A Sole Thromboprophylactic in Prescription of Postoperative Orthopedic Patients – A Review

Background: Venous thromboembolism (VTE) is one of the most well-known and feared sequelae of orthopaedic surgery. VTE is relatively common after arthroplasty, prophylaxis has been prescribed. The frequency of postoperative thromboembolic events increased in the absence of primary prevention. Following operations, immobilisation of a lower limb that restricts calf muscle contraction has been shown to be a key risk factor for VTE. VTE is the most frequent source of readmission in orthopaedic patients who have undergone major procedures. It should be emphasized that the best mechanical method for preventing VTE is early walking. Medication for VTE prophylaxis is prescribed more often than mechanical prophylaxis. After major orthopaedic surgery, anticoagulant treatment is essential for reducing morbidity and death. Following hospital discharge, prophylactic drug therapy aims to reduce the morbidity and mortality episodes associated with DVT and PE occurrences. Aspirin use for prevention of VTE following THA and TKA has gained popularity, especially among orthopaedic surgeons due to a minimal risk of postoperative haemorrhage, it also reduces the incidence of recurrent DVTs. Conclusion: Due to its low cost and easy administration without the requirement for regular blood testing, aspirin thromboprophylaxis following knee surgery appears promising. Aspirin saved more QALYs and was cost-effective. Aspirin was demonstrated to have a higher VTE prophylaxis profile than other medications with a time-related association to early mobilisation, healthier patients and medication compliance.

Tromboprofilaxis precoz y evolución en embarazadas con COVID-19 / Early thromboprophylaxis and evolution in pregnant women with COVID-19

Introducción: en marzo del año 2020 se declara Pandemia, por la aparición de un nuevo Coronavirus, el SARS-CoV2 (COVID-19). Las mujeres embarazadas presentan un riesgo mayor de presentar procesos tromboembólicos, por lo que se recomienda utilizar de manera profiláctica heparina, para prevención de procesos tromboembólicos durante la infección por SARS-CoV2. Objetivo: Describir la evolución de las embarazadas con infección por SARS-CoV2 con la utilización de heparina de bajo peso molecular, Enoxaparina, ajustada al peso de manera precoz. Metodología: estudio descriptivo prospectivo, observacional, de corte transversal. Resultados: en la evolución de 30 mujeres embarazadas con infección por SARS-CoV2, las edades más frecuentes corresponden a 31 a 35 años, mayor número de infectadas en el segundo trimestre del embarazo, el índice de masa corporal predominante en rango de sobrepeso y obesidad, la dosis de enoxaparina utilizada fue de 40 mg/día, ya que se ajustó al peso de la embarazada, las comorbilidades más frecuentes correspondieron al sobrepeso y obesidad, enfermedad hipertensiva del embarazo y diabetes gestacional, la sintomatología resultó muy variada, debido a las distintas variantes del virus, con más frecuencia la rinorrea, congestión nasal, tos, anosmia, disgeusia, cefalea, fiebre y dificultad respiratoria, y la mayoría de las embarazadas no estaban vacunadas. Conclusiones: ninguna de las 30 embarazadas que recibieron heparina de bajo peso molecular (Enoxapina), ajustada al peso, y de manera precoz, con infección por SARS.CoV2, falleció, ni requirió internación en Unidad de Terapia Intensiva. Una embarazada, fue internada por disnea moderada y saturación de oxígeno menor a 95%. Las restantes embarazadas tuvieron buena evolución en su domicilio, sin ninguna complicación

Introduction: in March 2020, a Pandemic was declared, due to the appearance of a new Coronavirus, SARS-CoV2 (COVID-19). Pregnant women have a higher risk of presenting thromboembolic processes, so it is recommended to use heparin prophylactically, to prevent thromboembolic processes during SARS-CoV2 infection. Objective: to describe the evolution of pregnant women with SARS-CoV2 infection with the early use of Enoxaparin, adjusted to the weight of low molecular weight heparin. Methodology: prospective, observational, cross-sectional descriptive study. Results: in the evolution of 30 pregnant women with SARS-CoV2 infection, the most frequent ages correspond to 31 to 35 years, the highest number of infected in the second trimester of pregnancy, the predominant body mass index in the range of overweight and obesity. , the dose of enoxaparin used was 40 mg/day, since it was adjusted to the weight of the pregnant woman, the most frequent comorbidities were overweight and obesity, hypertensive disease of pregnancy and gestational diabetes, the symptoms were highly varied, due to the different variants of the virus, more frequently rhinorrhea, nasal congestion, cough, anosmia, dysgeusia, headache, fever and respiratory distress, and most of the pregnant women were not vaccinated. Conclusions: none of the 30 pregnant women who received low molecular weight heparin (Enoxapine), adjusted for weight, and early, with SARS.CoV2 infection, died or required admission to the Intensive Care Unit. A pregnant woman was hospitalized due to moderate dyspnea and oxygen saturation less than 95%. The remaining pregnant women had a good evolution at home, without any complications

Concomitant acute lower extremity arterial and deep vein thrombosis developing in a patient under anticoagulant therapy after COVID 19 infection / Trombosis arterial aguda y trombosis venosa profunda concomitantes de extremidad inferior en un paciente bajo terapia anticoagulante después de infección por COVID 19

Abstract The hypercoagulable state continues after the Coronavirus 2019 (Covid 19) infection and prophylactic anticoagulants are recommended in this period. However, arterial and venous thromboembolic events can be observed during the convalescence period after the Covid 19. Here, we present the case of acute lower extremity arterial and venous thromboembolism developed in the post-Covid 19 period in a 77-years-old patient, under therapeutic doses of anticoagulant therapy (enoxparin 1mg/kg of weight every 12 hours). The patient, who had no previous history of arterial or venous thrombosis, was taken to emergency surgery with the diagnosis of ALI (acute limb ischemia) due to acute arterial thrombosis. An arterial thrombectomy was performed with the help of a 4F Fogarty catheter inserted from the left femoral artery under local anesthesia. All distal pulses of the patient were palpable in the postoperative period. After the platelet count became >100,000 mm3, 100 mg of acetylsalicylic acid daily was added to the therapeutic dose of enoxaparin sodium treatment. The patient was discharged, uneventfully, except for a minimal diameter increase secondary to deep venous thrombosis (DVT) on the fifth postoperative day, with a combination of enoxaparin and acetylsalicylic acid treatment. Endothelial injury, chronic immuno-thrombogenicity, and increased platelet aggregation in the post-Covid 19 recovery period can cause major thrombotic events, even weeks after the recovery. Anticoagulant therapy is recommended for thromboprophylaxis when the following statuses exist: ≥65 years, critical illness, cancer, prior VTE, thrombophilia, severe immobility, and elevated D- dimer. Combination treatment with long-term antiaggregant therapy may be prudent in thromboembolic events developed under anticoagulant therapy.

