Programas de Optimización Perioperatoria, Enhanced Recovery y Fast-track: ¿Por qué están en auge? ¿Qué son realmente y cómo se implementan en la práctica? / Perioperative optimization, enhanced recovery and fast-track programs: why are they booming? What are these programs actually and how are they implemented into practice?

RESUMEN Desde 2015 a la fecha, los autores de esta revisión hemos implementado numerosos programas de optimización perioperatoria en Latinoamérica. En el siguiente artículo, presentamos una introducción general a los conceptos de optimización perioperatoria y resumimos nuestra experiencia trabajando en la región. También a lo largo de esta revisión, los lectores podrán encontrar desarrollados los tres elementos centrales de la optimización perioperatoria. En primer lugar, la constitución y los roles dentro un equipo perioperatorio. En segundo término, el registro sistemático y estandarizado de la práctica quirúrgica y sus resultados. Y, por último, la descripción del ciclo de mejoría continua como método de trabajo para ajustar la práctica diaria sobre la base del análisis de datos propios.

ABSTRACT From 2015 to date, the authors of this review have implemented several enhanced recovery periope rative programs in Latin America. In the following article, we present a general introduction to the con cepts of perioperative optimization and summarize our experience working in the region. Throughout this review, readers will also find the three fundamental elements of perioperative optimization. First, the creation and roles of a perioperative team. Second, the systematic and standardized registration of the surgical practice and its outcomes. And finally, the description of the continuous improvement cycle as a working method for adjusting daily practice based on the analysis of one's own data.

Implementación de un programa ERAS® / Implementation of an ERAS® program

RESUMEN Enhanced Recovery After Surgery (ERAS) constituye una forma de trabajo que implica la puesta en marcha de medidas de cuidado antes, durante y después de una cirugía con el propósito de mejorar la experiencia del paciente a lo largo del periodo perioperatorio. Sin embargo, la aplicación aislada de medidas determinadas no es suficiente. Esta forma de trabajo requiere la creación de un equipo de trabajo multidisciplinario, el registro sistemático de datos y su utilización para aplicar un ciclo de mejora continua. En el Hospital Italiano de Buenos Aires, se han registrado 1331 pacientes desde no viembre del año 2015. La mediana de internación fue de 4 días y la readmisión de 7,3%. La adherencia global a las medidas del programa fue del 56% (preoperatorio 88%, intraoperatorio 60%, postopera torio 39%). En los procedimientos quirúrgicos más frecuentes pudimos observar una relación lineal e inversamente proporcional entre adherencia al programa y el tiempo de internación, con una dismi nución promedio de un día de internación por cada 10% de adherencia al programa en los procedi mientos quirúrgicos más frecuentes. A pesar de estos resultados, hemos encontrado dificultades en el sistema de registro de datos que limitan la aplicación del ciclo de mejora continua. La conformación de un equipo multidisciplinario, con una comunicación fluida y eficiente es fundamental para la imple mentación de un programa ERAS® que sea capaz de disminuir el tiempo de internación, la morbilidad y el índice de readmisión.

ABSTRACT Enhanced Recovery After Surgery (ERAS) is a model of care that involves the implementation of care pathways before, during and after surgery designed to improve patient's experience throughout the perioperative period. Yet, the implementation of individual ERAS protocol elements is not sufficient. This approach requires the creation of a multidisciplinary work team, systematic recording of data and the use of the information recorded to implement a cycle of continuous improvement. Since 2015, 1331 patients have been recorded by Hospital Italiano de Buenos Aires. Median length of hospital stay was 4 days and median readmission rate was 7.3%. The overall adherence to the protocol elements was 56% (88% in the preoperative period, 60% in the intraoperative period and 39% in the postope rative period) There was a linear and inverse correlation between the adherence to the program and length of hospitalization for the most common surgical procedures, with an average decrease of one day of hospitalization for each 10% increase in adherence with the program for the most common sur gical procedures. Despite these results, we have encountered difficulties in the data recording systems limiting the implementation of the cycle of continuous improvement. The creation of a multidiscipli nary team, with fluent and efficient communication, is essential for the implementation of an ERAS® program capable of reducing length of hospital stay, morbidity and readmission rates.

Asociación entre desenlaces clínicos y cumplimiento del protocolo de recuperación mejorada después de la cirugía (ERAS) en procedimientos colorrectales: estudio multicéntrico / Association between clinical outcomes and compliance with the Enhanced Recovery After Surgery (ERAS) protocol in colorectal procedures: A multicenter study

Introducción. Los protocolos de recuperación mejorada después de cirugía se han diseñado como una innovación en salud tras demostrarse que la mejora en los dispositivos médicos y la depuración de técnicas alcanzaron la meseta en disminución de complicaciones. Con estas estrategias de la medicina perioperatoria, en cirugía colorrectal se reducen la morbilidad y estancia hospitalaria. El objetivo del estudio fue evaluar si la tasa de adherencia al programa de recuperación mejorada después de la cirugía (ERAS) está asociada con los resultados quirúrgicos. Métodos. Estudio multicéntrico, observacional, retrospectivo de cohorte (2015-2019), en cinco hospitales latinoamericanos certificados por la sociedad ERAS. Se calculó la incidencia de complicaciones quirúrgicas durante el posquirúrgico inmediato (30 días) y la duración de la estancia hospitalaria. Se utilizaron análisis bivariado y regresión logística multivariada para evaluar los factores asociados con la tasa de complicaciones. Resultados. Fueron incluidos en el estudio 648 pacientes en cinco hospitales ERAS, con edad promedio de 61 años y mayor porcentaje de hombres (51 %). El cumplimiento global al protocolo ERAS fue de 75 % y la estancia promedio de 6,2 días (mediana: 4 días). Se tuvo un cumplimiento óptimo del protocolo ERAS (igual o mayor al 80 %) en 23,6 % de los pacientes. Se documentó fuga de la anastomosis en 4 %, complicaciones infecciosas en 8,4 %, íleo en 5,7 %, reingreso en 10,2 % y mortalidad de 1,1 %. El análisis multivariado mostró que los niveles de adherencia óptima al protocolo ERAS reducen significativamente la aparición de complicaciones como fuga de la anastomosis (OR 0,08; IC95% 0,01-0,48; p=0,005) y complicaciones infecciosas (OR 0,17; IC95%0,03-0,76; p=0,046).Discusión. Los resultados sugieren que un cumplimiento del programa ERAS mayor al 80 % se asocia a menor frecuencia de complicaciones en pacientes con cirugía electiva colorrectal

