shock was induced by intra-venous injection of lipopolysaccharide (LPS) in four of the five groups. Aortic blood flow (Qao), superior mesenteric artery flow (QSMA) and lactate were measured after LPS injection. Enterocyte damage was evaluated by measurements of serum citrulline and intestinal fatty acid-binding protein (I-FABP) after 4 h. RESULTS: The largest reduction in Qao occurred in group D (64 ± 17.3 to 38 ± 7.5 mL min-1; P = 0.04). QSMA also declined significantly in groups D and E and remained lower than in the other groups over 4 h (group D - baseline: 65 ± 31; 1 h: 37 ± 10; 2 h: 38 ± 10; 3 h: 46 ± 26; and 4 h: 48 ± 15 mL min-1; P < 0.005; group E - baseline: 73 ± 14; 1 h: 28 ± 4.0; 2 h: 37 ± 6.4; 3 h: 40 ± 11; and 4 h: 48 ± 11; P < 0.005; all in mL min-1). Serum citrulline was significantly lower in groups D (P = 0.014) and E (P = 0.019) in comparison to group A. The fluid administration regimen was similar in all groups. CONCLUSIONS: Vasopressin seems to negatively impact gut enterocyte function during endotoxic shock despite the association of an inodilator and adequate fluid replacement.

Avaliação da experiência de dor pós-operatória em pacientes de unidade de terapia intensiva / Evaluation of postoperative pain experience in intensive care unit patients

OBJETIVO: Verificar a experiência dos pacientes submetidos a grandes cirurgias que realizaram pós-operatório em unidade de terapia intensiva. MÉTODO: Trata-se de estudo observacional, prospectivo, avaliando pacientes admitidos na unidade de terapia intensiva em pós-operatório e que tiveram alta para uma das enfermarias do hospital. Todos assinaram termo de consentimento livre e esclarecido.. Foram excluídos os pacientes com dificuldades na comunicação. A coleta de dados foi por meio de entrevista composta por 13 questões relacionadas a dor. RESULTADOS: Foram incluídos 167 pacientes, sendo 69,5 por cento do sexo masculino, de 50 a 59 anos, permanecendo de um a três dias internados na unidade de terapia intensiva. Oitenta e cinco por cento dos pacientes não relataram dificuldades para expressar a dor, 98,8 por cento foram questionados e medicados rapidamente quando apresentaram sintomas de dor, 54,5 por cento foram abordados somente sobre a presença ou não de dor, não utilizando escalas de mensuração e a situação mais dolorosa relatada foi o incômodo devido à incisão cirúrgica e posição no leito. CONCLUSÃO: Houve maior preocupação da equipe de enfermagem com a ocorrência de dor e não com a qualidade, intensidade ou quanto o estímulo doloroso poderia estar gerando incômodo ao paciente, além da não utilização de escalas para avaliação clínica e individual da dor, necessitando de um treinamento contínuo com os profissionais de enfermagem no sentido de abordar e valorizar as queixas álgicas dos pacientes.

OBJECTIVE: This study assessed the role of the nursing staff in pain management and verified the pain experiences of patients undergoing major surgery and receiving postoperative care in the intensive care unit. METHOD: This was a prospective, observational study of postoperative patients who were admitted to the intensive care unit and later discharged to one of the hospital's regular wards. Patients with impaired communication were excluded. All patients signed an informed consent form. Data were collected using a questionnaire of 13 pain-related questions. RESULTS: A total of 167 patients were included, and 69.5 percent were male. Patient age ranged from 50-59 years, and the intensive care unit stay was one to three days. The majority of the patients (85 percent) reported no difficulties in expressing their painful symptoms, and the nursing approach in 54.5 percent of patients was only to recognize the presence or absence of pain. No pain scale was used. The most painful conditions included the surgical wound and bed positioning. CONCLUSION: The nursing team was apparently more concerned with the presence of pain than with its quality, severity or possible painful stimuli. Pain scales were not used, which suggests the need for continued education of the nursing professionals on the manner of approaching their patients and assessing their patients' pain.

Evaluation of postoperative pain experience in intensive care unit patients. / Avaliação da experiência de dor pós-operatória em pacientes de unidade de terapia intensiva.

OBJECTIVE: This study assessed the role of the nursing staff in pain management and verified the pain experiences of patients undergoing major surgery and receiving postoperative care in the intensive care unit. METHOD: This was a prospective, observational study of postoperative patients who were admitted to the intensive care unit and later discharged to one of the hospital's regular wards. Patients with impaired communication were excluded. All patients signed an informed consent form. Data were collected using a questionnaire of 13 pain-related questions. RESULTS: A total of 167 patients were included, and 69.5% were male. Patient age ranged from 50-59 years, and the intensive care unit stay was one to three days. The majority of the patients (85%) reported no difficulties in expressing their painful symptoms, and the nursing approach in 54.5% of patients was only to recognize the presence or absence of pain. No pain scale was used. The most painful conditions included the surgical wound and bed positioning. CONCLUSION: The nursing team was apparently more concerned with the presence of pain than with its quality, severity or possible painful stimuli. Pain scales were not used, which suggests the need for continued education of the nursing professionals on the manner of approaching their patients and assessing their patients' pain.

