Sistematização do processo de fiscalização do exercício profissional de enfermagem : uma abordagem de Gestão de Riscos

Dissertação (mestrado)—Universidade de Brasília, Instituto de Ciências Exatas, Departamento de Ciência da Computação, 2019.A implantação da Gestão de Riscos no Conselho Federal de Enfermagem tornou-se uma meta institucional frente à necessidade de efetivação da governança, transparência e antecipação proativa à redução de eventos que possam comprometer os objetivos estratégicos do órgão. Atualmente, a atividade finalística de Fiscalização Profissional, atribuída ao Sistema Conselho Federal - Conselhos Regionais de Enfermagem, encontra-se em fase de readequação e melhoria de processos. Este trabalho tem como objetivo identificar eventos de riscos associados ao processo de fiscalização do exercício profissional de enfermagem, propondo soluções de melhoria. A estratégia de pesquisa utilizada foi um estudo de caso sobre o atual processo de trabalho da fiscalização profissional, a abordagem da pesquisa foi qualitativa, sendo realizadas entrevistas aos especialistas das áreas de fiscalização profissional em âmbito nacional, além de observações e levantamento de informações junto às áreas interessadas pelo processo. Estão entre os principais resultados da pesquisa, a uniformização do processo da fiscalização do exercício profissional, a acepção de uma taxonomia de riscos aderente à área de negócio da fiscalização profissional, a avaliação de 1.640 elementos de riscos do processo, o desenvolvimento de um procedimento de fuzzyficação para maior distinção dos grupos de magnitude dos riscos avaliados, dado o grande volume de riscos identificados, além do desenvolvimento da versão inicial do sistema de informação que apoiará o registro e acompanhamento das inconformidades constatadas na inspeção fiscal.The implementation of Risk Management at the Federal Nursing Council (Cofen) has become an institutional goal in view of the need to implement governance, transparency and proactive anticipation to reduce events that could compromise the agency's strategic objectives. Currently, the final activity of Professional Supervision, attributed to the Cofen-Regional Nursing Councils System (Cofen-Coren System), is in a process of readjustment and improvement of processes. This work aims to identify risk events associated to the process of professional supervision of nursing practice, proposing improvement solutions. The research strategy used was a study of case on the current work process of the professional supervision, the approach of the research was qualitative, being carried out interviews to the specialists of the areas of professional supervision in the national scope of this autarchy (agency of professional regulation), besides observations and survey at the areas interested in this process. Among the main results of the research are the standardization of the process of professional practice supervision, the acceptance of a risk taxonomy adhering to the business area of professional supervision, the assessment of 1,640 risks elements of the process, the development of a fuzzification to distinguish the groups of magnitude of the risks evaluated, given the large volume of risks identified and the development of the initial version of the information system that will support the recording and monitoring of the non-conformities found in the Nursing Professional Supervision Process

Effects of volume resuscitation on splanchnic perfusion in canine model of severe sepsis induced by live Escherichia coli infusion

INTRODUCTION: We conducted the present study to investigate whether early large-volume crystalloid infusion can restore gut mucosal blood flow and mesenteric oxygen metabolism in severe sepsis. METHODS: Anesthetized and mechanically ventilated male mongrel dogs were challenged with intravenous injection of live Escherichia coli (6 × 10(9 )colony-forming units/ml per kg over 15 min). After 90 min they were randomly assigned to one of two groups – control (no fluids; n = 13) or lactated Ringer's solution (32 ml/kg per hour; n = 14) – and followed for 60 min. Cardiac index, mesenteric blood flow, mean arterial pressure, systemic and mesenteric oxygen-derived variables, blood lactate and gastric carbon dioxide tension (PCO(2); by gas tonometry) were assessed throughout the study. RESULTS: E. coli infusion significantly decreased arterial pressure, cardiac index, mesenteric blood flow, and systemic and mesenteric oxygen delivery, and increased arterial and portal lactate, intramucosal PCO(2), PCO(2 )gap (the difference between gastric mucosal and arterial PCO(2)), and systemic and mesenteric oxygen extraction ratio in both groups. The Ringer's solution group had significantly higher cardiac index and systemic oxygen delivery, and lower oxygen extraction ratio and PCO(2 )gap at 165 min as compared with control animals. However, infusion of lactated Ringer's solution was unable to restore the PCO(2 )gap. There were no significant differences between groups in mesenteric oxygen delivery, oxygen extraction ratio, or portal lactate at the end of study. CONCLUSION: Significant disturbances occur in the systemic and mesenteric beds during bacteremic severe sepsis. Although large-volume infusion of lactated Ringer's solution restored systemic hemodynamic parameters, it was unable to correct gut mucosal PCO(2 )gap

