Suspensiones quirúrgicas: un desafío para la gestión clínica post Covid 19

Objetivo: Determinar la frecuencia, las causas y los factores asociados de suspensión de cirugías programadas en un hospital de alta complejidad en un periodo de 5 años. Materiales y Método: Se realizó un estudio descriptivo transversal, en un hospital terciario del sur de Chile durante los años 2014 a 2018. Se describe la frecuencia de suspensión quirúrgica del establecimiento y por especialidad, especificando sus principales causas. Además, se identificaron aquellas suspensiones evitables y sus factores asociados mediante regresión logística. Resultados: La tasa de suspensión en los 5 años de estudio fue de 11,2%. Neurocirugía y Traumatología tuvieron la mayor tasa de suspensión (18,8% y 13,9%, respectivamente), mientras que Ginecología y Obstetricia la menor (4,1%). Las causas más frecuentes fueron la inasistencia del paciente (16,9%), la prolongación de la cirugía anterior (16,4%) y la paralización de actividades por motivos gremiales (7,9%). Un 80,1% de las causas fueron evitables. La especialidad quirúrgica y la edad del paciente fueron los factores asociados más relevantes. Discusión: Se evidenció una alta tasa de suspensiones quirúrgicas y la mayoría por causas evitables. Su disminución puede ser la intervención más costo efectiva para contribuir a reducir las extensas listas de espera quirúrgica posterior a la crisis sanitaria por COVID 19, ya que sólo requiere optimizar los recursos existentes. Conclusiones: La suspensión quirúrgica es un problema frecuente en el proceso quirúrgico. Nuestros resultados permiten identificar a los grupos de mayor riesgo de suspensión, asignar responsabilidades a los equipos quirúrgicos y desarrollar estrategias efectivas para su prevención.

Aim: To determine the frequency, the causes and the associated factors of the surgical cancellation of scheduled surgeries at the Hospital Base Valdivia between the years 2014 and 2018. Materials and Method: A descriptive cross-sectional study was carried out. Were described the frequency of suspension of scheduled surgeries of the establishment, by specialty and their main causes, identifying those that can be avoided. In addition, the factors associated with suspension were identified by logistic regression. Results: The suspension rate in the 5 years of study was 11.2%. Neurosurgery and Traumatology had the highest frequency of surgical cancellation (18.8% y 13.9%, respectively), Obstetrics, and Gynecology the lowest (4.1%). The most frequent causes of suspension were the absence of the patient (16.9%), the prolongation of the previous surgery (16.4%) and the suspension of activities due to Union reasons (7.9%). 80.1% of the causes were avoidable. The age and surgical specialty were the most relevant associated factorsm Discussion: A high rate of surgical suspensions and most for avoidable reasons were evident. Reducing surgical cancellations can be the most cost effective intervention to help reduce the extensive post-health crisis surgical waiting lists by COVID 19, as it only requires optimizing existing resources. Conclusions: Surgical suspension is a common problem in the surgical process. Our results allow to identify the groups most at risk of suspension, assign responsibilities to surgical teams and develop effective strategies for their prevention.

Para uma suspensão do tempo ordinário - a experiência da festa, do tédio e do divã / For a suspension of ordinary time - the experience of partying, boredom, and couch

RESUMO: Este ensaio pretende analisar se, em nossos dias, ainda é possível uma suspensão do tempo ordinário. Ou seja, pretende explorar várias dimensões de nossas vidas nas quais o tempo cronológico poderia ou não ser colocado em suspensão; se sim, tal possibilidade nos levaria a experienciar outra forma de temporalidade? Principio a análise desde a perspectiva da experiência nas festas populares - o carnaval, por exemplo, ainda seria um espaço de transgressão (do ordinário ao profano)? Enveredo então por uma reflexão sobre o passatempo e a indústria cultural. E, em um segundo movimento, investigo se poderíamos suspender aquele tempo ordinário em nossa vida privada, como na experiência do tédio. Outras possibilidades visadas são os casos do divã e do amor. Nestes últimos, teríamos realmente uma outra experiência de temporalidade?

