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- Bäckman, Carl G
(author)
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The photo-diary and follow-up appointment on the ICU: Giving back the time to patients and relatives. : A descriptive and interventional study
- 2011
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Doctoral thesis (other academic/artistic)abstract
- Background: Patients on the ICU often spend a great deal of their time either unconscious or heavily sedated. When they return from the zone between life and death they are often in a state of confusion where dreams and delusions are intertwined with reality and it is not always easy to distinguish them apart. These experiences could lead to psychological problems and post-traumatic stress disorder (PTSD). Recovery may be improved by filling in the significant memory gaps and explaining what really happened during the “chaotic” time on the ICU. The provision of a diary describing the patients’ stay in ICU on a day to day basis and a follow-up meeting (together named the ICU-diary concept), may help the whole family to understand.Aim: The principal aim of this thesis was to see if the ICU-diary concept was of help to patients and relatives in the recovery after critical illness. A further aim was to look for precipitants in the ICU of PTSD.Material and Methods: ICU patients in a handful of European countries and their relatives have been studied. The studies have been single and multi-centred and we have used descriptive observational, randomised controlled and cohort study designs, including matched case-control designs. Quantitative methods have been used with questionnaires and structured interviews using established instruments (i.e Post-traumatic stress syndrome screening-14, Post-traumatic diagnostic scale, ICU memory tool, Short Form-36, Pearlin-Schooler Mastery Scale, Hopelessness scale) as the principal means of data collection.Results: The ICU-diary concept was seen to be a positive and useful aid in helping patients and their relatives understand the events that took place during the time on the ICU. It also decreased the risk for PTSD among patients and relatives. Patients that were supported with the ICU-diary concept perceived a better health-related quality of life even 3 years after the ICU stay. We did not find any definite improvement by the ICU-diary concept in mastery and hope. Variations in how the patients were cared for in the ICU had a significant effect on the development of PTSD. The implementation of an ICU diary, for instance, was associated with a lower frequency of PTSD.Conclusions: The ICU-diary concept was found helpful by patients and their relatives. It was associated with a reduction in new onset PTSD and improved health-related quality of life. The results are encouraging and suggest that an ICU diary may represent an important first step to help patients and relatives come to terms with their experiences during critical illness.ISBN 978-
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| 2. |
- Berkius, Johan, 1960-
(author)
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Intensive care in chronic obstructive pulmonary disease : treatment with non-invasive ventilation and long-term outcome
- 2013
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Doctoral thesis (other academic/artistic)abstract
- Background: Chronic obstructive pulmonary disease (COPD) is a major cause of chronic morbidity and mortality throughout the world. When we began this project our knowledge about the outcome of COPD patients admitted to the ICU in Sweden was scarce.Aims: To investigate the characteristics, survival and health-related quality of life (HRQL) of COPD patients admitted to Swedish ICUs. To investigate how ICU personnel decide whether to use invasive or non-invasive ventilatory treatment (NIV) of the newly admitted COPD patient in need of ventilatory support. To investigate outcome according to mode of ventilation.Material and methods: Detailed data, including HRQL during recovery, from COPD patients admitted to ICUs that participated in the Swedish intensive care registry were analysed. A questionnaire was distributed to personnel in 6 of the participating ICUs in order to define factors deemed important in making the choice between invasive and non-invasive ventilation immediately after admission. The answers were analysed.Results: The proportion of COPD patients admitted to Swedish ICUs in need of ventilatory support is 1.3-1.6 % of all admissions. The patients are around 70 years-old and are severely ill on admission, with high respiratory rates and most have life-threatening disturbances in their acid-base balance and blood gases. There are more women than men. The short- and long-term mortality is high despite intensive care treatment. The majority of patients are treated with NIV. The length of stay on the ICU is shorter when NIV is used. The choice between NIV and invasive ventilation in these patients may be irrational. It is guided by current guidelines, but other non-patient-related factors seem to influence this decision. NIV seems to be preferable to invasive ventilation at admission, not only according to short-term benefits but also to long-term survival. Failure of NIV followed by invasive ventilation does not have a poorer prognosis than directly employing invasive ventilation. The health-related quality of life of COPD patients after treatment on Swedish ICUs is lower than in the general population. However it does not decline between 6 and 24 months after ICU discharge. After 24 months the HRQL is quite similar to that of COPD patients not treated on the ICU.Conclusions: COPD patients in need of ventilatory support admitted to Swedish ICUs are severely ill on admission, and their short- and long-term mortality is high despite ICU care and ventilatory treatment. Non-invasive ventilation should be the first line treatment on admission. NIV has short- and long-term benefits compared to invasive ventilation, without increasing mortality risk in case of failure. After discharge from the ICU and recovery, the HRQL of COPD patients is lower than in the general population, but comparable to COPD patients not treated on the ICU.
