Development and validation of the Ex-Care BR model: a multicentre initiative for identifying Brazilian surgical patients at risk of 30-day in-hospital mortality.

BACKGROUND: Surgical risk stratification is crucial for enhancing perioperative assistance and allocating resources efficiently. However, existing models may not capture the complexity of surgical care in Brazil. Using data from various healthcare settings nationwide, we developed a new risk model for 30-day in-hospital mortality (the Ex-Care BR model). METHODS: A retrospective cohort study was conducted in 10 hospitals from different geographic regions in Brazil. Data were analysed using multilevel logistic regression models. Model performance was assessed using the area under the receiver operating characteristic curve (AUROC), Brier score, and calibration plots. Derivation and validation cohorts were randomly assigned. RESULTS: A total of 107,372 patients were included, and 30-day in-hospital mortality was 2.1% (n=2261). The final risk model comprised four predictors related to the patient and surgery (age, ASA physical status classification, surgical urgency, and surgical size), and the random effect related to hospitals. The model showed excellent discrimination (AUROC=0.93, 95% confidence interval [CI], 0.93-0.94), calibration, and overall performance (Brier score=0.017) in the derivation cohort (n=75,094). Similar results were observed in the validation cohort (n=32,278) (AUROC=0.93, 95% CI, 0.92-0.93). CONCLUSIONS: The Ex-Care BR is the first model to consider regional and organisational peculiarities of the Brazilian surgical scene, in addition to patient and surgical factors. It is particularly useful for identifying high-risk surgical patients in situations demanding efficient allocation of limited resources. However, a thorough exploration of mortality variations among hospitals is essential for a comprehensive understanding of risk. CLINICAL TRIAL REGISTRATION: NCT05796024.

Three-Dimensional Printed Laryngoscopes as Allies Against COVID-19.

The COVID-19 pandemic has caused an overload on the health care system on a global scale. Because the disease affects the respiratory system, patients may require ventilator equipment for breathing, and consequently, numerous tracheal intubations have been performed. The video laryngoscope is a medical device that aids this procedure. It is used by anesthesiologists to visualize the anatomical structures of the larynx during tube insertion. Unfortunately, many hospitals worldwide are unable to afford sufficient units of this medical device. To satisfy the high demand, low-cost alternatives employing three-dimensional (3D) printing techniques have been developed for health care professional's use. With the intention of ensuring the efficiency, reproducibility, and security of the 3D-printed laryngoscope, this article presents a novel model with versions for pediatric and adult use, which was developed under the supervision of a medical team. The mechanical performance of 3D-printed prototypes (of the proposed models) was evaluated using mechanical assays, and the results indicated a satisfactory safety factor.

IMPLEMENTATION OF ENHANCED RECOVERY AFTER COLORECTAL SURGERY (ERAS) PROTOCOL: INITIAL RESULTS OF THE FIRST BRAZILIAN EXPERIENCE.

BACKGROUND: Guidelines for enhanced recovery after surgery have their bases in colonic surgery, through the first protocols published in 2012. Since then, this practice has spread throughout the world, mainly due to improvements in surgical outcomes associated with resource savings. AIM: To analyze the first prospective results after the implementation of the guidelines. METHODS: Were retrospectively analyzed 48 patients operated in the institution prior to the standardization. This group was then compared with a series of 25 patients operated consecutively after the guidelines were implemented. RESULTS: With a 68.6% compliance rate, hospital length of stay (p=0.002), use of abdominal drains (p<0.001) and mechanical bowel preparation (p<0.001) were reduced. Mortality rates, anastomotic fistula, abdominal abscesses and reoperations were also reduced, but without statistical significance. CONCLUSION: Enhanced recovery after surgery protocols benefit patients care, resulting in better outcomes and possibly resource savings. Even with some limitations, its implementation is feasible in the Brazilian Public Health System.

ENHANCED RECOVERY (ERAS) AFTER LIVER SURGERY:COMPARATIVE STUDY IN A BRAZILIAN TERCIARY CENTER.