Abstract: This essay aims to examine whether, nowadays, it is still possible to suspend ordinary time. In other words, aims to explore the various dimensions of our lives in which chronological time could be suspended; if so, such a possibility would lead us to experience another form of temporality? Beginning the analysis from the perspective of experience in popular festivities - carnival, for instance, would still be a space of transgression (of the ordinary to the profane)? Follows a reflection about pastimes and the culture industry. Next, I investigate if we could suspend ordinary time in our private life, as the experience of boredom. Other possibilities would be the cases of couch and of love. In those latter, would we really have a different experience of temporality?

Analysis on the causes of unscheduled suspensions of knee and hip arthroplasty / 北京大学学报(医学版)

Objective:To analyze and summarize the causes of unscheduled suspension of knee and hip arthroplasty and to provide the method for optimizing the patient's pre-operative management and improving the efficiency of medical resources as well as the patient's satisfaction.Methods: The data for this report was retrospectively collected from September 2013 to August 2014 in our hospital,from cases of knee and hip arthroplasty that were suspended before the scheduled operation time.Acquisition data from the collected cases including the patients' gender,age and the surgical procedure.At the same time,the suspension reasons were recorded and analyzed.All the decisions of suspension was made by the surgeons and the anesthesiologists according to the abnormal result of preoperative examinations,after communicating with the patients and their families and obtaining their understandings.Results: In the collecting period,our department scheduled 1 146 cases of knee and hip arthroplasty,among which 1 003 were completed,143 suspended (12.5％ suspension rate).Among the causes of suspension,the top four common causes were cardiovascular disease (44/143,31％),other infections (20/143,14％),bacteriuria (18/143,13％) and inappropriate surgical indication (16/143,11％).Other causes include surgeon's reason,Blood system abnormalities,high inflammatory index,deep vein thrombosis,other diseases uncontrolled,abnormal liver function and poor diabetes mellitus control,etc.For the rate of suspension,there was no significant difference between the patients with different genders (male: 15.0％,and female: 11.7％,P=0.149),or age (≤50 years: 13.0％;51-65 years: 11.6％;66-80 years 13.3％;>80 years 11.1％;P=0.864).However compared with knee arthroplasty,hip arthroplasty had a higher suspension rate (knee arthroplasry 11.1％,hip arthroplasry 16.1％,P=0.021).Conclusion: It is important to educate and manage the patients before their knee and hip arthroplasty.Through clear diagnosis,detailed medical history analysis careful physical examination,and targeted outpatient examinations and tests for which priority was focused on cardiovascular or other system diseases we could minimize the occurrence of operative suspension post hospitalization,therefore improving the efficiency of the use of medical resources.

Skype análise / Skype analysis / Skype análisis

O autor discute a necessidade de utilizar, na prática clínica, a análise a distância em circunstâncias determinadas. Comenta a bibliografia sobre análise por telefone e relata aspectos de sua experiência no uso do Skype, que conta com exíguas publicações a respeito. Vê inúmeros pontos positivos que validam sua aplicação, ainda que a sensorialidade do encontro analítico esteja diminuída. Propõe que deve ser vista como uma modalidade específica: a Skype análise.

This paper discusses the need for distance analysis in clinical practice in certain circumstances. The author comments on the bibliography of telephone analysis and describes aspects of his experience with Skype analysis, about which there are few published works. He argues that positive aspects validate its use, even though sensoriality of the analytic encounter is diminished. He suggests Skype analysis as a specific form of analysis.

El autor discute la necesidad del uso, en la práctica clínica, del análisis a distancia, en determinadas circunstancias. Comenta la bibliografía sobre el análisis por teléfono y relata aspectos de su experiencia con el uso del Skype, que cuenta con escasas publicaciones al respecto. Observa inúmeros aspectos positivos que validan su aplicación, aunque la sensorialidad del encuentro analítico esté disminuida. Propone que debe verse como una modalidad específica, la Skype análisis.

