Gotowa bibliografia na temat „Anaesthesia and intensive care”

Maintenance of anaesthesia using the intravenous agent propofol has increased following development of pharmacokinetic models. An analyser capable of determining propofol concentrations at the point of care may lead to an improved accuracy of drug delivery. Validation work on a novel analyser measuring propofol concentration in near real time demonstrate a high level of precision for samples in the clinical range. Further work in the clinical setting was carried out using the novel propofol analyser to further research its potential use in a diverse patient cohort. Studies were performed in intensive care correlating blood propofol concentrations with depth of sedation, demonstrating a correlation with organ failure. The Marsh model of Target Controlled Anaesthesia was poorer at predicting propofol concentration in patients with significant organ dysfunction than in those without organ failure (correlation coefficient 0.36 vs. 0.73 respectively). Studies in the operating room were performed in which measured propofol concentrations were compared with those predicted using the Marsh model. Results demonstrated significant inaccuracies of the model (bias 32%, precision -8.7 to 72.6%). A method of Marsh model bias correction using a single blood propofol measurement was tested. Results demonstrated insufficient predictability to allow a single point calibration.

The objectives of this thesis are : 1) To provide a review of the literature on the significance, pathogenesis, diagnosis and management of secondary infections in the Intensive Care Unit. 2) To present the findings of a study of the technique of selective parenteral and enteral antisepsis regimen (SPEAR) in the patient population of the Respiratory ICU at Groote Schuur Hospital, aimed at reducing the incidence of secondary infection and, further to evaluate the study in terms of the effect of SPEAR on the incidence of secondary infection and its influence on the mortality due to secondary infection. 3) To present the findings of the effect of SPEAR on patient bacterial colonisation in the ICU, and to evaluate its longterm influence on the microbial flora of the ICU.

This study consisted of two stages. Stage 1 investigated the reproducibility and practicality of two observational sedation assessment scales for use in critically ill children. The two scales were different in design, the first being simple in design requiring a single assessment of the patient. The second was more complex in design requiring assessment of five patient parameters to obtain an overall sedation score. It was established that nursing staff preferred the second, more complex sedation scale mainly because it was perceived to give a more accurate assessment of level of sedation and anxiety rather than merely level of sedation. Stage 2 investigated the pharmacokinetics and pharmacodynamics of midazolam in critically ill children. 52 children, aged between 0 and 18 years were recruited to the study and 303 blood samples taken to analyse midazolam and its metabolites, 1-hydroxymidazolam (1-OH) and 4-hydroxymidazolam (4-OH). A significant correlation was found between midazolam plasma concentration and sedative effect (r=0.598, p=0.01). It was found that a midazolam plasma concentration of 223ng/ml (±31.9) achieved a satisfactory level of sedation. Only a poor correlation was found between dose of midazolam and plasma concentration of midazolam. Similarly only a poor correlation was found between sedative effect and dose of midazolam. Clearance of midazolam was found to be 6.3ml/kg/min (±0.36), which is lower than that reported in healthy children (9.11-13.3ml/kg/min). neonates produced the lowest clearance values (1.63ml/kg/min), compared to children aged 1 to 12 months (8.52ml/kg/min) who achieved the highest clearance values. Clearance was found to decrease after the age of 12 months to values of 5.34ml/kg/min in children aged 7 yeas and above. Patients with renal (n=5) and liver impairment (n=4) were found to have reduced midazolam clearance (1.37 and 0.74ml/kg/min respectively). Disease state was found to affect production of 1-OH. Patients with renal impairment (n=5) produced the lowest 1-OH midazolam plasma ratio (0.059) compared to patients with head injury (0.858).