Fatores de risco adquiridos e profilaxia da trombose venosa profunda em unidade de terapia intensiva / Acquired risk factors and prophylaxis for deep-vein thrombosis at the intensive therapy unit

O estudo caracterizou os fatores de risco adquiridos da trombose venosa profunda de acordo com aspectosgerais, clínicos, cirúrgicos e medicamentosos; estratificou o risco pela Sociedade Brasileira de Angiologia eCirurgia Vascular e verificou as medidas profiláticas mediante prescrições médicas e de enfermagem. Utilizousemétodo transversal e prospectivo, por meio da análise dos prontuários de 112 pacientes de uma UTI. Evidenciou-se elevada prevalência de fatores de risco em pacientes clínicos e cirúrgicos considerados de Alto Risco. Nos clínicos predominou a infecção e nos cirúrgicos a anestesia geral e o tempo cirúrgico maior de duas horas. Verificou-se que a profilaxia medicamentosa utilizada foi a Heparina não fracionada enquantoas medidas mecânicas como movimentação, deambulação precoce e elevação de membros inferiores, namaioria dos prontuários, não foram identificadas nas prescrições médicas e de enfermagem. Conclui-se que a profilaxia farmacológica e mecânica deve ser realizada em pacientes de UTI, sendo importante a estratificação do risco para que o tratamento seja o mais adequado possível.

This study has characterized the acquired risk factors for deep-vein thrombosis according to general, clinical,surgical, and drug aspects. These data were used to establish the risk of stratification in agreement with theclassification recommended by the Brazilian Society of Angiology and Vascular Surgery (BSAVS). Prophylacticmeasures were also verified through medical and nursing prescriptions. This prospective cross-sectional study was accomplished through the analysis of 112 medical records of intensive care unit patients. Risk factors prevailed and became evident regarding high-risk clinical and surgical patients. Among clinical patients, the infection has predominated. However, in relation to surgical patients, general anesthesia andsurgical time longer than 2 hours were prevailing. It was verified that the prophylactic drug used was unfractionated Heparin, while mechanical measures against thrombosis, such as movement, early ambulation, and elevation of the legs could not be identified in most of the medical and nursing prescriptions found onmedical records. It has been concluded that the pharmacological and mechanical prophylaxis should beperformed in ICU patients. The bottom line is that the risk stratification for the treatment is the most suitable as possible.

Horas de cuidados de enfermagem em UTI: utilização do sistemade pontuação de intervenções terapêutica / The amount of time provided by nursing care in an intensive care unit: using a therapeutic intervention scoring system

Estudo descritivo, com abordagem quantitativa, realizado em um sistema de atenção médica suplementar com o objetivo de mensurar o nível de gravidade dos pacientes por intermédio do sistema de intervenção de pontuação terapêutica (TISS 28) e calcular as horas de cuidados de enfermagem em UTI. A coleta de dados foi realizada por meio do índice TISS 28, no período de outubro a dezembro de 2005 e incluiu 98 pacientes admitidos na UTI. Os resultados evidenciaram um nível de gravidade alto, incluindo intervenções terapêuticas de maior complexidade aplicadas aos pacientes, chamados de Suporte Avançado em UTI e demonstrou que o tempo gasto para a assistência de enfermagem nesse estudo está subdimensionado. Conclui-se que a alta freqüência das categorias e o número elevado de horas destinadas à assistência de enfermagem trouxeram subsídios para o enfermeiro compreender a sua realidade de trabalho.

This is a descriptive and quantitative study, performed at a suplementary medical care system aiming atmeasuring the patients’ severity level using the Therapeutic Intervention Scoring System (TISS 28) and calculating the amount of time provided by nursing care in an ICU. Data were collected by means of the TISS 28 index from October to December 2005, 98 patients admitted in the ICU comprised the study. The results showed a high-severity level including high complexity therapeutic interventions applied to the patients referred as Advanced ICU Life Support. It has been shown that the time provided by nursing care in thepresent study is subdimensioned. It has been concluded that the increased frequencies of categories and the high amount of time provided by the nursing care can make nurse to understand the reality of their work environment.