Introduction. Enhanced Recovery After Surgery (ERAS) protocol has been designed as an innovation in health after demonstrating that the improvement in medical devices and the refinement of techniques reached the plateau in reducing complications. With these strategies of perioperative medicine, in colorectal surgery morbidity and hospital stay are reduced. The aim of the study was to evaluate whether the rate of adherence to the ERAS protocol is associated with surgical outcomes.Methods. Multicenter, observational, retrospective cohort study (2015-2019), in five Latin American hospitals certified by the ERAS Society. The incidence of surgical complications during the immediate postoperative period (30 days) and length of hospital stay were calculated. Bivariate analyzes and multivariate logistic regression were used to assess factors associated with complication rates.Results. 648 patients were included in the study in five ERAS hospitals, with an average age of 61 years and a higher percentage of men (51%). Overall compliance with the ERAS protocol was 75% and the average stay was 6.2 days (median: 4 days). There was optimal compliance with the ERAS protocol (equal to or greater than 80%) in 23.6% of the patients. Anastomotic leak was documented in 4%, infectious complications in 8.4%, ileus in 5.7%, readmission in 10.2%, and mortality in 1.1%. Multivariate analysis showed that optimal adherence levels to the ERAS protocol significantly reduce the appearance of complications such as anastomotic leakage (OR 0.08; 95%CI 0.01-0.48; p=0.005) and infectious complications (OR 0.17; 95%CI 0.03-0.76; p=0.046).Discussion. The results suggest that compliance with the ERAS program greater than 80% is associated with a lower frequency of complications in patients with elective colorectal surgery

The History of ERAS (Enhanced Recovery After Surgery) Society and its development in Latin America

The shortage of hospital beds and changes in the payment model have promoted an increased attention and financing of programs that focus on perioperative care efficiency in. Latin America. In this paper, Enhanced Recovery After Surgery (ERAS) programs developed by the ERAS® Society will be discussed. The implementation and use of ERAS®Society Guidelines consistently demonstrated a reduction in postoperative complications, hospital stay and costs. In the current paper, the definition of ERAS programs, their core elements, and the results of their implementation and regional developments are presented with special focus on Latin America.

Políticas da educação superior no Brasil (2003-2010): democratização ou expansão? / Policies of higher education in Brazil (2003-2010): democratization or expansion?

Objetiva-se com este trabalho discutir sobre o processo de expansão da educação superior no Brasil. Nesse sentido, procuramos revisar pontos determinantes e elementos caracterizadores do Programa de Apoio a Planos de Reestruturação e Expansão das Universidades Federais (REUNI) refletindo sobre o acesso à universidade pública. Para isso realizamos uma breve discussão sobre Estado e políticas públicas, em especial as políticas para a educação superior, levando-se em consideração a relação estabelecida entre tais elementos e resgatando os determinantes desse movimento e suas particularidades. Buscamos analisar as políticas educacionais voltadas para a educação superior durante o governo Fernando Henrique Cardoso (FHC) e Lula, no que diz respeito ao acesso, bem como seus elementos norteadores. Essa contextualização leva em consideração, que a educação não pode ser considerada como fenômeno neutro e, portanto, decorre da intervenção do Estado, e os efeitos do espaço no qual está inserido. As análises indicam que o processo de reformas para a educação superior implementadas no Brasil, principalmente no âmbito do REUNI está impregnado de objetivos ideológicos, ações e contradições que se estabelecem em relação aos pressupostos teóricos e práticos, apresentando elementos que ao mesmo tempo resultam na reforma do Estado e buscam dar sustentação aos interesses sociais.

The objective of this work is to discuss the process of expansion of higher education in Brazil. In this sense, we seek to review determining points and elements that characterize the Federal University Restructuring and Expansion Program Support Program (REUNI), reflecting on access to the public university. In order to do so, we present a brief discussion about State and public policies, especially policies for higher education, taking into account the established relationship between these elements and rescuing the determinants of this movement and its particularities. We sought to analyze educational policies focused on higher education during the Fernando Henrique Cardoso (FHC) and Lula government, in terms of access, as well as its guiding elements. This contextualization takes into account, that education can not be considered as a neutral phenomenon and, therefore, stems from the intervention of the State, and the effects of the space in which it is inserted. The analysis indicates that the process of reforms for higher education implemented in Brazil, mainly within REUNI is impregnated with ideological objectives, actions and contradictions that are established in relation to theoretical and practical presuppositions, presenting elements that at the same time result in the reform Of the state and seek to support social interests.