Transferência do cuidado de pacientes com baixo risco de mortalidade no pós-operatório: relato de experiência / Transferencia del cuidado de pacientes con bajo riesgo de mortalidad en el postoperatorio: relato de experiencia / Transfer of the care of patients with low risk of mortality in postoperative: experience report

Resumo OBJETIVO Descrever a implantação de um fluxograma de transferência do cuidado de pacientes em pós-operatório, a partir de um modelo de classificação de risco. MÉTODO Relato de experiência sobre a implantação de projeto piloto entre sala de recuperação pós-anestésica e unidade de internação cirúrgica, desenvolvido entre dezembro/2016 e março/2017, visando a transferências do cuidado de pacientes com baixo risco de mortalidade pós-operatória, em um hospital universitário do Sul do Brasil. RESULTADOS O projeto possibilitou agilizar a alta do paciente da Sala de Recuperação Pós-Anestésica para a unidade de internação cirúrgica, qualificar os registros quanto aos cuidados de enfermagem e otimizar o tempo dos enfermeiros, em ambas unidades, para as atividades assistenciais. CONCLUSÃO A implementação de um fluxograma de transferência do cuidado a partir da classificação de risco para pacientes em pós-operatório contribuiu para uma comunicação mais efetiva, culminando em melhorias na segurança do paciente.

Resumen OBJETIVO Describir la implantación de un diagrama de flujo de transferencia del cuidado de pacientes en postoperatorio a partir de un modelo de clasificación de riesgo. MÉTODO Relato de experiencia sobre la implantación de un proyecto piloto entre sala de recuperación postanestésica y unidad de internación quirúrgica, desarrollado entre diciembre/2016 y marzo/2017, con vistas a transferencias del cuidado de pacientes con bajo riesgo de mortalidad postoperatoria, en un hospital universitario del sur de Brasil. RESULTADOS El proyecto posibilitó mayor agilidad del alta del paciente para la unidad de internación quirúrgica, calificación de los registros y cuidados de enfermería referentes al cuadro clínico del paciente, y optimización del tiempo de los enfermeros, en ambas unidades, para las actividades asistenciales. CONCLUSIÓN La implementación de un diagrama de flujo de transferencia del cuidado a partir de la clasificación de riesgo para pacientes en postoperatorio contribuyó a una comunicación más efectiva, culminando en mejoras en la seguridad del paciente.

Abstract OBJECTIVE Describe the implementation of care transfer flow chart in postoperative, based on a risk classification model. METHOD Experience report on the implementation of a pilot project between the post-anesthetic recovery room and the surgical hospitalization unit, developed between December/2016 and March/2017, aimed at transferring s the care of patients with low risk of postoperative mortality, in a university hospital in the South of Brazil. RESULTS The project made it possible to expedite the discharge of the patient from the Post-Anesthetic Recovery Room to the surgical hospitalization unit, to qualify the records regarding nursing care and to optimize the time of nurses in both units for care activities. CONCLUSION The implementation of a care transfer flow chart from the risk classification for postoperative patients contributed to a more effective communication, culminating in improvements in patient safety.

Dexmedetomidine as an anesthetic adjuvant in cardiac surgery: a cohort study

ABSTRACT Objective: α-2-agonists cause sympathetic inhibition combined with parasympathetic activation and have other properties that could be beneficial during cardiac anesthesia. We evaluated the effects of dexmedetomidine as an anesthetic adjuvant compared to a control group during cardiac surgery. Methods: We performed a retrospective analysis of prospectively collected data from all adult patients (> 18 years old) undergoing cardiac surgery. Patients were divided into two groups, regarding the use of dexmedetomidine as an adjuvant intraoperatively (DEX group) and a control group who did not receive α-2-agonist (CON group). Results: A total of 1302 patients who underwent cardiac surgery, either coronary artery bypass graft or valve surgery, were included; 796 in the DEX group and 506 in the CON group. Need for reoperation (2% vs. 2.8%, P=0.001), type 1 neurological injury (2% vs. 4.7%, P=0.005) and prolonged hospitalization (3.1% vs. 7.3%, P=0.001) were significantly less frequent in the DEX group than in the CON group. Thirty-day mortality rates were 3.4% in the DEX group and 9.7% in the CON group (P<0.001). Using multivariable Cox regression analysis with in hospital death as the dependent variable, dexmedetomidine was independently associated with a lower risk of 30-day mortality (odds ratio [OR]=0.39, 95% confidence interval [CI]: 0.24-0.65, P≤0.001). The Logistic EuroSCORE (OR=1.05, 95% CI: 1.02-1.10, P=0.004) and age (OR=1.03, 95% CI: 1.01-1.06, P=0.003) were independently associated with a higher risk of 30-day mortality. Conclusion: Dexmedetomidine used as an anesthetic adjuvant was associated with better outcomes in patients undergoing coronary artery bypass graft and valve surgery. Randomized prospective controlled trials are warranted to confirm our results.