BACKGROUND: After the publication of the first recommendations of ERAS Society regarding colonic surgery, the proposal of surgical stress reduction, maintenance of physiological functions and optimized recovery was expanded to other surgical specialties, with minimal variations. AIM: To analyze the implementation of ERAS protocols for liver surgery in a tertiary center. METHODS: Fifty patients that underwent elective hepatic surgery were retrospectively evaluated, using medical records data, from June 2014 to August 2016. After September 2016, 35 patients were prospectively evaluated and managed in accordance with ERAS protocol. RESULTS: There was no difference in age, type of hepatectomy, laparoscopic surgery and postoperative complications between the groups. In ERAS group, it was observed a reduction in preoperative fasting and in the length of hospital stay by two days (p< 0.001). Carbohydrate loading, j-shaped incision, early oral feeding, postoperative prevention of nausea and vomiting and early mobilization were also significantly related to ERAS group. Oral bowel preparation, pre-anesthetic medication, sub-costal incision, prophylactic nasogastric intubation and abdominal drainage were more common in control group. CONCLUSION: Implementation of ERAS protocol is feasible and beneficial for health institutions and patients, without increasing morbidity and mortality.

Enhanced recovery (eras) after liver surgery: comparative study in a brazilian terciary center / Recuperação otimizada (eras) após cirurgia hepática: estudo comparativo de um centro terciário brasileiro

ABSTRACT Background: After the publication of the first recommendations of ERAS Society regarding colonic surgery, the proposal of surgical stress reduction, maintenance of physiological functions and optimized recovery was expanded to other surgical specialties, with minimal variations. Aim: To analyze the implementation of ERAS protocols for liver surgery in a tertiary center. Methods: Fifty patients that underwent elective hepatic surgery were retrospectively evaluated, using medical records data, from June 2014 to August 2016. After September 2016, 35 patients were prospectively evaluated and managed in accordance with ERAS protocol. Results: There was no difference in age, type of hepatectomy, laparoscopic surgery and postoperative complications between the groups. In ERAS group, it was observed a reduction in preoperative fasting and in the length of hospital stay by two days (p< 0.001). Carbohydrate loading, j-shaped incision, early oral feeding, postoperative prevention of nausea and vomiting and early mobilization were also significantly related to ERAS group. Oral bowel preparation, pre-anesthetic medication, sub-costal incision, prophylactic nasogastric intubation and abdominal drainage were more common in control group. Conclusion: Implementation of ERAS protocol is feasible and beneficial for health institutions and patients, without increasing morbidity and mortality.

RESUMO Racional: Após a publicação das primeiras recomendações da Sociedade ERAS sobre a cirurgia do cólon, a proposta de redução do estresse cirúrgico, manutenção das funções fisiológicas e recuperação otimizada foi ampliada para outras especialidades cirúrgicas, com pequenas variações. Objetivo: Analisar a implementação dos protocolos ERAS para cirurgia hepática em um centro terciário. Métodos: Cinquenta pacientes submetidos à cirurgia hepática eletiva foram avaliados retrospectivamente, utilizando dados de prontuários, de junho de 2014 a agosto de 2016. Após setembro de 2016, 35 pacientes foram prospectivamente avaliados e manejados de acordo com o protocolo ERAS. Resultados: Não houve diferença de idade, tipos de hepatectomia, cirurgia laparoscópica e complicações pós-operatórias entre os grupos. No grupo ERAS, observou-se redução no jejum pré-operatório e no tempo de internação hospitalar de dois dias (p<0,001). A carga de carboidratos, a incisão em forma de J, a alimentação oral precoce, a prevenção pós-operatória de náuseas e vômitos e a mobilização precoce também foram significativamente relacionadas ao grupo ERAS. Preparo mecânico do cólon, medicação pré-anestésica, incisão subcostal, intubação nasogástrica profilática e drenagem abdominal foram mais comuns no grupo controle. Conclusão: A implementação do protocolo ERAS é viável e benéfica para instituições de saúde e pacientes, sem aumentar a morbidade e a mortalidade.