Eventos adversos na assistência de enfermagem em uma unidade de terapia intensiva / Nursing care adverse events at an intensive care unit

OBJETIVO: A compreensão dos eventos adversos facilita a investigação da qualidade da assistência e auxilia na avaliação dos serviços de saúde. O objetivo deste estudo foi identificar os eventos adversos na assistência de enfermagem em uma unidade de terapia intensiva. MÉTODOS: Os dados foram coletados em um impresso próprio, denominado ficha de ocorrências, por um período de dez meses, no qual os pacientes foram monitorados durante o período de internação na unidade. RESULTADOS: Foram registrados 550 eventos adversos sendo: 26 relacionados aos cinco certos na administração de medicamentos, 23 à medicações não administradas, 181 às anotações inadequadas da medicação, 28 à falhas na instalação de drogas em bomba de infusão, 17 à não realização da inalação, 8 ao manuseio incorreto de seringas e agulhas, 53 aos procedimentos de enfermagem não realizados, 46 ao manuseio incorreto de artefatos terapêuticos e diagnósticos, 37 aos alarmes dos equipamentos utilizados de maneira incorreta e 131 à falhas nas anotações de enfermagem. CONCLUSÃO: A existência de eventos adversos no cuidado prestado pela enfermagem são indicadores importantes que evidenciam a qualidade da assistência na unidade de terapia intensiva. Portanto, os eventos adversos devem ser utilizados para subsidiar a educação permanente da equipe de enfermagem.

OBJECTIVE: The understanding of adverse events may simplify the inquiry regarding the quality of nursing care, presuming a foregrounding role in evaluating health services. The aim of the study was to identify adverse events in nursing care in an intensive care unit. METHODS: Data were collected using an appropriate form known as problem-oriented record (POR) over a 10-month period; patients were monitored throughout their intensive care unit stay. RESULTS: Over the study period, 550 adverse events were recorded as follows: 26 concerned the "five rights" related to drug administration; 23 to non-administered medication; 181 to inappropriate medication records; 28 to failure in infusion pump assembly; 17 to not performed inhalation; 8 to incorrect handling of needles and syringes; 53 to not performed nursing procedures; 46 to incorrect handling of therapeutic and diagnostic devices; 37 to alarms/warnings of devices used incorrectly; and 131 to failure in data recording by nurses. CONCLUSION: The occurrence of adverse events in the care given to patients by the nursing team are significant indicators that disclose the quality of nursing care. Therefore, these events should be analyzed to support in-service training of the nursing staff.

Nursing care adverse events at an intensive care unit. / Eventos adversos na assistência de enfermagem em uma unidade de terapia intensiva.

OBJECTIVE: The understanding of adverse events may simplify the inquiry regarding the quality of nursing care, presuming a foregrounding role in evaluating health services. The aim of the study was to identify adverse events in nursing care in an intensive care unit. METHODS: Data were collected using an appropriate form known as problem-oriented record (POR) over a 10-month period; patients were monitored throughout their intensive care unit stay. RESULTS: Over the study period, 550 adverse events were recorded as follows: 26 concerned the "five rights" related to drug administration; 23 to non-administered medication; 181 to inappropriate medication records; 28 to failure in infusion pump assembly; 17 to not performed inhalation; 8 to incorrect handling of needles and syringes; 53 to not performed nursing procedures; 46 to incorrect handling of therapeutic and diagnostic devices; 37 to alarms/warnings of devices used incorrectly; and 131 to failure in data recording by nurses. CONCLUSION: The occurrence of adverse events in the care given to patients by the nursing team are significant indicators that disclose the quality of nursing care. Therefore, these events should be analyzed to support in-service training of the nursing staff.

Morte: percepção e sentimentos de acadêmicos de enfermagem / Death: perception e empaties of nursing students

Introdução: O tema morte sempre foi objeto de muita especulação e de muito interesse por parte do serhumano, já que envolve um sentimento de apreensão e medo ao seu redor. Contudo, é no contexto do profissional da saúde que esse assunto se torna mais relevante e desafiador, uma vez que estes profissionais se deparam inúmeras vezes com a morte de seus pacientes no seu dia-a-dia de trabalho. Objetivos: Caracterizar o perfil dos acadêmicos de enfermagem da 1ª a 4ª séries de uma instituição do noroeste paulista e identificar a percepção e sentimentos destes em relação à morte. Método: Participaram deste estudo 132 acadêmicos que responderam a um questionário contendo cinco perguntas para sua caracterização e sete perguntas de múltipla escolha sobre a sua percepção e sentimentos sobre a morte. Resultados: O perfil dos acadêmicos de enfermagem foi de pessoas jovens, a maioria entre 20 a 25 anos, sexo feminino, solteiros e seguidores da religião católica. A percepção das dificuldades e sentimentos evidenciados pelos acadêmicos em relação ao tema morte e morrer demonstrou despreparo para lidarem com esta situação, devido ao estresse, ansiedade e insegurança relatados, o que parece dificultar a atuação do enfermeiro no que se refere ao apoio e conforto necessários ao paciente terminal e seu familiar. Conclusão:. É relevante a implantação de uma educação tanatológica na graduação, que venha ao encontro das exigências requeridas durante os estudos clínicos em campo a fim de desenvolver a capacidade dos estudantes no enfrentamento da morte.