Experimental study of the pipe replacement cycle for the suspension of ventilator / 中国实用护理杂志

Objective To compare the detection results by bacteria pathogenic rate of ventilatorassociated pneumonia (VAP) pipeline and ventilator patients with mechanical ventilation,to investigate whether need to replace the ventilator weaning patients underwent another test of pipeline during mechanical ventilation.Methods This study selected using the ventilation mechanical ventilation for more than 48 hours,try (48 ± 4) hours required to mechanical ventilation in 69 patients.They were divided into two groups according to admission time,group A was in need of replacement ventilation pipeline of new again during mechanical ventilation,group B used the original pipeline.In offline,try again during mechanical ventilation after mechanical ventilation,once daily for 4 days to collect ventilator pipe air outlet samples for bacterial culture counts were observed,while offline,use again after 2 hours,12 hours of ventilator,24 hours,2 days,3 days,4 days of body temperature,white blood cell count,neutrophil classification and other indicators.The incidence of VAP was compared between two groups.Results The temperature,white blood cell count,neutrophil classification were (38.5 ± 1.6)℃,(11.8 ± 3.5)×109/L,0.85±0.16 in group A,while (38.4 ± 2.0) ℃,(12.1 ± 3.7)×109/L,0.84 ± 0.20 in group B,and there were no significant differences between two groups,P＞0.05.The incidence of VAP was 37.1％(13/35) and 35.3％(12/34) in group A and group B,and there was no significant difference,P＞ 0.05.Conclusion There is no necessary for trial offline patients without respiratory infection to change the ventilator pipe when to re-ventilate during the 7 days using period of the ventilator pile.

Clinical efficacy of combined procedures for the surgical correction of congenital ptosis accompanied by epicanthus / 中华医学美学美容杂志

Objective To observe the effects of combined surgeries for the correction of congenital ptosis accompanied by epicanthus.Methods 80 cases (105 eyes) of congenital ptosis were analyzed in this study.64 cases (80 eyes),with levator muscle strength more than 4 mm,were treated with suspension of frontal aponeurosis,and 16 cases (25 eyes),with levator muscle strength less than 4 mm,were treated with shorten operation of levator palpebrae superioris.Furthermore,all these patients were corrected the epicanthus at the same time.Results Except the under correction in 5 cases (8 eyes),the remaining patients were corrected satisfactorily.Postoperative palperbal fissure length was averagely increased by 2.0± 1.0 mm,inner canthic diameter was averagely decreased by 4.0± 2.0 mm,the eyelid height was increased by average 9.0±1.0 mm,the inclination of palpebral fissure was 12.0°±2.0°;64 cases (80 eyes) were treated with suspension of frontal aponeurosis,postoperative recurrence were 7.5％ (6/80),no postoperative recurrence were 92.5％ (74/80),complication were 5.0％ (4/80);16 cases (25 eyes) were treated with shorten operation of levator palpebrae superioris,postoperative recurrence were 8.0％ (2/25),and no postoperative recurrence were 8.0％ (2/25);complication rates were 4.0％ (1/25).Conclusions This procedure of combined surgeries can reduce the recurrence rate effectively.Moreover,the satisfactory,functional,and aesthetic results can be obtained simultaneously with this method.

Recent trend of precedents for National Health Insurance

This paper introduces the major issues related to the Health Insurance Act and the core content of recent precedents, in order to prevent health insurance arguments and to contribute to health insurance-related administrative litigation. The basis of Korea's health insurance system is the National Health Insurance Act. After providing medical services, the medical cost is covered by the National Health Insurance Corporation (NHIC). If the doctor was paid deceptively or improperly, then the NHIC will seize the entire payment, and the Minister of Health and Welfare will order the doctor to suspension practice or, similarly, fine the doctor for five times the original payment. In addition, doctors who have used deception will have their license suspended. If the doctor has any objection against this administrative measure, he or she can file an administrative lawsuit. So far, if the action was illegal, the court has generally made principle-based judgments, regardless of whether the behavior was intentional or negligent; however, recently, especially in cases related to the court of first instance (only a few cases), the court has made a judgment clearly cancelling the measure under the condition that the measure was beyond the level by analyzing the reason why the practitioner committed an offense. From the practitioners' point of view, it is encouraging that the judges have started to understand the reality of the medical field. Further, this paper argues that judges should increase their understanding the medical field and specific validity. This article reviews the litigation process related to the National Health Insurance Act and recent trends in its precedents. From now on, these judgments should support the arguments of practitioners. Con-clusively, these judgments were the result of legal actions; therefore, doctors should avoid taking an attitude of annoyance toward lawsuits or being intimidated by the organization, and as a result, respond passively by simply paying out the lawsuit settlements.