Sepsis: from bench to bedside

Sepsis is a syndrome related to severe infections. It is defined as the systemic host response to microorganisms in previously sterile tissues and is characterized by end-organ dysfunction away from the primary site of infection. The normal host response to infection is complex and aims to identify and control pathogen invasion, as well as to start immediate tissue repair. Both the cellular and humoral immune systems are activated, giving rise to both anti-inflammatory and proinflammatory responses. The chain of events that leads to sepsis is derived from the exacerbation of these mechanisms, promoting massive liberation of mediators and the progression of multiple organ dysfunction. Despite increasing knowledge about the pathophysiological pathways and processes involved in sepsis, morbidity and mortality remain unacceptably high. A large number of immunomodulatory agents have been studied in experimental and clinical settings in an attempt to find an efficacious anti-inflammatory drug that reduces mortality. Even though preclinical results had been promising, the vast majority of these trials actually showed little success in reducing the overwhelmingly high mortality rate of septic shock patients as compared with that of other critically ill intensive care unit patients. Clinical management usually begins with prompt recognition, determination of the probable infection site, early administration of antibiotics, and resuscitation protocols based on "early-goal" directed therapy. In this review, we address the research efforts that have been targeting risk factor identification, including genetics, pathophysiological mechanisms and strategies to recognize and treat these patients as early as possible

Sepsis: From Bench to Bedside

Sepsis is a syndrome related to severe infections. It is defined as the systemic host response to microorganisms in previously sterile tissues and is characterized by end-organ dysfunction away from the primary site of infection. The normal host response to infection is complex and aims to identify and control pathogen invasion, as well as to start immediate tissue repair. Both the cellular and humoral immune systems are activated, giving rise to both anti-inflammatory and proinflammatory responses. The chain of events that leads to sepsis is derived from the exacerbation of these mechanisms, promoting massive liberation of mediators and the progression of multiple organ dysfunction. Despite increasing knowledge about the pathophysiological pathways and processes involved in sepsis, morbidity and mortality remain unacceptably high. A large number of immunomodulatory agents have been studied in experimental and clinical settings in an attempt to find an efficacious anti-inflammatory drug that reduces mortality. Even though preclinical results had been promising, the vast majority of these trials actually showed little success in reducing the overwhelmingly high mortality rate of septic shock patients as compared with that of other critically ill intensive care unit patients. Clinical management usually begins with prompt recognition, determination of the probable infection site, early administration of antibiotics, and resuscitation protocols based on “early-goal” directed therapy. In this review, we address the research efforts that have been targeting risk factor identification, including genetics, pathophysiological mechanisms and strategies to recognize and treat these patients as early as possible

“EU ACREDITO EM FILOSOFIA”: FANATISMO RELIGIOSO, INTOLERÂNCIA E ANTI-INTELECTUALISMO NO FILME ALEXANDRIA (2009)