Background: Neonates who require specialized care and life-saving therapies in neonatal intensive care units (NICUs) and neonatal special care units (NSCUs) can be exposed to separation from their parents and families. Consequently, establishing a parental-neonate bond can be difficult. However, addressing this problem of separation through involving parents and families in neonatal care to improve parent-professional collaboration can result in positive outcomes for neonates and their families. Family-centred care (FCC) has developed over decades and is broadly recommended as an ideal model of care in daily clinical practice in NICUs. However, FCC implementation is challenging at individual, organizational, cultural, and healthcare system levels. In particular, developing countries are challenged by the lack of material resources, infrastructure, and staff shortages. In Thailand, the practical incorporation of FCC into daily clinical practice in neonatal care units is difficult, and it has not been sustainably achieved. Furthermore, there has been minimal research reporting on the development, implementation, and evaluation of FCC in the neonatal critical care context within Thailand. Aim and Objectives: The aim of this PhD study has been to develop, implement and evaluate innovation to facilitate FCC by improving respect, collaboration, and support in a Thai NICU. It had three objectives, each representing a distinct phase in the study: (1) to identify perceptions, current practices and FCC strategies; (2) to develop and implement an innovation to facilitate FCC by improving respect, collaboration, and support in a Thai NICU; and (3) to evaluate the FCC innovation developed in Phase 2. Methods and Results Design: The multistage, mixed-methods study design applied the Participatory Intervention Model (PIM) to guide the innovation’s development, implementation, and evaluation to facilitate FCC by improving respect, collaboration, and support in a Thai NICU. Setting and context: This study was conducted in a tertiary care hospital in southern Thailand (February 2020-January 2021). Ethics approval was obtained from the Research Ethics Committee of Hatyai Hospital and Griffith University. Phase 1: Identification of perceptions, current practices, and FCC strategies Phase 1 was planned to include data collection over 3 months. Due to the COVID-19 pandemic, it was reduced to 2 months during the very early stages of the pandemic (February to March 2020). This phase consisted of two parts, including surveys and interviews with parents and the interdisciplinary professionals. Participants: Participants consisted of two groups: parents of neonates (all gestational ages with no life-threatening or life-limiting diagnosis) who had an expected NICU stay of at least 72 hours and visited the study NICU at least once, and interdisciplinary professionals with a permanent position for at least 1 year in the study unit. Part A: Survey of parents and interdisciplinary professionals Surveys of parents and interdisciplinary professionals were conducted using the validated Perceptions of Family Centred Care – Parent (PFCC-P) and Perceptions of Family Centred Care – Staff (PFCC-S) instruments which were translated into Thai. Sample size: Sample size was based on availability of parents and interdisciplinary professionals over the planned 3-month Phase 1 period. Recruiting parent participants in Phase 1 was prior/during the very early stages of the COVID-19 pandemic and needed to be stopped prior to pre-determined sample size of 100 parents due to visitor restriction (n = 85). Eighty-five parents and 20 interdisciplinary professionals completed the surveys. Data analysis: Demographic characteristics of parents, interdisciplinary professionals, and neonates are reported using descriptive statistics. The subscale scores for parents and interdisciplinary professionals were not normally distributed, so medians were calculated for each of the three sub-scales (respect, collaboration, and support). Parents’ and interdisciplinary professionals’ perceptions of FCC (PFCC-P & PFCC-S) were compared using the Mann-Whitney U test to examine differences in medians in the preimplementation phase because they were unpaired groups. Part B: Semi-structured interviews with parents and interdisciplinary professionals Face-to-face, semi-structured, individual interviews were planned to gain information from extended family members and parents and interdisciplinary professionals; however, given the visitation restrictions, only parents and interdisciplinary professionals were recruited to participate (during the first half of February 2020). Sample size: The sample size was determined when data saturation was identified. Eight interdisciplinary professionals and nine parents participated in face-to-face interviews. Data analysis: Thematic analysis was used to analyse the transcribed Thai language interviews. Results: The survey results across the median of three subscales demonstrated that parents and interdisciplinary professionals’ perceptions on the FCC strategies in current practice were 2-3/4 (Interquartile range [IQR] 1.7-3.8) and 3-4/4 (2.85-3.55), respectively. Considering the median subscale scores, the interdisciplinary professionals had significantly higher subscale scores for respect (median 3.00 (95% CI, 2.91-3.24) vs 2.50 (2.37-2.81)), collaboration (median 3.22 (3.10-3.37) vs 2.33 (1.9-2.62)), and support (median 3.20 (3.03-3.39) vs 2.60 (2.03-2.61)) (all p ≤ 0.001). The interview findings highlighted that the interdisciplinary professionals in this study accepted that the three critical elements of FCC (respect, collaboration, and support) were necessary to be