Resumen El estado de hipercoagulabilidad continúa después de la infección por Coronavirus 2019 (Covid-19) y la anticoagulación profiláctica se recomienda durante este período. Sin embargo, eventos tromboembólicos arteriales y venosos se pueden observar durante el período de convalecencia posterior al Covid-19. Se presenta el caso de trombosis venosa profunda (TVP) y arterial agudas de una extremidad inferior en una paciente de 77 años, bajo terapia anticoagulante (enoxparin 1mg/kg de peso, cada 12 horas), en el período post- Covid 19. La paciente, sin historia previa de trombosis arterial ni venosa, fue llevada a cirugía de emergencia con el diagnóstico de isquemia aguda de extremidades por trombosis arterial aguda. Se le realizó trombectomía arterial con la ayuda de un catéter Fogarty 4F insertado desde la arteria femoral izquierda bajo anestesia local. Todos los pulsos distales del paciente fueron palpables en el periodo postoperatorio. Después de que las plaquetas llegaron a ser mayores a100.000 mm3, 100 mg de ácido acetilsalicílico diarios se añadieron a la dosis terapéutica del tratamiento con enoxaparina sódica. La paciente fue dada de alta sin incidencias, excepto por un mínimo aumento de diámetro secundario a la TVP, al quinto día postoperatorio con la combinación de enoxaparina y ácido acetilsalicílico. La lesión endotelial, la inmunotrombogenicidad crónica y la agregación plaquetaria aumentada en el período de recuperación posterior a Covid-19 pueden causar eventos trombóticos importantes incluso semanas después de la recuperación. La combinación con terapia antiagregante a largo plazo puede ser prudente en los casos de eventos tromboembólicos desarrollados en pacientes con terapia anticoagulante.

Tromboprofilaxis en pacientes hospitalizados: implementación de un programa multifacético / Thromboprophylaxis in hospitalized patients: implementation of a multifacetical program

Resumen La enfermedad tromboembólica venosa es la causa prevenible más frecuente de muerte hospitalaria. A pesar de contar con evidencia y recomendaciones sobre la utilidad de la tromboprofilaxis, la adherencia por parte de los médicos a las mismas es muy variable, y frecuentemente subóptima. El objetivo de este estudio fue evaluar un programa institucional con estrategias multifacéticas dirigido a médicos, sobre tromboprofilaxis en internación y estimar el cambio en la adecuación de la tromboprofilaxis antes y después de la intervención. La intervención se mantuvo durante 6 años, fue múltiple, utilizando acciones pasivas como car telería, y activas, como educación médica continua, confección y adopción de una guía institucional de práctica clínica y un sistema de soporte informático para la decisión clínica. La adecuación basal de la tromboprofilaxis mejoró de 59% a 82% después de la intervención y se mantuvo en el tiempo. La mejora en la adecuación se asoció a una reducción de los sangrados mayores, en particular en pacientes intervenidos quirúrgicamente.

Abstract Venous thromboembolic disease is the most common preventable cause of hospital death. Despite the existence of evidence of the usefulness of thromboprophylaxis and recommendations, adherence by physicians to them is highly variable, and frequently suboptimal. The objective was to evaluate the change in the adequacy of thromboprophylaxis before and after an intervention on thromboprophylaxis with multifaceted strategies for physicians. The intervention was a 6 years institutional program with multiple strategies: passive actions such as posters and active actions as continuous medical education, adaptation of an institutional clinical practice guide and a computerized clinical decision support system. The baseline adequacy of thromboprophylaxis improved from 59% to 82% and was maintained over time. The improvement in fitness was associated with a reduction in major bleeding, particularly in patients undergoing surgery.

Venous thromboembolism risk assessment and prophylaxis in hospitalised medical patients in the Cape Town metropole, South Africa

Background. Venous thromboembolism (VTE) is regarded as the most preventable cause of inpatient death in hospital settings globally. VTE can be prevented through the provision of non-pharmacological and/or pharmacological thromboprophylaxis following individualised risk screening. The Caprini risk assessment model (RAM) offers a validated and well-established approach for VTE risk assessment in medical inpatients. Literature findings describe a trend towards inappropriate and under-prescribing of thromboprophylaxis in this population. Together with concerns regarding clinicians' perceived importance of VTE risk assessment, the need to clarify these aspects of practice is evident. Objectives. To describe VTE risk assessment and prophylaxis practices of medical practitioners in public sector hospitals in Western Cape Province, South Africa (SA). Methods. A retrospective, cross-sectional study design was employed in the medical wards of two district hospitals and one regional hospital in the Cape Town metropole, Western Cape. Medical folders of adult medical inpatients admitted between January and July 2020 were reviewed to assess VTE risk using the Caprini RAM. Thromboprophylaxis therapy prescribed and contraindications to chemoprophylaxis were also evaluated. Results. Of 380 patients included in the review, 51.6% were female, and the average age was 52.1 years (range 18 - 96); 21.3% had their weight recorded, while none had their height documented. Infectious disease was the predominant diagnosis (49.2%) detected in the sample. Common VTE risk factors identified included bed rest/restricted mobility for <72 hours (76.3%) and serious infection (67.4%). A total of 97.1% of patients (n=369) were found to be at moderate or higher risk of VTE (Caprini score ≥2). Of this at-risk group, 24.1% were eligible to receive chemoprophylaxis, yet no prescription for thromboprophylaxis was identified. Seventy percent of patients (n=266) were prescribed chemoprophylaxis, with enoxaparin accounting for 98.5% of regimens. Contraindications to chemoprophylaxis were recorded in 13.4% of patients. Conclusions. Although rates of VTE prophylaxis in medical inpatients may be improving, thromboprophylaxis still remains critically underutilised in this population. This study highlighted a consequence of this trend, with inappropriate chemoprophylaxis prescribing becoming more evident. Mechanical prophylaxis prescribing in medical inpatients is lacking, despite the associated benefits. RAMs should be adapted for the SA setting, where infectious diseases are prevalent. Future research should assess RAM use by clinicians, as this could provide insight into improving RAM uptake and thromboprophylaxis prescribing.