Clopidogrel use after myocardial revascularization: prevalence, predictors, and one-year survival rate

Abstract Introduction: Antiplatelet therapy after coronary artery bypass graft (CABG) has been used. Little is known about the predictors and efficacy of clopidogrel in this scenario. Objective: Identify predictors of clopidogrel following CABG. Methods: We evaluated 5404 patients who underwent CABG between 2000 and 2009 at Duke University Medical Center. We excluded patients undergoing concomitant valve surgery, those who had postoperative bleeding or death before discharge. Postoperative clopidogrel was left to the discretion of the attending physician. Adjusted risk for 1-year mortality was compared between patients receiving and not receiving clopidogrel during hospitalization after undergoing CABG. Results: At hospital discharge, 931 (17.2%) patients were receiving clopidogrel. Comparing patients not receiving clopidogrel at discharge, users had more comorbidities, including hyperlipidemia, hypertension, heart failure, peripheral arterial disease and cerebrovascular disease. Patients who received aspirin during hospitalization were less likely to receive clopidogrel at discharge (P≤0.0001). Clopidogrel was associated with similar 1-year mortality compared with those who did not use clopidogrel (4.4% vs. 4.5%, P=0.72). There was, however, an interaction between the use of cardiopulmonary bypass and clopidogrel, with lower 1-year mortality in patients undergoing off-pump CABG who received clopidogrel, but not those undergoing conventional CABG (2.6% vs 5.6%, P Interaction = 0.032). Conclusion: Clopidogrel was used in nearly one-fifth of patients after CABG. Its use was not associated with lower mortality after 1 year in general, but lower mortality rate in those undergoing off-pump CABG. Randomized clinical trials are needed to determine the benefit of routine use of clopidogrel in CABG.

Tratamento cirúrgico do câncer de esôfago / Surgical treatment for esophageal cancer

Este estudo tem como objetivo analisar os resultados do tratamento cirúrgico do câncer de esôfago na Seção deCirurgia Abdominopélvica do Instituto Nacional de Câncer (INCA). Foram analisados, retrospectivamente, osprontuários de 93 pacientes portadores de câncer de esôfago, submetidos à esofagectomia no INCA entre janeirode 1997 e dezembro de 2005 (período no qual organizou-se o Grupo de Esôfago). Os principais parâmetrosavaliados no estudo foram: tempo de internação hospitalar, percentual de morbidade operatória e percentual de mortalidade operatória. Em relação aos resultados, a mediana de idade foi de 57 anos (25 anos a 85 anos), sendo71 pacientes do sexo masculino e 22 pacientes do sexo feminino. A mediana do tempo de internação foi de 20 dias. O percentual de complicação operatória foi de 61 por cento e a mortalidade operatória foi de 7 por cento. Após a avaliaçãodos resultados e revisão da literatura, pode-se concluir que a esofagectomia por câncer de esôfago, apesar deapresentar elevada morbidade operatória, permanece como o tratamento-padrão para pacientes com doença ressecávele sem contra-indicação clínica; e que a redução da mortalidade operatória com a esofagectomia, atualmenteobservada, decorre de uma melhor seleção de pacientes para os quais é indicada a cirurgia, além de maior nível de especialização da equipe cirúrgica e atenção voltada para os cuidados per e pós-operatórios.

This study analyzes the results of surgical treatment for esophageal cancer at the Department of Abdominal and Pelvic Surgery, Brazilian National Cancer Institute (INCA). Medical files were analyzed retrospectively for a total of 93 patients with esophageal cancer who underwent esophagectomy from January 1997 to December 2005 (theperiod in which the Esophageal Study Group was formed). The main target parameters in the study were length of hospitalization and percentages of operative morbidity and mortality. Mean age was 57 years (25-85), with 71 males and 22 females. Mean hospitalization time was 20 days. The surgical complications rate was 61%, and surgical mortality was 7%. We conclude that esophagectomy for esophageal cancer presents high surgical morbidity, but remains the standard treatment for patients with resectable disease and without clinical contraindications. The currently observed reduction in surgical mortality related to esophagectomy has resulted from better patient selection,in addition to greater specialization by the surgical team and improved peri- and post-operative care.