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| 3. |
- Steins, Krisjanis, 1971-
(author)
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Discrete-Event Simulation for Hospital Resource Planning : Possibilities and Requirements
- 2010
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Licentiate thesis (other academic/artistic)abstract
- The delivery of health care services has been under pressure due to limited funding and increasing demand. This has highlighted the need to increase not only the effectiveness but also the efficiency of health care delivery. Discrete-event simulation has been suggested as an analysis tool in health care management to support the planning of health care resources.The overall purpose of this thesis is to investigate the possibilities and requirements for using discrete-event simulation in analyzing and planning the use of hospital resources. This is achieved by three case studies that focus on improvements in patient flow of emergency patients that require a radiology examination, intensive care unit capacity planning and operating room allocation strategies, respectively.The first case investigates the current stage of digitization and process orientation in hospital care as a prerequisite for efficient process simulation and analysis. The study reveals an emergency-radiology patient flow process that is not very well measured and uncovers disparate information systems storing incompatible and fragmented data. These results indicate that the current degree of process orientation and the current IT infrastructure does not enable efficient use of quantitative process analysis and management tools like simulation.In the second case the possibilities to develop generic hospital unit simulation models by building and validating a generic intensive care unit (ICU) model are explored. The results show that some of the modeling approaches described in literature cannot replicate the actual behavior observed in all studied ICUs. It is important to identify patient groups for different admission priorities, to account for over-utilizations in the model logic, and to discover and properly model dependencies in the input data. The research shows that it is possible to develop a generic ICU simulation model that could realistically describe the performance of different real ICUs in terms of occupancy, coverage and transfers.The value of simulation modeling in health care management is examined in the third case through the development and use of a simulation model for optimal resource allocation and patient flow in a hospital operating department. The goal of the simulation modeling in this case was to identify bottlenecks in the patient flow and to try different alternatives for allocation of operating room capacity in order to increase the utilization of operating room resources. The final model was used to evaluate four different proposed changes to operating room time allocation.
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- Walther, Sten, 1954-
(author)
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Nebulized corticosteroid in septic lung injury : An experimental study in pigs
- 1992
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Doctoral thesis (other academic/artistic)abstract
- Sepsis is occasionally complicated by the adult respiratory distress syndrome (ARDS). Auto injury by immunocompetent cells are given a central role in the pathogenesis, but our understanding of the mechanisms remains fragmentary. Treatment in septic ARDS is mainly supportive, no causal therapy exists. Mortality is high at 50-70%.The main purposes of the prese~t series of experiments in pigs were to study mechanisms involved in Gram positive and Gram negative septic lung injury, and to investigate effects of intrapulmonary delivery of nebulized drug on mediators of injury and on pulmonary integrity and function. Nebulized corticosteroid with a high anti-inflammatory activity, beclomethasone dipropionate 10 and 50 pg/kg given every 6 hours, improved gas exchange, lung mechanics, pulmonary and systemic haemodynamics and outcome for a 44 hour observation period in pigs with staphylococcal sepsis. The pulmonary effects of a corticosteroid with still higher anti-inflammatory activity, fluticasone 100pg/kg, given in endotoxaemia were similar to those seen after beclomethasone dipropionate in staphylococcal sepsis, the main difference was an increase in pulmonary artery pressures followingfluticasone. Angiotensin converting enzyme (ACE) activity in serum was analyzed and related to the stabilized systemic haemodynamics which were found in pigs treated with nebulized corticosteroid. The results indicated an association between systemic vasoregulation and ACE activity in sepsis, but they did not support that blood pressure was preserved by an ACE-dependent mechanism in corticosteroid treated pigs. Sepsis increased pulmonary sequestration of radiolabelled autologous granulocytes. This increase was significantly attenuated by nebulized beclomethasone dipropionate. The endotoxin-induced immediate accumulation of radiolabelled transferrin in the lungs, whichprobably indicated increased transcapillary protein flow, was abolished by fluticasone.In conclusion, nebulized corticosteroid given in moderate doses in sepsis reduced pulmonaty granulocyte sequestration, abolished pulmonary capillary protein leak and attenuated pulmonary dysfunction with resultant increase in survival. These protective effects of nebulized corticosteroid inexperimental septic lung injury indicate a therapeutic role in the treatment of ARDS.
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