Utilización de tromboprofilaxis en el período grávido - puerperal por Ginecólogos y Residentes de Ginecología del Uruguay

Resumen: Introducción: La enfermedad tromboembólica venosa en el período grávido - puerperal es una de las primeras causas de morbi-mortalidad materna. No existe un consenso acerca de las directivas para su abordaje, por lo que el objetivo de esta investigación fue conocer cómo se desempeñan los Ginecólogos y Residentes de Ginecología del Uruguay, con respecto a distintos factores de riesgo, la indicación de tromboprofilaxis y las herramientas disponibles. Metodología: Se realizó de julio a octubre del 2020, un estudio observacional, descriptivo, transversal donde se incluyeron a Ginecólogos y Residentes de Ginecología del Uruguay, mediante una encuesta electrónica anónima a través de la plataforma Survey Monkey. Resultados: Se obtuvo un n de 159 encuestados. El 57,3% refirió pensar sistemáticamente en factores de riesgo para enfermedad tromboembólica venosa. Las guías más utilizadas para la clasificación del riesgo e indicación de tromboprofilaxis fueron la American College of Obstestricians and Gynecologists con un 81,0% y la Royal College of Obstestricians and Gynaecologists con un 13,0%. La herramienta terapéutica con mayor disponibilidad es la heparina de bajo peso molecular y la menos utilizada es la compresión neumática intermitente. Conclusiones: Existen inconsistencias entre la clasificación de riesgo e indicación de tromboprofilaxis en diferentes situaciones clínicas. Existe un porcentaje no despreciable de profesiones que no piensan sistemáticamente en factores de riesgo para eventos tromboembólicos durante el período grávido - puerperal.

Abstract: Introduction: One of the main causes of maternal morbity and mortality in the pregnant - puerperal period is venous thromboembolic disease. There is no consensus on the guidelines to address this illness. The main objective of this research was to know how Gynecologists and Gynecology Residents of Uruguay perform, in reference to considering potential risk factors, indication for thromboprophylaxis and the tools available. Methodology: An observational, descriptive, cross-sectional study carried out from July to October 2020, including Gynecologists and Gynecology Residents of Uruguay, through an anonymous online survey using the Survey Monkey platform. Results: A final n of 159 respondents was obtained. 57.3% of which referred to think systematically about risk factors for venous thromboembolic disease. The most popular guidelines for risk classification and indication of thromboprophylaxis were the American College of Obstestricians and Gynaecologists with 81.0% and the Royal College of Obstestricians and Gynaecologists with 13.0%. The most chosen therapeutic tool was low molecular weight heparin, and the least preferred one was intermittent pneumatic compression. Conclusions: There are incoherences between the risk classification and the actual indication of thromboprophylaxis in different clinical situations. There´s still a non-negligible percentage of professionals that do not systematically consider risk factors for thromboembolic events during the pregnant-puerperal period.

Resumo: Introdução: A doença tromboembólica venosa no período gestação - puerpério é uma das principais causasde morbidadee mortalidade materna. Nãohá consenso sobre as diretrizes para o seu abordagem, por issoo objetivo desta pesquisa foi saber como encarao os ginecologistas e os residentes em ginecologia do Uruguai, no que dizrespeito à fatores de risco, indicação de tromboprofilaxia e as ferramentas disponíveis. Metodologia: Estudo observacional, descritivo e transveral realizado de julho a outubro de 2020, que incluiu ginecologistas e residentes em ginecologia do Uruguai. Um levantamento eletrônico anónimo foi desenvuelto através da plataforma SurveyMonkey. Resultados: Foram estudados 159 entrevistados. 57,3% relataram pensarsobre fatores de risco para doença tromboembólica venosa. As diretrizesmais utilizadas para classificação de risco e indicação de tromboprofilaxia foram o American College of Obstestricians and Gynecologists com 81,0% e o Royal College of Obstestricians and Gynaecologists com 13,0%. A ferramenta mais selecionada é heparina de baixo peso molecular e a menos utilizada é a compressão pneumática intermitente. Conclusões: Há inconsistências entre a classificação de risco e a indicação de tromboprofilaxia em diferentes situações clínicas. Ainda há um numero consideravel de profisionais que não pensam sistematicamente em fatores de risco para eventos tromboembólicos durante o período gravidez - puerperal.

Tromboprofilaxis, anticoagulación y coagulopatía en tiempos de pandemia: recomendación de la ACATA, ACMI, SCC CCV y ACMV / Thromboprophylaxis, anticoagulation and coagulopathy in times of pandemic: The ACATA, ACMI, SCC CCV and ACMV recommendation

Resumen Introducción La enfermedad por coronavirus 2019 (COVID-19) puede predisponer a tromboembolia venosa o trombosis arterial debido a una respuesta inflamatoria aumentada, hipoxia, inmovilización y coagulación intravascular diseminada; hasta en un 20 a 50% de pacientes hospitalizados con COVID-19 tienen alteraciones hematológicas relacionadas con coagulopatía (dímero D elevado, tiempo de protrombina prolongado, trombocitopenia y/o fibrinógeno bajo). Evaluaciones post mortem evidencian depósitos trombóticos microvasculares típicos, ricos en plaquetas en vasos pequeños de pulmones y otros órganos. Objetivo Brindar una aproximación práctica y actualizada en el manejo del paciente con riesgo elevado o que presentan eventos tromboembólicos en el marco de la actual pandemia por COVID-19. Material y métodos: Se realizó una revisión narrativa que incluyó estudios observacionales descriptivos. Se efectuó una búsqueda de la literatura de evidencia médica en diferentes buscadores como Science Direct y PubMed, usando las palabras claves “thromboprophylaxis”, “anticoagulation”, “thrombosis”, “anticoagulant”, “COVID-19”, “SARS-CoV-2”, “coronavirus”. Posteriormente se escribieron las recomendaciones generales referentes al tema. Conclusiones Existen diferentes formas en las que la pandemia por COVID-19 puede predisponer al desarrollo de enfermedades trombóticas o tromboembólicas, el efecto directo o indirecto de este virus relacionado con la tormenta de citocinas que precipita el inicio del síndrome de respuesta inflamatoria sistémica y predispone al desarrollo de eventos trombóticos; también las intervenciones disponibles pueden tener interacciones farmacológicas con antiagregantes y/o anticoagulantes.