implemented into clinical practice. However, they believed that in reality it was not easy in the Thai NICUs context. This finding identified that the challenge to promote parent-healthcare professional partnerships was associated with the structure and processes of the healthcare delivery system. In addition, the individuality of families' readiness and healthcare providers' perceptions of parents’ involvement as obstacles to providing care were found to be challenges to current practices of FCC. Phase 2: Development and implementation of innovation to facilitate FCC This phase was achieved by two different methods: strategy development working group and implementation of the FCC innovation. Strategy development working group: The development of FCC innovations by the strategy development working group (June to August 2020) was based on Phase 1 findings and the reported integrative literature review. In addition, the FCC innovations were considered within the policies and practices of the NICU in the context of COVID- 19 in Thailand. The development working group members were key and high-level stakeholders in the NICU. Educational activities for the healthcare professional team to incorporate the FCC innovations into their clinical practice in NICU were provided. Implementation of the FCC innovation: The FCC innovations were then implemented over 2 months (September to October 2020), during a period of restrictions on parents and staff arising from COVID-19. Results: The working group identified the gaps in the three key elements (respect, collaboration, and support) to providing FCC in a Thai NICU through the analysis of Phase 1’s results in consort with the findings from the integrative review. A preliminary protocol for the FCC innovations and implementation plan were developed consistent with the challenges associated with COVID-19 in Thailand. FCC practice innovations associated with improving communication were established, including changes and updates to the material within the parent booklet with specific material related to COVID- 19, neonatal updates at bedside or conducted via telephone calls, interdisciplinary family meeting for complex care situations, structured communication checklists, and documentation templates. In addition, although visiting restrictions were limiting, parents were provided with more flexibility as to when they could visit based on individual circumstances. The majority of the healthcare providers in this setting (80%) attended the educational activities to incorporate the FCC innovations into their clinical practice in the NICU. The FCC innovations were incorporated into daily NICU practice by nurses in cooperation with other healthcare providers and ancillary support staff during the pandemic. Phase 3: Evaluation of the FCC innovation Phase 3 (post-implementation) was conducted over 3 months (November 2020-January 2021), and it focused on evaluating the FCC innovations. This phase repeated the collection of data from the validated PFCC-P and PFCC-S surveys of parents and interdisciplinary professionals' perceptions, as per Phase 1, to assess respect, collaboration, and support changes after implementing the FCC innovations in the Thai NICU during the pandemic. Sample size: One hundred parents and 20 interdisciplinary professionals completed the surveys. Data analysis: As per Phase 1 for demographic characteristics. The Mann-Whitney U test was used to analyse parents' perceptions of the items of the PFCC-P pre- and postimplementation given they were two independent groups. Wilcoxon signed-rank test was used to compare the perceptions of the interdisciplinary professionals pre- and postimplementation using the PFCC-S given they were matched samples. Results: The participants consisted of 83 pairs of parents (i.e., mother and/or father of neonate participated) (35 pre; 48 post), which represented 102 neonates (50 pre; 52 post). There were 185 parents; 85 pre-implementation and 100 post-implementation. For the NICU health care team, 20 participated. The median scores of parents' perceptions post-implementation significantly improved for respect (2.50 to 3.50; 95%CI, 3.02-3.53), collaboration (2.33 to 3.33; 2.90- 3.40), support (2.60 to 3.60; 2.84-3.62), and the overall score (2.50 to 3.43) (p < 0.001, 95%CI 2.93-3.51). There was an absolute difference of at least 0.3 in the pre- and postimplementation scores for three subscales and overall score, where 0.3 corresponds to 10% of the rating scale. Comparatively, interdisciplinary professionals' perception of FCC did not significantly change pre- and post-implementation for respect ([median] 3.00 to 2.92; 95%CI, 2.87-3.16), collaboration (3.22 to 3.33; 3.16-3.47), support (3.20 to 3.20; 2.96-3.28) and overall (3.15 to 3.20; 95%CI, 3.10-3.25). Conclusions:Results from this study indicate that incorporating FCC innovations in the NICU appeared to be successful, despite the challenges of COVID-19. The key finding was that the innovations incorporated in the NICU were primarily based on communication strategies, a simple means to support, collaborate with, and respect parents that required low investment within the complex situation arising from COVID-19. These innovations were essential to engage collaborative working between parents and healthcare providers to promote parents as partners in a neonatal critical care team. To successfully implement FCC innovations in different settings, further innovations associated with communication methods need to target the specifics of individuals involved, healthcare settings, and available resources.<br>Thesis (PhD Doctorate)<br>Doctor of Philosophy (PhD)<br>School of Nursing & Midwifery<br>Griffith Health<br>Full Text