O tema deste artigo é a análise do filme Alexandria (2009), dirigido pelo cineasta Alejandro Amenábar, tendo como protagonista principal a atriz Rachel Weisz. O seu objetivo principal é cotejar a representação cinematográfica sobre o fanatismo, intolerância e anti-intelectualismo cristão que culmina no linchamento da filosofa Hipátia de Alexandria, com a contextualização baseada na historiografia especializada. Desse modo, a metodologia valeu-se da análise de obras históricas (Gibbon, Russel, Scholasticus) e da teoria sociológica (Max Weber) para contribuir para um melhor conhecimento da história do Cristianismo que se desenrola na cidade de Alexandria e também para um melhor aproveitamento do filme, seja para deleite estético, seja como fonte de representação histórica. A conclusão do artigo demonstra que o filme faz uso de elementos ficcionais para a sua estruturação narrativa, mas constitui-se num documento sobre a importância simbólica da morte de Hipátia para a reflexão sobre o fanatismo, intolerância e anti-intelectualismo religioso

Impact of Plasma-Lyte pH 7.4 on acid-base status and hemodynamics in a model of controlled hemorrhagic shock

OBJECTIVE: Intravenous infusion of crystalloid solutions is a cornerstone of the treatment of hemorrhagic shock. However, crystalloid solutions can have variable metabolic acid-base effects, perpetuating or even aggravating shock-induced metabolic acidosis. The aim of this study was to compare, in a controlled volume-driven porcine model of hemorrhagic shock, the effects of three different crystalloid solutions on the hemodynamics and acid-base balance. METHODS: Controlled hemorrhagic shock (40% of the total blood volume was removed) was induced in 18 animals, which were then treated with normal saline (0.9% NaCl), Lactated Ringer's Solution or Plasma-Lyte pH 7.4, in a blinded fashion (n = 6 for each group). Using a predefined protocol, the animals received three times the volume of blood removed. RESULTS: The three different crystalloid infusions were equally capable of reversing the hemorrhage-induced low cardiac output and anuria. The Lactated Ringer's Solution and Plasma-Lyte pH 7.4 infusions resulted in an increased standard base excess and a decreased serum chloride level, whereas treatment with normal saline resulted in a decreased standard base excess and an increased serum chloride level. The Plasma-Lyte pH 7.4 infusions did not change the level of the unmeasured anions. CONCLUSION: Although the three tested crystalloid solutions were equally able to attenuate the hemodynamic and tissue perfusion disturbances, only the normal saline induced hyperchloremia and metabolic acidosis

Tissue perfusion assesment in shock

Apesar das diversas inovações tecnológicas e do melhor entendimento fisiopatológico dos estados de choque, esta condição permanece com elevada taxa de morbimortalidade. Uma das explicações mais aceitas para a taxa elevada é o desenvolvimento da síndrome de disfunção de múltiplos órgãos (SDMO), secundária à hipoperfusão tecidual persistente. Assim, é evidente a importância da avaliação da perfusão tecidual em tais quadros, bem como possíveis interferências terapêuticas a partir da avaliação. Nesta revisão, são abordadas noções básicas sobre a monitorização clínica e laboratorial da perfusão tecidual no choque, incluindo transporte de O2, consumo e taxa de extração de O2 saturação venosa mista de O2, lactato e gradiente gastroarterial de CO2. Tais dados são fundamentais para a correta interpretação e melhor intervenção terapêutica, visando adequar o desequilíbrio presente entre oferta/consumo de O2 e, desta forma, interromper a série de eventos fisiopatológicos que resulta em SDMO e, em muitas condições, em morte. Nesse contexto, algumas metas devem ser alcançadas durante a ressuscitação de pacientes com síndrome do choque, a saber: pressão arterial média > 65 mmHg; diurese ³ 1 ml/kg/hora; débito cardíaco suficiente para manter uma SvO2 >65%; lactato sérico < 2 mmol/L, destacando que, mesmo quando normalizadas as variáveis sistêmicas de oxigenação, graves distúrbios perfusionais regionais ainda podem existir, sendo necessário recorrer à monitorização regional através da avaliação do pCO2-gap.Although new technologies have emerged and the tissue perfusion assessment has improved, shock remains with a high mortality ratio. Multiple organ dysfunction syndrome (MODS) due to tissue hypoperfusion is the best reason to explain this high mortality ratio in these patients. Hence, tissue perfusion assessment has the pivotal role in the shocked patient evaluation, because some therapeutic interventions can be performed. In this review, will be highlighted the main clinic signs and laboratories findings observed in hypoperfusion syndromes, including oxygen transport, oxygen delivery, oxygen consumption, oxygen extraction ratio, oxygen mixed venous saturation, arterial lactate end gastric-arterial CO2 gradient. These concepts are very important to understand and choose the best intervention for breaking events that are responsible for MODS development and death. The goals of resuscitation are also provided including mean arterial pressure above 65 mm Hg, mixed venous oxygen saturation above 65%, and lactate levels below 2 mMol/L. However, regional hypoperfusion can persist despite of restoring global hemodynamic variables. Hence, gastric-mucosal PCO2 could be a therapy-guide.   &nbsp