Abstract Introduction Coronavirus 19 infection can predispose to VTE or arterial thrombosis due to a heightened inflammatory response, hypoxia, immobility and DIC. Up to 20-50% of hospitalized patients with COVID-19 have hematological disorders related to coagulopathies (elevated D-dimer, prolonged PT, thrombocytopenia and/or low fibrinogen). Post-mortem examinations show typical platelet-rich microvascular thrombotic deposits in the small vessels of the lungs and other organs. Objective To provide a practical, updated approach to the treatment of patients at high risk for or with ongoing thromboembolic events in the current COVID-19 pandemic setting. Material and methods A narrative review was performed including descriptive observational studies. A search of the medical evidence literature was carried out in different search engines such as ScienceDirect and PubMed, using the following key words: “thromboprophylaxis”, “anticoagulation”, “thrombosis”, “anticoagulant”, “COVID-19”, “SARS-CoV-2”, and “coronavirus”, and general recommendations on the topic were subsequently composed. Conclusions The are various ways in which the COVID-19 pandemic may predispose to the development of thrombotic or thromboembolic diseases. The virus may have a direct or indirect effect related to the cytokine storm which triggers the onset of systemic inflammatory response syndrome and predisposes to the development of thrombotic events. The available interventions may also have pharmacological interactions with antiplatelet drugs and/or anticoagulants.

Trombosis venosa profunda y trombofilia congénita / Deep-vein thrombosis and congenital thrombophilia

Introducción: La trombofilia es un desorden de la hemostasia congénito o adquirido que predispone al desarrollo de trombosis. Las trombofilias congénitas más frecuentes son las deficiencias de antitrombina III, proteína C y proteína S, el factor V Leiden, la mutación del gen de la protrombina (G20210A) y las mutaciones de la enzima metilentetrahidrofolato reductasa (MTHFR). Objetivo: Describir el manejo anestésico en un paciente portador de trombofilia congénita. Presentación del caso: Se reporta un paciente de 19 años de edad con antecedentes de historia familiar y personal de trombosis venosa profunda, tratamiento con doble antiagregación plaquetaria y asociación de tres mutaciones para trombofilia congénita, G20210A, A1298C MTHFR y C677T MTHFR que recibe anestesia espinal para una herniorrafia inguinal. Se mantiene tratamiento con aspirina, se suspende clopidogrel 7 días antes de la cirugía y durante ese tiempo se administra fraxiparina 0.6 Uds. subcutánea diarias hasta 12 h antes de la cirugía, se utiliza medias elásticas, deambulación precoz y reinicio de clopidogrel 24 h después de la cirugía, con evolución satisfactoria. Conclusiones: La tromboprofilaxis en pacientes portadores de trombofilia congénita es mandatoria, por eso resulta determinante la utilización de heparina de bajo peso molecular junto al resto de las medidas de prevención de la trombosis venosa profunda(AU)

Introduction: Thrombophilia is a congenital or acquired hemostasis disorder that predisposes to thrombosis development. The commonest congenital thrombophilias are deficiencies of antithrombin III, protein C and protein S, factor V Leiden, prothrombin gene mutation (G20210A), and methylenetetrahydrofolate reductase (MTHFR) mutations. Objective: To describe the anesthetic management in a patient with congenital thrombophilia. Case presentation: The case is reported of a 19-year-old patient with a family and personal history of deep-vein thrombosis, treatment with double antiplatelet therapy and association of three mutations for congenital thrombophilia (G20210A, A1298C MTHFR and C677T MTHFR), who receives spinal anesthesia for an inguinal herniorrhaphy. Aspirin treatment is maintained. Clopidogrel is suspended seven days before surgery. During this time, fraxiparin is administered subcutaneously in 0.6-mL units daily, up to twelve hours before surgery. Elastic stockings are used, early ambulation is allowed, and clopidogrel is restarted 24 hours after surgery, with satisfactory evolution. Conclusions: Thromboprophylaxis in patients with congenital thrombophilia is mandatory, a reason why the use of low-molecular-weight heparin, together with the rest of the prevention measures against deep-vein thrombosis, is decisive(AU)

Respuesta a diferentes escenarios y complicaciones hematológicas en COVID-19 / Response to different scenarios and hematological complications in COVID-19.

Las enfermedades infecciosas emergentes y reemergentes son desafíos constantes para la salud pública en todo el mundo. Los casos recientes de neumonía de causa desconocida en Wuhan, China, han llevado al descubrimiento de un nuevo tipo de Coronavirus (2019-nCoV), que son virus de Ácido Ribonucleico (RNA) envueltos, de forma común encontrados en humanos, otros mamíferos y aves, capaces de causar enfermedades respiratorias, entéricas, hepáticas y neurológicas 1. La amenaza a la salud de la infección por Coronavirus 2 asociado al SRAS (SARS-CoV-2) y la enfermedad que produce el mismo llamada Enfermedad por Coronavirus (COVID-19) ya está estable- cida con sus tasas de infección y mortalidad de manera considerable más altas si se lo compara con otros virus respiratorios adquiridos en la comunidad 2. En tal sentido es necesario dar una respuesta por parte de la Unidad Técnica de Hematología en relación a esta pandemia con el ánimo de aportar al manejo integral de estos pacientes, homogeneizar criterios clínicos, lidiar de mejor manera con la incertidumbre en el diagnóstico y tratamiento de COVID-19. El SARS CoV-2 y su enfermedad COVID-19, en la mayoría de pacientes tiene una presentación con síntomas leves. Sin embargo, en el 5% de los casos diagnosticados requerirán de una Unidad de Cuidados Intensivos (UCI)3, ya que presentan Síndrome de Dificultad Respiratoria Aguda (SDRA), shock séptico, Insuficiencia Multiorgánica y coagulopatía hemorrágica, así como trombótica, incluyendo Coagulación Intravascular Diseminada (CID), alcanzado en las salas de UCI una tasa mortalidad por COVID-19 entre el 22% al 62% en algunas series 4. Adicional, se ha observado que el grupo de pacientes con mala evolución presentan un estado hiperinflamatorio, asemejándose al cuadro clínico descrito de una linfohistiocitosis hemofagocítica secundaria, que en este caso sería desencadenada por SARS CoV-2 5. Un grupo de Hematólogos de diferentes hospitales de la ciudad de Quito: Especialidades Carlos Andrade Marín-Instituto Ecuatoriano de Seguridad Social (HECAM-IESS), Metropolitano; y, hospitales de la ciudad de Guayaquil: Teodoro Maldonado Carbo-IESS, Hospital Luis Vernaza y Clínica Gilbert, basados en la evidencia científica disponible y experticia profesional, elaboraron éste protocolo con las recomendaciones según los diferentes escenarios y complicaciones hematológicas.