Hepatectomía extendida: una alternativa segura en lesiones hepatobiliares malignas / Extended hepatectomy: a safe procedure for hepatobiliary malignancy

Introducción: La hepatectomía extendida, definida como la resección de 5 o más segmentos hepáticos, se ha asociado a un elevado riesgo perioperatorio. El objetivo del presente estudio es comparar los resultados quirúrgicos de pacientes sometidos a resecciones hepáticas de más de 2 segmentos versus hepatectomía extendida. Material y Método: Se analizó nuestra serie prospectiva de pacientes entre agosto 2002 y junio 2005. Se excluyeron resecciones laparoscópicas, unisegmentarias y no anatómicas. Se configuraron 2 grupos: Grupo I: Hepatectomías extendidas, Grupo II: Resecciones hepáticas de 2 a 4 segmentos. Se analizaron variables demográficas, indicaciones, uso de hemoderivados, función hepática postoperatoria, morbilidad y mortalidad. Resultados: En este período se realizaron 59 hepatectomías. Veintinueve cumplieron los criterios de inclusión. Grupo I: (n=14,) Grupo II: (n=15). Todos los pacientes del primer grupo fueron resecados por lesiones malignas (9 metástasis, 5 tumores primarios). El promedio de segmentos resecados fue 5.5 para el grupo I y 2.3 para el Grupo II. Los tiempos operatorios promedio fueron 283 y 199 minutos, respectivamente (p=0.025). Se transfundieron un promedio de 2.69 y 0.85 U GR en cada grupo (p=0.009). La estadía hospitalaria promedio fue 13.6 días para el primer grupo, y 7.35 para el segundo (p=0.004). En el Grupo I, 4 de 14 pacientes presentaron complicaciones quirúrgicas y 1 de 15 en el grupo II (p=0.1). Fallece un paciente de cada grupo, debido a insuficiencia hepática postoperatoria. Conclusiones: A pesar del gran volumen de parénquima resecado, la hepatectomía extendida es una alternativa segura para el tratamiento de lesiones hepáticas malignas.

Introduction: Extended hepatectomy has been associated with a high perioperative risk. The aim of this study is to compare the surgical results in patients who underwent a hepatic resection of more than two Couinaud's segments versus an extended hepatectomy (more than four segments). Methods: Our prospective database from August 2002 to June 2005 was reviewed. Non-anatomical, unisegmental and laparoscopic resections were excluded. There were two groups. Group I: Extended hepatectomies; Group II: Hepatic resections from 2 to 4 segments. Demographic characteristics, indications for surgery, technical aspects, use of hemocomponents, post-operative liver function, morbidity and mortality were reviewed. Results: In this period, 59 hepatectomies were performed. 29 procedures achieved the inclusion criteria. Group I: (n=14), Group II: (n=15). Hepatobiliary malignancy was the surgical indication in all cases in Group I (9 liver metastases, 5 primary liver tumors). Mean number of resected segments were 5.5 for Group 1, and 2.3 for Group II. Mean operative time was 283 and 199 minutes, respectively (p=0.025). Mean red blood cell units transfused were 2.69 and 0.85 in each group (p=0.009). Mean postop hospital stay was 13.6 days por the first group and 7.3 for the second group (p=0.004). In Group I, 4 of 14 patients developed a postoperative complication and 1 of 15 in Group II (p=0.1). Postoperative liver failure was present in two patients from Group I, one of them died. In Group II, 1 patient died secondary to liver failure. Conclussions: Extended hepatectomy is a safe procedure for hepatobiliary malignancy even when a large amount of liver parenchyma is resected.

Resultados de la colecistectomía videolaparoscópica en el adulto mayor / Analysis of laparoscopic cholecystectomy in the elderly

Se presenta la experiencia en el tratamiento quirúrgico de la patología vesicular litiásica, mediante videolaparoscopia, en una serie prospectiva de 119 pacientes de 60 o más años de edad, de ambos sexos, operados entre Marzo de 2003 y Marzo de 2004, en el Departamento y Servicio de Cirugía del Hospital Barros Luco Trudeau analizando la patología médica asociada, presente en el 70 por ciento, los hallazgos relevantes del estudio ecotomográfico preoperatorio (99,1 por ciento), las cifras de conversión a cirugía laparotómica (19 por ciento), la morbilidad (8,4 por ciento) y la mortalidad (0 por ciento).

We report our surgical experience in videolaparoscopic cholecystectomy in 119 patients with 60 or more years old, operated between March 2003 and March 2004, at the Barros Luco's Surgical Department and Service. We analized the medical pathology (70 percent of patients); the relevant finding at the preoperative ultrasonic study (99,2 percent of patients); the conversion rate (19 percent) and postoperatory results.