Vasodilators in Septic Shock Resuscitation: A Clinical Perspective

ABSTRACT: Microcirculatory abnormalities have been shown to be frequent in patients with septic shock despite “normalization” of systemic hemodynamics. Several studies have explored the impact of vasodilator therapy (prostacyclin, inhaled nitric oxide, topic acetylcholine and nitroglycerin) on microcirculation and tissue perfusion, with contradictory findings.In this narrative review, we briefly present the pathophysiological aspects of microcirculatory dysfunction, and depict the evidence supporting the use of vasodilators and other therapeutic interventions (fluid administration, blood transfusion, vasopressors and dobutamine) aiming to improve the microcirculatory flow in septic shock patients

Avaliação hemodinâmica macro e micro-circulatória no choque séptico

Tissue perfusion evaluation, particularly at the bedside may be very complex inseveral septic patients. Therefore, the evaluation of hemodynamic variables is crucial for an adequate management of those patients. Oxygen delivery and consumption are important variables, but with limited relation to prognosis. In the same direction, lactate levels and mixed or central venous oxygen saturation reflect imbalance between oxygen delivery and consumption. Gastric mucosal PCO2 monitoring and direct visualization of microcirculation may provide a local evaluation of tissue perfusion in shock states with important blood flow heterogeneity.A avaliação da perfusão tecidual, especialmente à beira do leito, pode ser complexa em muitos pacientes sépticos. Assim, impõe-se, atualmente, uma reavaliação da monitoração das variáveis de perfusão tecidual. Oferta e consumo de oxigênio são variáveis importantes; no entanto, principalmente a oferta de oxigênio apresenta pouca relação com prognóstico. Da mesma forma, os níveis séricos de lactato e a análise da saturação venosa de oxigênio (SvO2ou ScO2), traduzem o equilíbrio sistêmico entre oferta e consumo de oxigênio. A monitoração da pCO2 da mucosa gástrica e a visualização direta da microcirculação são instrumentos que auxiliam a avaliação local da perfusão tecidual, podendo ser útil em estados de importante heterogeneidade na distribuição de fluxo

GLÓRIA A DEUS NAS ALTURAS! A APROPRIAÇÃO SIMBÓLICA DO PICO DOS PIRENEUS PELO CATOLICISMO A PARTIR DA ROMARIA DA SANTÍSSIMA TRINDADE EM PIRENÓPOLIS (GO)

O objetivo deste artigo é analisar a apropriação religiosa dos lugares altos em disputa com outros tipos de apropriações vigentes atualmente, tais como a estética, a esportiva, a econômica e a ecológica, tendo como estudo de caso a Romaria da Santíssima Trindade, conhecida popularmente como Festa do Morro, que acontece, todos os anos, desde 1927, no mês de julho, no município de Pirenópolis (GO), no pico mais alto da Serra dos Pireneus. A hipótese que guia o artigo é que o Pico dos Pireneus foi estratégico para a reafirmação da hegemonia da Igreja católica em Goiás, na década de 1930, que, na pessoa do bispo do Emanuel Gomes de Oliveira, apoiou a romaria e elaborou um projeto de construção de um monumento católico no pico da serr