Monitoramento de pacientes cirúrgicos no pós-alta: avaliação do risco de complicações / Remote monitoring of surgical patients after discharge: assessment of the risk of complications

O monitoramento das complicações de pacientes cirúrgicos no período pós-alta é um desafio, principalmente pela dificuldade de seguimento no ambiente domiciliar. Neste sentido, este estudo possibilitou construir e validar diretrizes para monitorar pacientes cirúrgicos no período pós-alta hospitalar durante o período de aparecimento de complicações. Para isso, foi desenvolvida uma pesquisa multimétodo em quatro etapas consecutivas e encadeadas: 1 - Prospecção, revisão e análise dos aplicativos voltados ao paciente cirúrgico; 2 - Revisão integrativa sobre as complicações pós-alta; 3 - Desenvolvimento de diretrizes de monitoramento; e 4 - Avaliação da viabilidade da diretriz proposta por meio do seguimento de egressos de artroplastia de joelho e quadril. Na primeira etapa, nas bases de dados, 14 estudos que apresentavam algum aplicativo (apps) para smartphone voltados ao paciente cirúrgico foram selecionados, sendo predominante estudos procedentes dos Estados Unidos da América (28.6%). Das bases de patentes, 10 registros foram recuperados, sendo 60% dos apps na base de patente americana (USPTO), hospedados em sistemas híbridos (iPhone e Android) e desenvolvidos de 2014 a 2018 (80%). Havia uma série de apps voltados aos pacientes cirúrgicos, como alvos e/ou usuários, no entanto, pautados, sobretudo, na troca de mensagens de texto e imagens e concentrados no auxílio ao médico/equipe de saúde na preparação do paciente, durante o procedimento ou no período pós-cirúrgico hospitalar, não havendo aplicativos para assistência pós-alta em domicílio. Na segunda etapa, 10 estudos primários incluídos mostraram que as complicações infecciosas foram as mais comuns, com destaque para pneumonia e infecção urinária e do sítio cirúrgico. Nos estudos, a presença de complicações esteve ligada à necessidade de reoperações ou pior sobrevida e aumento da mortalidade. A frequência de monitoramento e o tempo de seguimento foram incomuns nos estudos. Com base nisto, na etapa 3, criou-se uma diretriz em que foram elencadas 16 complicações elegíveis para serem utilizadas no monitoramento de pacientes cirúrgicos no período pós-alta hospitalar. De acordo com o consenso dos especialistas, é necessário o monitoramento do paciente, ao menos, uma vez por dia (68,8%). Por outro lado, o tempo máximo de monitoramento apresentou maior variação, de 48 horas até 30 dias, no caso da presença de sinais e sintomas de infecção. Ao testar a aplicabilidade do instrumento com 99 pacientes, 32,3% desenvolveram, ao menos, uma complicação, sendo que 10,1% desenvolveram mais de uma complicação num seguimento de 30 dias. Dor (31; 31,3%) e Infecção (12; 12,1%) foram as complicações mais prevalentes. Identificou-se associação estatística entre os desfechos clínicos dos pacientes submetidos à cirurgia de joelho e quadril e a presença de complicações no período pós-operatório (p<0,001). Desta forma, acredita-se que a monitorização do egresso cirúrgico no domicilio é imprescindível para a vigilância epidemiológica da ocorrência de complicações e direcionamento da politicas públicas de prevenção e controle

Monitoring the complications of surgical patients in the post-discharge period is a challenge, mainly due to the difficulty of follow-up at home. This study made it possible to build and validate guidelines for monitoring surgical patients in the post-discharge period during the period of complications. For this, a multi-method research was developed in four consecutive and linked stages: 1 - Prospecting, reviewing and analyzing applications aimed at surgical patients; 2 - Integrative review on the main post-discharge complications; 3 - Development of monitoring guidelines; and 4 - Evaluation of the feasibility of the proposed guideline through home follow-up of patients undergoing knee and hip arthroplasty surgery. In the first stage, in the databases, 14 studies that presented an application (apps) for smartphones aimed at the surgical patient were selected, with predominant studies coming from the United States of America (28.6%). From the patent bases, 10 records were recovered, 60% of the apps on the United States patent base (USPTO), hosted on hybrid systems (iPhone and Android) and developed from 2014 to 2018 (80%). There were a number of apps aimed at surgical patients, as targets and / or users, however, based mainly on the exchange of text messages and images and focused on assisting the doctor / health team in preparing the patient during the procedure, or in the hospital post-surgical period, with no applications for post-discharge assistance at home. In the second stage, 10 primary studies included showed that infectious complications were the most common, with emphasis on pneumonia and urinary and surgical site infection. In the studies, the presence of complications was linked to the need for reoperations or worse survival and increased mortality. Monitoring frequency and follow-up time were uncommon in the studies. Based on this, in step 3, a guideline was created in which 16 eligible complications were listed for use in monitoring surgical patients in the post-hospital discharge period. According to the experts' consensus, it is necessary to monitor the patient at least once a day (68.8%). On the other hand, the maximum monitoring time showed a greater variation, from 48 hours to 30 days, in the case of the presence of signs and symptoms of infection. When testing the applicability of the instrument with 99 patients, 32.3% developed at least one complication, with 10.1% developing more than one complication in a 30-day follow-up. Pain (31; 31.3%) and Infection (12; 12.1%) were the most prevalent complications. A statistical association was identified between the clinical outcome of patients undergoing knee and hip surgery and the presence of complications in the postoperative period (p <0.001). Thus, it is believed that the monitoring of surgical egress at home is essential for the epidemiological surveillance of the occurrence of complications and the direction of public policies for prevention and control

Etiology and treatment of intra thoracic gastric perforation after esophageal reconstruction with stomach / 中华胸心血管外科杂志

Objective To investigate the etiological factors and treatment of thoraco-gastric perforation (TGP) after esophagogastrostomy. Methods Retrospective analysis was carried out in 16 patients with thoraco-gastric perforation after esophagogastrostomy in our department from March 1974 to March 2004. The etiological factor, clinical feature, experiment test and the method of treatment were compared between TGP and patients of thoracic esophageal anastomosis leak (TEAL). Results Thoraco-gastric perforation occurs within 2～5 days postoperatively. Among these 16 cases, in 8, local necrosis of gastric wall was found which was caused by severe contusion and massive ligature. In 5, were penetrative injury of gastric wall caused by suture needle. In 3,unsuitable purse-string suturing of corner of greater or lisser gastric curvature. Hydropneumothorax occurred after thoraco-gastric perforation. Chest fluid was brown and turbid with putrefactive odor. With medium examination, anastomosis was normal, but medium and air bubbles were found outside of the stomach. Perforation were repaired and covered by pedicle tissue-flap in all cases. 15 cases were cured with no sequence. Conclusion TGP after esophagectomy were correlated with technique of surgery. TGP often occurs early after esophagogastrostomy. Transthoracic repairing of TGP should be done as soon as possible. The healing ratio of reparation was about 93.8%.