Emerging and reemerging infectious diseases are constant challenges to public health worldwide. Recent cases of pneumonia of unknown cause in Wuhan, China have led to the discovery of a new type of Coronavirus (2019-nCoV), which are enveloped ribonucleic acid (RNA) viruses, commonly found in humans, other mammals, and birds, capable of cause respiratory, enteric, liver and neurological diseases 1. The health threat of SARS-associated coronavirus 2 (SARS-CoV-2) and the disease that produces it called COVID-19 has already been established with its considerably higher infection and mortality rates compared to other respiratory viruses acquired in the community 2. In this sense, it is necessary to give a response from the Hematology Technical Unit in relation to this pandemic in order to contribute to the comprehensive management of these patients, homogenize clinical criteria, better deal with uncertainty in the diagnosis and treatment of COVID-19. SARS CoV-2 and its disease COVID-19, in the majority of patients have a presentation with mild symptoms. However, in 5% of diagnosed cases they will require an Intensive Care Unit (ICU) 3, since they present Acute Respiratory Distress Syndrome (ARDS), septic shock, Multiple Organ Failure and hemorrhagic coagulopathy, as well as thrombotic, including Coagulation Disseminated Intravascular (DIC), achieved in the ICU wards a mortality rate for COVID-19 between 22% and 62% in some series 4. Additionally, it has been observed that the group of patients with poor evolution present a hyperinflammatory state, resembling the clinical picture of secondary hemopha- gocytic lymphohistiocytosis, which in this case would be triggered by SARS CoV-2 5. The group of Hematologists from the hospitals of the city of Quito: Specialties Carlos Andrade Marín HECAM-IESS, Metropolitano; and, hospitals in the city of Guayaquil: Teodoro Maldonado Carbo-IESS, Luis Vernaza Hospital and Gilbert Clinic, based on the available scientific evidence and professional expertise, prepared this protocol with the recommendations according to the different hematological scenarios and complications.

Enfermedad tromboembólica venosa en el embarazo / Venous thromboembolic disease in pregnancy

Resumen: La enfermedad tromboembólica venosa como trombosis venosa profunda y tromboembolismo pulmonar, son causa importante de mortalidad materna, además se han considerado un problema de salud pública en diferentes países. La trombosis venosa profunda y el tromboembolismo pulmonar son considerados parte de una misma enfermedad con diversos síntomas clínicos que afectan al paciente. Algunas cifras epidemiológicas de la enfermedad tromboembólica venosa son que su incidencia se encuentra en torno a 167 por cada 1,000,000 personas por año, en mujeres embarazadas se presenta con una incidencia de 0.5-2.2 por 1,000 embarazos además que es de elevada mortalidad, se ha incrementado en los últimos diez años y en sus factores de riesgo podemos mencionar: trombofilia, tabaquismo, raza, hipertensión, hemorragia obstétrica, transfusiones, obesidad, cesárea principalmente. El abordaje terapéutico dependerá de la expresión clínica de la enfermedad tromboembólica venosa. Por lo que esta revisión incluye datos sobre la epidemiología, patogénesis, inflamación, factores de riesgo relacionados a la enfermedad tromboembólica venosa en el embarazo, la identificación de factores de riesgo no sólo son fundamentales para el diagnóstico, sino que también son importantes para prevenir y tratar la enfermedad.

Abstract. Venous thromboembolic disease such as deep venous thrombosis and pulmonary thromboembolism are important causes of maternal mortality and has also been considered a public health problem in different countries. Deep venous thrombosis and pulmonary thromboembolism are considered part of the same disease with various clinical symptoms that affect the patient. Some epidemiological numbers of the venous thromboembolic disease are that its incidence is around 167 for every 1,000,000 people per year, in pregnant women it appears with an incidence of 0.5-2.2 per 1,000 pregnancies besides that it is of high mortality, it has increased in the last ten years and in their risk factors we can mention: thrombophilia, smoking, race, hypertension, obstetric hemorrhage, transfusions, obesity, cesarean section mainly. The therapeutic approach will depend on the clinical expression of venous thromboembolic disease. So this review includes data on the epidemiology, pathogenesis, inflammation, risk factors related to venous thromboembolic disease in pregnancy, the identification of risk factors are not only essential for diagnosis, but are also important to prevent and treat the disease.

Tromboprofilaxis en el paciente quirúrgico COVID-19 / Thromboprophylaxis in the COVID-19 surgical patient

Clotting disorders have been one of the problems that clinicians have dealt with in the course of learning about this new disease. There is very little evidence and limited recommendations by scientific societies on the management of thromboprophylaxis in the COVID-19 surgical patient, in addition to the fact that the effects of this pathology on surgical injury are unknown. The thrombotic risk assessment for the COVID-19 surgical patient is unprecedented in this regard. Some predictors and risk factors for thrombosis have been systematically reported as prognostic markers, including elevation of D-dimer, fibrinogen, IL6, serum ferritin, prolongation of clotting times, detection of antiphospholipid antibodies and other independent factors that contribute to measure severity. of COVID-19 such as lactate dehydrogenase and marked lymphopenia. The foregoing predictors and risk factors for thrombosis for COVID-19 disease have been adapted adjusted to the categories present on the Caprini scale in order of increasing complexity and in relation to morbidity and mortality. In this sense, the choice of the measure or measures that each patient requires will depend on their particular risk of developing venous thromboembolic disease against the anticipated risk of surgical bleeding complications from the surgery to which they will be subjected, allowing the identification of patients likely to develop complications. through the modified Caprini scoring system and you see guide and establish optimal thromboprophylaxis strategies.