Implementation of enhanced recovery after colorectal surgery (eras) protocol: initial results of the first brazilian experience / Implementação do protocolo de recuperação otimizada após cirurgia colorretal (eras): resultados iniciais da primeira experiência brasileira

ABSTRACT Background: Guidelines for enhanced recovery after surgery have their bases in colonic surgery, through the first protocols published in 2012. Since then, this practice has spread throughout the world, mainly due to improvements in surgical outcomes associated with resource savings. Aim: To analyze the first prospective results after the implementation of the guidelines. Methods: Were retrospectively analyzed 48 patients operated in the institution prior to the standardization. This group was then compared with a series of 25 patients operated consecutively after the guidelines were implemented. Results: With a 68.6% compliance rate, hospital length of stay (p=0.002), use of abdominal drains (p<0.001) and mechanical bowel preparation (p<0.001) were reduced. Mortality rates, anastomotic fistula, abdominal abscesses and reoperations were also reduced, but without statistical significance. Conclusion: Enhanced recovery after surgery protocols benefit patients care, resulting in better outcomes and possibly resource savings. Even with some limitations, its implementation is feasible in the Brazilian Public Health System.

RESUMO Racional: Os protocolos de recuperação otimizada após as operações têm as suas bases na cirurgia colônica, através das primeiras diretrizes publicadas em 2012. Desde então, tal prática difundiu-se pelo mundo, principalmente em virtude de melhorias nos resultados cirúrgicos associadas à economia de recursos. Objetivo: Apresentar os primeiros resultados prospectivos após a implementação das novas medidas. Métodos: Foram analisados de forma retrospectiva 48 pacientes operados na instituição previamente à aplicação do protocolo. Esse grupo foi então comparado com uma série de 25 pacientes operados de forma consecutiva após a implementação das diretrizes. Resultados: Com taxa de adesão de 68.6% às medidas propostas, observou-se redução do tempo de internação hospitalar (p=0.002), do uso de drenos abdominais (p<0.001) e do preparo mecânico do cólon (p<0.001). As taxas de mortalidade, de fístula da anastomose, de abscessos abdominais e de reoperações também foram reduzidas, porém sem significância estatística. Conclusão: A adesão às medidas recomendadas no protocolo é benéfica para pacientes e equipe de assistência, acarretando em melhores resultados e possível economia de recursos. Mesmo com algumas limitações, a sua implementação é factível no Sistema Único de Saúde Brasileiro.

Evaluation and perioperative management of patients with diabetes mellitus. A challenge for the anesthesiologist / Avaliação e manejo perioperatório de pacientes com diabetes melito. Um desafio para o anestesiologista

Abstract Diabetes mellitus (DM) is characterized by alteration in carbohydrate metabolism, leading to hyperglycemia and increased perioperative morbidity and mortality. It evolves with diverse and progressive physiological changes, and the anesthetic management requires attention regarding this disease interference in multiple organ systems and their respective complications. Patient's history, physical examination, and complementary exams are important in the preoperative management, particularly glycosylated hemoglobin (HbA1c), which has a strong predictive value for complications associated with diabetes. The goal of surgical planning is to reduce the fasting time and maintain the patient's routine. Patients with Type 1 DM must receive insulin (even during the preoperative fast) to meet the basal physiological demands and avoid ketoacidosis. Whereas patients with Type 2 DM treated with multiple injectable and/or oral drugs are susceptible to develop a hyperglycemic hyperosmolar state (HHS). Therefore, the management of hypoglycemic agents and different types of insulin is fundamental, as well as determining the surgical schedule and, consequently, the number of lost meals for dose adjustment and drug suspension. Current evidence suggests the safe target to maintain glycemic control in surgical patients, but does not conclude whether it should be obtained with either moderate or severe glycemic control.

Resumo O diabetes melito (DM) é caracterizado por alteração no metabolismo de carboidratos que leva à hiperglicemia e ao aumento da morbimortalidade perioperatória. Cursa com alterações fisiológicas diversas e progressivas e, para o manejo anestésico, deve-se atentar para a interferência dessa doença nos múltiplos sistemas orgânicos e suas respectivas complicações. Anamnese, exame físico e exames complementares são importantes no manejo pré-operatório, com destaque para a hemoglobina glicosilada (HbA1c), que tem forte valor preditivo para complicações associadas ao diabetes. O planejamento cirúrgico tem como objetivos a redução do tempo de jejum e a manutenção da rotina do paciente. Pacientes portadores de DM Tipo 1 precisam receber, mesmo em jejum perioperatório, insulina para suprir as demandas fisiológicas basais e evitar cetoacidose. Já os pacientes portadores de DM Tipo 2, tratados com múltiplos fármacos injetáveis e/ou orais, são suscetíveis ao desenvolvimento de um estado hiperosmolar hiperglicêmico (EHH). Assim, o manejo dos hipoglicemiantes e dos diferentes tipos de insulina é fundamental, além da determinação do horário cirúrgico e, consequentemente, do número de refeições perdidas para adequação de doses ou suspensão dos medicamentos. As evidências atuais sugerem o alvo de manutenção da glicemia seguro para os pacientes cirúrgicos, sem concluir se deve ser obtido com controle glicêmico intensivo ou moderado.