To cure e to caee in situazioni di fine vita: la proporzionalità e le cure palliative

Per affrontare i temi bioetici inerenti alla fine della vita occorre mettere a fuoco la questione della proporzionalità dei trattamenti. Spesso la dimenticanza del limite intrínseco all'arte medica può sfociare in un duplice e contraddittorio atteggiamento: l'accanimento terapeutico da una lato, l'abbandono terapeutico dall'altro. L'incapacità di riconoscere nel concreto la finitezza porta infatti a non accettare la morte, a negare la sua ineluttabilità o a sfuggirla nella sua complessità antropologica ed esistenziale. La negazione del limite, inoltre, ha come esito anche un possibile rapporto conflittuale tra i medico e il paziente, con il risultato della strutturazione di una medicina difensiva e di stampo contrattualistico. La proporzionalità di cui si parla è un criterio, e come tale richiede una valutazione puntuale, nella situazione, senza una rigida e aprioristica codificazione. Spesso, comunque, la ritrosia ad accettare, a livello sociale o nella comunità scientifica medica, il criterio di sospensione dei trattamenti quando questi si rivelano sproporzionati, nasce dalla confusione concettuale tra uccidere e permettere di morire, nonché tra omissione e sospensione. La differenza tra queste azioni sfuma solo se si sposta il peso della valutazione sull'intenzione o sulle conseguenze, la cui omogeneità veicolerebbe l'equivalenza morale degli atti. Nelle pagine che seguono si mostra inoltre la connessione della cura con il tema della qualità di vita e con l'importante campo delle cure palliative.

An effort to address the bioethical issues inherent in the process of dying requires a focus on the proportional aspect of treatment. Failing to bear in mind the intrinsic limit to the art of medicine can result in dual and contradictory behavior: artificial support therapy on the one hand and therapeutic abandonment on the other. In real situations, the inability to recognize the limits of the power of medicine is, in one way or another, equivalent to not accepting death, to denying its inevitable role or to evading its anthropological and existential complexity. Moreover, denying that limit can lead to a possible conflict between the physician and the patient, resulting in medicine that is defensive and contractual in nature. The proportionality in question is a criterion and, as such, it demands a particular assessment of the situation, without rigid and dogmatic codification. However, the reluctance that exists at the social level or within the medical scientific community to accept suspension of treatment when it is shown to be disproportionate is born of the conceptual confusion between unlawful death and permitting death; that is, between omission and suspension. The difference between these two acts disappears only if the weight of the assessment is shifted to the intention or the consequences, the oneness of which would unite the moral equivalent of the acts. The article also shows the relationship between treatment and quality of life and the important field of palliative care.

Para afrontar los temas bioéticos inherentes al proceso de fin de la existencia es necesario enfocar el tema de la proporcionalidad de los tratamientos. Con frecuencia el olvido del límite intrínseco del arte de la medicina puede desembocar en un doble y contradictorio comportamiento: de una parte la terapia de mantenimiento artificial y de otro lado el abandono terapéutico. La incapacidad de reconocer en la realidad concreta el límite del poder médico conlleva, de una forma o de otra, a no aceptar la muerte, a negar su parte ineluctable o a evadir su complejidad antropológica y existencial. Además, la negación del límite tiene como efecto una posible relación de conflicto entre el médico y el paciente, dando como resultado la estructuración de una medicina defensiva y de tipo contractual. La proporcionalidad de la cual se habla es un criterio, y como tal exige una evaluación puntual en la situación, sin una codificación rígida y a priori. Sin embargo, la reticencia a aceptar a nivel social o en la comunidad científica médica, el criterio de suspensión de los tratamientos cuando estos demuestran ser desproporcionados, nace de la confusión conceptual entre asesinar o permitir morir, entre omisión y suspensión. La diferencia entre estas dos acciones desaparece solamente si se desplaza el peso de la evaluación hacía la intención o hacía las consecuencias, cuya homogeneidad uniría la equivalencia moral de los actos. En las siguientes páginas también se muestra la relación del tratamiento con el tema de la calidad de vida y con el importante campo de los cuidados paliativos.