Los trastornos de la coagulación han sido uno de los problemas con que los clínicos han lidiado en el transcurso del conocimiento de esta nueva patología. Existe muy escasa evidencia y limitadas recomendaciones por parte de las Sociedades Científicas sobre el manejo de la tromboprofilaxis en el paciente quirúrgico COVID-19, aunado a que se desconoce los efectos de esta patología sobre la injuria quirúrgica. La evaluación del riesgo trombótico en cuanto al paciente quirúrgico COVID-19 no cuenta con precedentes al respecto. Algunos predictores y factores de riesgo de trombosis se han informado sistemáticamente como marcadores pronóstico, entre ellos la elevación del dímero-D, fibrinógeno, IL6, ferritina sérica, prolongación de tiempos de coagulación, detección anticuerpos antifosfolípidos y otros factores independientes que contribuyen a medir la gravedad de COVID-19 como lo es la lactato deshidrogenasa y la linfopenia marcada. Los anteriores predictores y factores de riesgo de trombosis para la enfermedad de COVID-19 se han adaptado ajustados a las categorías presentes en la escala de Caprini en orden creciente de complejidad y en relación a la morbimortalidad. En este sentido la elección de la o las medidas que requiere cada paciente dependerá de su riesgo particular de desarrollar enfermedad tromboembólica venosa contra el riesgo anticipado de complicaciones hemorrágicas quirúrgicas de la cirugía a la que será sometido, permitiendo identificar a los pacientes susceptibles de desarrollar complicaciones a través del sistema de puntuación modificado de Caprini y a la vez guiar y establecer estrategias óptimas de tromboprofilaxis.

Implementação de protocolo para profilaxia de tromboembolismo venoso: um estudo antes e depois em pacientes clínicos e cirúrgicos / Protocol implementation for venous thromboembolism prophylaxis: a before-and-after study in medical and surgical patients

RESUMO Objetivo Este estudo visou avaliar a adequação da prescrição de profilaxia de tromboembolismo venoso (TEV) após a implementação do protocolo. Métodos Trata-se de um estudo antes e depois realizado em um hospital de cuidados terciários no Rio Grande do Sul, Brasil. Pacientes clínicos e cirúrgicos internados, com 18 anos ou mais, foram avaliados para o risco de TEV e, posteriormente, para adequação da tromboprofilaxia, de acordo com o risco. As avaliações ocorreram antes e depois de uma estratégia de implementação de protocolo, que consistiu em uma plataforma on-line para acessar o protocolo, uma postagem pública do diagrama do protocolo, alertas clínicos na sala de convívio médico, alertas de e-mail e alertas pop-up no sistema informatizado de prescrição médica. O Desfecho principal foi a adequação da prescrição de profilaxia do TEV de acordo com o protocolo. Resultados Foram avaliados 429 pacientes para adequação da tromboprofilaxia (213 antes e 216 depois). A prevalência de adequação aumentou de 54% para 63% (pré e pós-intervenção, respectivamente) e após o ajuste por tipo de paciente e fase do estudo, a razão de prevalência atingiu (RP) = 1,20, intervalo de confiança de 95% (IC) 1,02-1,42. Conclusões os resultados mostraram que a adequação geral da prescrição de tromboprofilaxia foi discretamente melhorada. Apesar desses resultados, este estudo fornece evidências, até o momento, de uma série de estratégias para implementar o protocolo em instituições privadas em países de renda média com uma equipe médica aberta, pois há poucas pesquisas investigando esse tipo de intervenção simples e pragmática.

ABSTRACT Objective This study aimed to assess the adequacy of venous thromboembolism (VTE) prophylaxis prescription after a protocol implementation. Methods This was a before-and-after study conducted in a tertiary care hospital in Rio Grande do Sul, Southern Brazil. Medical and surgical inpatients aged 18 years or older were assessed for VTE risk and subsequently for thromboprophylaxis adequacy, according to their risk. The evaluations occurred before and after the protocol strategy implementation; it consisted of an online platform to access the protocol, a public posting of the protocol diagram, clinical alerts on the medical staff TV, e-mail alerts, and pop-up alerts on the computerized physician order entry system. The main outcome measure was the adequacy of VTE prophylaxis prescription according to the protocol. Results A total of 429 patients were evaluated for thromboprophylaxis adequacy (213 before and 216 after). The prevalence of adequacy increased from 54% to 63% (pre and post-intervention, respectively), and after adjustment for patient type and phase of the study, the prevalence ratio reached (PR)=1.20, 95% confidence interval (CI) 1.02-1.42. Conclusion The results showed that the overall appropriateness of thromboprophylaxis prescription was weakly improved. Despite these results, this study provides evidence to date a bunch of strategies for protocol implementations in private institutions in middle-income countries with an open medical staff, as there are few studies investigating these simple and pragmatic interventions.

Anticoagulación en COVID-19 / Anticoagulation in COVID-19

La vida del mundo cambió como la conocíamos, desde diciembre de 2019, por una nueva pandemia viral, el "Coronavirus 2". Virus de alta contagiosidad y gravedad por el Síndrome Respiratorio Agudo Severo (SARS CoV-2) provocando alta morbimortalidad, desbordado las Unidades de Cuidados Intensivos del mundo, para atender a estos pacientes cuyo cuadro es primariamente respiratorio. Actualmente, además se enfrenta a una segunda amenaza, el aumento sustancial en comparación a otros pacientes hospitalizados (no COVID-19) de las complicaciones tromboembólicas.Esta publicación pretende realizar una revisión de la información actualizada disponible respecto a la epidemiología, fisiopatología y manejo de la enfermedad tromboembólica en pacientes con COVID-19 hospitalizados.

The life of the world changed as we knew it, since december 2019, due to a new viral pandemic, the "Coronavirus 2". Virus of high contagiousness and severity due to Severe Acute Respiratory Syndrome (SARS CoV-2) causing high morbidity and mortality, overwhelmed the Intensive Care Units of the world, to care for these patients whose primarily respiratory symptoms. Currently, it also faces a second threat, the substantial increase compared to other hospitalized patients (not COVID-19) of thromboembolic complications.This publication aims to review the updated information available regarding the epidemiology, pathophysiology, and management of thromboembolic disease in hospitalized COVID-19 patients.