The theme “death” has always been a matter of much speculation and interest by the human being, once it involves a feeling of deep concern and fear. Therefore, in the health professionals’ context, this subject has become more relevant and challenging, once these professionals, likewise doctors and nurses, cope with this situation during their daily routine. Objective: This study aims at characterizing the profile of nursing students from First to Fourth Grade, in a nursing school in the Northwest of São Paulo State, and identifies their perception and empathy when dealing with this matter. The sample was composed of 132 nursing students. A semi-structured questionnaire with 5 personal identification questions and 7 multiple-choice questions related to their perception and empathy concerning “death”. Results: The profile of nursing students was as follows: most of them were young people, female, single, age ranging from 20 to 25 years and catholic. The perception of the difficulties and empathy highlighted by the nursing students regarding the death and the dying revealed their unpreparedness to deal with this kind of situation, mostly in consequence of the stress, anxiety, and unreliableness reported, what hampers the nurse practice and performance regarding providing support and reassurance necessary to the terminal patient and his/her family. Conclusion: The implementation of undergraduate studies concerning death and dying is a very relevant issue meeting with the requirements claimed during clinical practice studies with the purpose to improve the students’ attitude to death.

Visita em Unidades de Terapia Intensiva: concepção dos familiares quanto à humanização do atendimento / Visit on Intensive Care Units: The Families´ Understanding on Care Humanization

A Unidade de Terapia Intensiva (UTI) é considerada um ambiente hostil e invasivo. Portanto, o envolvimentoda família com o paciente é importante para o processo de humanização, pois a presença da família junto aoente querido contribui com o tratamento e para a sua recuperação. Objetivo: Verificar a concepção dosfamiliares quanto a visita em UTI. Método: Estudo descritivo exploratório realizado na UTI da Emergência deum hospital do noroeste paulista, realizado por meio de entrevista, utilizando-se um formulário com questõesfechadas e abertas relacionadas às orientações recebidas sobre a unidade, aprovação do horário de visitas,atendimento da equipe multiprofissional, reconhecimento do enfermeiro na equipe, sentimentos e importânciados familiares na recuperação do cliente. Foram entrevistados 41 familiares, nos meses de julho a outubro de2005, durante o horário de visita. Os dados foram analisados em freqüência e porcentagens e apresentadosem tabelas. Resultados: A família sente necessidade de atenção e da companhia de um profissional para obterinformações sobre como seu familiar passou o dia, as intercorrências e outros acontecimentos que permeiama rotina dessas pessoas e da unidade, e desejam mais um horário para visitas. Considerações: Uma assistênciahumanizada necessita de um enfermeiro mais atuante, dando orientações completas e freqüentes aos familiares.Sobretudo, é o profissional com maior capacidade e conhecimento para atuar junto à família, considerandoseu contato ininterrupto com o paciente e, assim, pode amenizar a ansiedade vivida, enfatizando a importânciada presença da família na recuperação do seu ente querido.

Introduction: The hospital Intensive Care Unit (ICU) is considered a hostile and invasive environment. Thus,the patient family involvement is important for the humanization process, once the presence of the patients’family improve the care and recovery of their loved ones. Objectives: To identify the ICU patients’ familyneeds and to observe primary health care to the families of these patients. Method: An exploratory descriptivestudy was performed at an emergency intensive care unit of a hospital at a Northwestern State of São Paulo.Individual structured interviews were used with a questionnaire with core open-ended questions to allow therespondents to explain their own viewpoints and experiences as completely as possible. Family data onwhether a family received information about the unit; approval of visit hours; whether they were receivingsupport from the multidisciplinary team; whether they were told of the specific role of each ICU caregiver;and the feelings and the importance of the family on the patient’s recovery. From July to October 2005, a totalof 41 family members completed the questionnaire during the visit hours. Results: The family needs attentionand help from a health professional to be provided with the appropriate, clear, and compassionate informationon the diagnosis, prognosis, or treatment of the patient, and more visit hours allowed per day. Conclusion: Ahumanized assistance requires a more active nurse, who provides the family members usual and completeinformation. Taking into account the interaction between health professionals and family members; thenurses are the most qualified caregiver to provide all the information to the family members. Moreover, theyare usually in touch with the patient, and can also diminish the family anxiety; emphasizing the importance ofthe family´s presence on the recovery of their loved ones.