Limitaciones de esfuerzos terapéuticos: Resultados de un registro prospectivo en una sala de clínica médica / Limitation of life-sustaining treatment: A prospective study developed in a clinical ward

El objetivo de este trabajo fue describir el proceso de limitación de los esfuerzos terapéuticos (LET) en los pacientes internados en una sala general. Para ello se realizó un estudio prospectivo descriptivo, desarrollado en la sala de internación general de un hospital universitario. Fueron evaluados pacientes que tuviesen alguna LET, asistidos por el servicio de clínica médica en un período de 60 días consecutivos. Durante el mismo se hospitalizaron 402 pacientes, 62 (15%) tuvieron algún tipo de LET. Este último grupo estaba compuesto por un 66% de mujeres, la mediana de edad fue de 86 años (78-90) y de la duración de hospitalización de 12 días (8-18). La mala calidad de vida fue la causa más frecuente de LET (69%). Se brindó información acerca de las limitaciones a 43 familias (69%) y 8 pacientes (13%). En la decisión participaron el médico de cabecera (50%), médicos de planta (50%), residentes (40%), la familia (42%) y los propios pacientes (11%). En 7 casos hubo constancia en la historia clínica (11%). Diecisiete pacientes (27%) con LET fallecieron durante la internación, mientras que 44 (71%) fueron dados de alta. En conclusión, la limitación de esfuerzos terapéuticos en nuestros pacientes constituyó un hecho frecuente. No se logró identificar un proceso uniforme o sistematizado para la toma de la decisión de LET. Resulta innegable la necesidad de normativas que guíen al equipo de salud en la toma de decisiones, tranquilicen a familiares y acompañen a los pacientes en sus reales necesidades.

The purpose of this study is to describe the limiting life-sustaining treatment process of patients admitted to a general ward. A prospective descriptive study was designed. The setting was the general ward of universitary hospital. Study participants were patients assisted by the internal medicine department during a 60- consecutive days period who had limitations of life sustaining treatments. During the study period, 402 patients were hospitalized, 62 (15%) of them had limitations of life support care. The median patient age of the last group was 86 years (78-90), 66% were women and the length of stay was 12 days (8-18). A low quality of life was the most frequent cause of limitation (69%). Information about the limitations was provided to 43 families (69%) and 8 patients (13%). The primary care physician participated in the decision in 50% of the cases, while the attending physician, the resident in charge, patient's family and patients themselves participated in 50%, 40%, 42% and 11% of the cases respectively. The decision of limiting life-sustaining treatments was recorded in seven patient's charts (11%). Seventeen (27%) patients with limitations died during the hospital stay while 44 (71%) were discharged. In conclusion, we found a frequent life sustaining treatment limitation in our patients. These decisions did not follow a uniform or systemized process. The need of guidelines to sort the medical and ethical challenges imposed to the medical team is undeniable.

Combined Therapy of Subaxillary Mini-incision,Suspension of Pulmonary Lobe,Folding Ligation and General Adhesion for Intractable Pneumothorax / 中国微创外科杂志

Objective To investigate the therapeutic effect of a new surgical procudure for intractable pnumothorax.Methods Subaxillary mini-incision and folding ligation of bullae of lung were conducted without suture if possible.Parietal pleura was rubbed with a dry gauze roll and irrigated with hydrogen peroxide solution.The corresponding pulmonary segments were suspended on the parietal pleura to keep the lung tissues in inflation state and to avoid over compression of the lungs.Pleural cavity was irrigated with 5-10 ml lidocaine for 3 days after the surgery.Results The operation was successfully conducted in 21 cases(including 1 case of bilateral surgery).The average operation time was 45 min(range:30-60 min);and the average blood loss was 70 ml(range:50-100 ml).No complications occurred.The follow-up time was 6-72 months,25 months in average,and no recurrence of pneumothorax occurred.Conclusions This therapeutic method combining subaxillary mini-incision,suspension of pulmonary lobe,folding ligation and general adhesion is effective,minimally invasive,safe and inexpensive for treating intractable pnumothorax.