Enfermedad tromboembólica venosa: factores de riesgo y profilaxis en pacientes hospitalizados / Venous thromboembolic disease: risk factors and prophylaxis in hospitalized patients

Un alto porcentaje de pacientes hospitalizados puede presentar trombosis venosa profunda con sus corresponientes consecuencias. Objetivos: Determinar el riesgo y tratamiento profiláctico de enfermedad tromboembólica venosa (ETEV) en pacientes hospitalizados. Métodos:investigación de tipo observacional, transversal y multicéntrica. Se aplicó la escala de Caprini para identificar factores de riesgo en pacientes hospitalizados de cuatro hospitales del área Metropolitana de Caracas. Por otra parte, se aplicó una encuesta a médicos residentes y especialistas de las distintas sedes hospitalarias para determinar su conocimiento en profilaxis para ETEV. Resultados: Se registraron 851 pacientes hospitalizados con edad 48,6 + 19,3 años, con predominio del género masculino (59 %). Estaban en servicios quirúrgicos 489 pacientes (57,5 %) y servicios médicos 362 pacientes (42,5 %). Según la escala de Caprini 154 pacientes (18,1 %) estaban en riesgo moderado, y 642 pacientes (75,4 %) en riesgo alto. Recibieron tratamiento profiláctico 61 pacientes (7,7 %), siendo la medicación y la dosis adecuada solo en el 32,8 % de estos pacientes. En cuanto al conocimiento de ETEV, el 96,9 % de los médicos conoce la enfermedad, pero solo el 58,5 % reconoce la embolia pulmonar como parte de esta entidad. Solo el 49,2 % de los encuestados conoce o aplica escalas de riesgo para esta enfermedad. El tratamiento farmacológico es conocido por el 93,8 % de los médicos. Solo el 56,6 % de los médicos realiza seguimiento a los pacientes, siendo el lapso menor de 3 meses el más frecuente (40 %). Conclusiones: en nuestro estudio hay predominio de pacientes con alto riesgo para ETEV. El uso de profilaxis farmacológica es muy bajo. El conocimiento de escalas de riesgo no es adecuado(AU)

Venous thromboembolic disease is frequent in hospitalized patients.Objectives: To determine the risk and prophylactic therapy of venous thromboembolic disease (VTE) in patients with medical and surgical pathologies according to the Caprini scale. Methods: an observational, transversal and multicenter research was performed. The Caprini scale was applied to identify risk factors in medical and surgical hospitalized patients of four hospitals in the metropolitan area of Caracas. Also, a survey was applied to residents and specialists from the different hospitals to determine the knowledge about prophylactic treatment for VTE. Results: we registered 851 hospitalized patients with an age of 48,6 + 19,3 years, mainly men (59 %). There were 489 surgical patients (57,5 %) and 362 medical patients (42,5 %). According to Caprini risk scale 154 patients (18,1 %) were at middle risk and 642 patients (75,4 %) were at high risk. Prophylactic treatment was indicated in 61 patients (7,7 %), this treatment was adequate (doses and drug type) only in 32 % of these patients. About the ETV, 96,9 % of the medical doctors had knowledge of this illness, but only 58,5 % recognize pulmonary embolism as part of this entity. Only 49,2 % knows or applies risk scales for ETV. 56,6 % follows the patients, more frequently for less of 3 months (40 %). Conclusions: we found is a high predominance of moderate to high risk patients for ETV. Pharmacological prophylaxis was very low. ETV risk scales knowlegde is not adequate(AU)

Thromboprophylaxis after bariatric surgery

BACKGROUND: Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a known cause of morbidity and mortality after bariatric surgery. However, the data concerning appropriate thromboprophylaxis after bariatric surgery is uncertain. The objective of this study was to evaluate the efficacy and safety of extended duration thromboprophylaxis in post-bariatric surgery patients.METHODS: We conducted a retrospective study of consecutive patients who underwent bariatric surgery from November 2014 to October 2018 at King Fahad General Hospital in Jeddah, Saudi Arabia. All included patients were treated with extended duration thromboprophylaxis.RESULTS: We identified 374 patients who underwent bariatric surgery during the study period. Of these, 312 patients (83%) were followed for at least 3 months. The most common type of surgery was a laparoscopic sleeve gastrectomy (N=357) and the median weight was 110 kg. The cumulative incidence of symptomatic postoperative VTE at 3 months was 0.64% (95% confidence interval, 0.20–1.52). All events occurred after hospital discharge. The most commonly used pharmacological prophylaxis (91%) for VTE prevention after bariatric surgery was enoxaparin 40 mg subcutaneously twice daily for 10–14 days after hospital discharge. There were no reported cases of bleeding or VTE related mortality after 3 months.CONCLUSION: Extended thromboprophylaxis after bariatric surgery appears to be an effective and safe strategy for VTE prevention. Large prospective studies are needed to evaluate the optimal thromboprophylaxis regimen after bariatric surgery.

Caracterización de neonatos de madres con hipercoagulabilidad en régimen tromboprofiláctico / Characterization of neonates of mothers with hypercoagulability in thromboprophylactic regimen

Introducción: Hace una década, en el Instituto de Hematología e Inmunología se comenzó la tratamiento de mujeres con pérdidas recurrentes de embarazos por trastornos de hipercoagulabilidad. Objetivo: Caracterizar clínicamente a estos neonatos e identificar los efectos adversos de la terapia tromboprofiláctica en los recién nacidos. Métodos: Se realizó estudio descriptivo, de corte transversal entre enero de 2014 y agosto de 2017, que incluyó 62 recién nacidos, hijos de madres con diagnóstico de trombofilia que utilizaron durante la gestación, régimen de tromboprofilaxis con heparinas de bajo peso molecular y aspirina. Todas las gestantes fueron evaluadas con sistematicidad en las consultas de Hemostasia y Obstetricia, del Instituto de Hematología e Inmunología y Hospital Enrique Cabrera, respectivamente. Resultados: La mayoría de los neonatos nacieron a término, con apgar normal y pesos superiores a 2 500 g. El 82,3 por ciento de las gestantes comenzaron la tromboprofilaxis con menos de 5 semanas de gestación. Hubo diferencias significativas cuando se compararon los pesos de los neonatos de las madres que comenzaron el tratamiento temprano con aquellas que lo iniciaron tardíamente. El tipo de trombofilia y la edad materna no influyeron en los pesos de los neonatos, pero aquellas gestantes con sintomatología más grave tuvieron hijos de menor peso que, aunque no fue significativo, requiere una observación. Ningún recién nacido presentó efectos secundarios a la terapia tromboprofiláctica. Conclusiones: Los neonatos nacidos de madres con trombofilia que iniciaron tromboprofilaxis de forma temprana no fueron diferentes a los recién nacidos de madres sin hipercoagulabilidad(AU)

Introduction: A decade ago, at the Institute of Hematology and Immunology, treatment of women with recurrent pregnancy losses due to hypercoagulability disorders began. Objective: Clinically characterize these infants and identify the adverse effects of thromboprophylactic therapy in newborns. Methods: A descriptive and transversal study was carried out between January 2014 and August 2017, which included 62 children of mothers with a diagnosis of thrombophilia who used during pregnancy, a thromboprophylaxis regimen with low molecular weight heparins and aspirin. All pregnant women were systematically evaluated in the Hemostasis and Obstetrics consultations of the Institute of Hematology and Immunology and Hospital Enrique Cabrera. Results: The majority of the neonates were born at term, with normal apgar and weights above 2,500 g. 82.3 percent of pregnant women started thromboprophylaxis with less than 5 weeks of gestational age. There were significant differences when the weights of the infants of the mothers who started the treatment early were compared with those who started it late. The type of thrombophilia and maternal age did not influence the weights of the neonates, but those cases with more severe symptoms had children of lower weight, which although it was not significant, requires observation. No newborn presented side effects to thromboprophylactic therapy. Conclusions: Infants born to mothers with thrombophilia who started thromboprophylaxis early were not different from those born to mothers without hypercoagulability(AU)

The risks for thromboembolism following caesarean section

Background: Maternal mortality can be due to various reasons. Maternal mortality following thromboembolism is a cause for concern. Venous thromboembolism is a very serious condition following caesarean section. Thromboprophylaxis should be given to the mothers with high risk for thromboembolism, who deliver by caesarean section. The objective of this study was to do to assess the risk status for thromboembolism among women delivered by caesarean section.Methods: A hospital based cross- sectional study was conducted among four hundred mothers who delivered by caesarean section. The study was conducted for a period of eight months from January to August 2017. The risks for thromboembolism was assessed and as per the guideline and hospital policy, thromboprophylaxis was given.Results: Out of four hundred patients, medical comorbidities were present for three patients. Patients who were overweight were 122. Two had systemic infection. The number of patients with high, intermediate and low risk of venous thromboembolism were 4,65 and 331.Conclusions: The study suggests that thromboprophylaxis is to be given for all the patients with any risk for thromboembolism, after caesarean section.

Deep Vein Thrombosis and Pulmonary Embolism Following Unilateral and Simultaneous Bilateral Total Knee Arthroplasty

Objective: Venous thromboembolism (VTE), which comprises pulmonary embolism and deep vein thrombosis, is a known complication of total knee arthroplasty (TKA). However, data on the risk of VTE after simultaneous bilateral TKA, compared to that after single knee arthroplasty, is scarce. Methods: A retrospective study of electronic medical records of all adult patients who underwent simultaneous bilateral TKA or single unilateral TKA was conducted. Results: A total of 669 patients underwent TKA. Of these, 134 underwent simultaneous bilateral TKA while 535 underwent single unilateral TKA. All patients underwent pharmacological thromboprophylaxis for a median duration of 30 days. The incidence of confirmed VTE in all patients was 1.8% (95% confidence interval, CI: 0.9-3.0). VTE occurred in 8 of the 134 patients (6%, 95% CI: 2.2-10.4) who underwent simultaneous bilateral TKA and in 4 of the 535 patients (0.7%, 95% CI: 0.2-1.5) who underwent single unilateral TKA. The odds ratio of confirmed VTE was 8.42 (95% CI: 2.49-28.4; p=0.001). Conclusion: The risk of VTE is significantly higher following simultaneous bilateral TKA than following single unilateral TKA. Further studies are needed to evaluate high-risk patients and to determine the appropriate thromboprophylaxis regimen.

Papel da deambulação na prevenção do tromboembolismo venoso em pacientes clínicos: onde estamos? / Role of ambulation to prevent venous thromboembolism in medical patients: where do we stand?

O tromboembolismo venoso (TEV), que compreende o espectro de manifestações de trombose venosa profunda e/ou embolia pulmonar, é uma complicação comum, grave e evitável em pacientes hospitalizados. Embora a perda da mobilidade recente ou continuada represente um dos principais fatores de risco relacionados ao desenvolvimento de TEV, não existem critérios claros e uniformes para a definição do conceito de imobilidade. A diversidade dessas descrições dificulta a interpretação e a comparação dos resultados de estudos clínicos randomizados no que se refere à influência dos diferentes níveis de imobilidade na magnitude do risco de TEV e ao papel da deambulação precoce, de forma isolada, na prevenção de tais eventos. O entendimento dessas limitações é mandatório para a utilização e interpretação adequadas das ferramentas de avaliação de risco de TEV, e para a indicação da melhor estratégia de prevenção de trombose em pacientes clínicos hospitalizados. O objetivo deste estudo é revisar as principais evidências da literatura quanto ao papel da deambulação na prevenção do TEV

Venous thromboembolism (VTE) encompasses the spectrum of manifestations of deep venous thrombosis and/or pulmonary embolism and is a common, serious, and preventable complication in hospitalized patients. Although immobility plays an important role in determining VTE risk in medical patients, no clear and uniform criteria exist to guide clinicians in assessing immobility. The variation in the descriptions that do exist makes it difficult to interpret and compare the results of randomized clinical trials with respect to the influence of different levels of immobility on the magnitude of VTE risk and the role that early ambulation as an isolated factor plays in prevention of such events. Understanding these limitations is a prerequisite for the proper use and interpretation of VTE risk assessment tools and for indicating the best strategy for preventing venous thrombosis in hospitalized medical patients. The objective of this study was to review the main evidence reported in the literature on the role of ambulation in prevention of VTE

Enhanced recovery after surgery in liver resection: current concepts and controversies / 대한마취과학회지

Enhanced recovery after surgery (ERAS) attenuates the stress response to surgery in the perioperative period and hastens recovery. Liver resection is a complex surgical procedure where the enhanced recovery program has been shown to be safe and effective in terms of postoperative outcomes. ERAS programs have been shown to be associated with lower morbidity, shortened postoperative stay, and reduced cost with no difference in mortality and readmission rates. However, there are challenges that are unique to hepatic resection such as safety after epidural catheterization and postoperative coagulopathy, intraoperative fluids and postoperative organ dysfunction, need for low central venous pressure to reduce blood loss, and non-lactate containing intravenous fluids. This narrative review briefly discusses these concerns and controversies and suggests revisiting some of the strong recommendations made by the ERAS society in light of the recent evidence.