[Evaluation and perioperative management of patients with diabetes mellitus. A challenge for the anesthesiologist]. / Avaliação e manejo perioperatório de pacientes com diabetes melito. Um desafio para o anestesiologista.

Diabetes mellitus (DM) is characterized by alteration in carbohydrate metabolism, leading to hyperglycemia and increased perioperative morbidity and mortality. It evolves with diverse and progressive physiological changes, and the anesthetic management requires attention regarding this disease interference in multiple organ systems and their respective complications. Patient's history, physical examination, and complementary exams are important in the preoperative management, particularly glycosylated hemoglobin (HbA1c), which has a strong predictive value for complications associated with diabetes. The goal of surgical planning is to reduce the fasting time and maintain the patient's routine. Patients with Type 1 DM must receive insulin (even during the preoperative fast) to meet the basal physiological demands and avoid ketoacidosis. Whereas patients with Type 2 DM treated with multiple injectable and/or oral drugs are susceptible to develop a hyperglycemic hyperosmolar state (HHS). Therefore, the management of hypoglycemic agents and different types of insulin is fundamental, as well as determining the surgical schedule and, consequently, the number of lost meals for dose adjustment and drug suspension. Current evidence suggests the safe target to maintain glycemic control in surgical patients, but does not conclude whether it should be obtained with either moderate or severe glycemic control.

Changes in Purines Concentration in the Cerebrospinal Fluid of Pregnant Women Experiencing Pain During Active Labor.

Labor pain has been reported as a severe pain and can be considered as a model of acute visceral pain. It is well known that extracellular purines have an important role in pain signaling in the central nervous system. This study analyzes the relationship between extracellular purines and pain perception during active labor. A prospective observational study was performed. Cerebrospinal fluid (CSF) levels of the purines and their metabolites were compared between women at term pregnancy with labor pain (n = 49) and without labor pain (Caesarian section; n = 47). Control groups (healthy men and women without chronic or acute pain-n = 40 and 32, respectively) were also investigated. The CSF levels of adenosine were significantly lower in the labor pain group (P = 0.026) and negatively correlated with pain intensity measured by a visual analogue scale (r = -0.48, P = 0.0005). Interestingly, CSF levels of uric acid were significantly higher in healthy men as compared to women. Additionally, pregnant women showed increased CSF levels of ADP, GDP, adenosine and guanosine and reduced CSF levels of AMP, GTP, and uric acid as compared to non-pregnant women (P < 0.05). These findings suggest that purines, in special the nucleoside adenosine, are associated with pregnancy and labor pain.

Preoperative evaluation: screening using a questionnaire.

BACKGROUND AND OBJECTIVE: Prior to elective surgery it is essential to know in advance the patient's clinical condition. The aim of this study was to compare the preoperative evaluation (POE) through questionnaire responses with preanesthetic evaluation by the anesthesiologist. METHOD: Prior to their preoperative evaluation, patients answered a questionnaire with information regarding age, weight, height, scheduled surgery, past medical and surgical history, allergies, medications and doses used, social history (illicit drugs, alcohol, smoking), functional capacity and exercise tolerance. Preoperative evaluation was performed by an anesthesiologist who had no access to the questionnaire data or knowledge about the research. The questionnaire data were compared with the preoperative evaluation by two independent investigators, in order to answer the questions: 1) Was the questionnaire evaluation effective - could the patient undergo surgery without the need for face-to-face consultation? 2) Has been there any relevant information - ability to change the anesthetic approach - not assessed by the questionnaire, but assessed by the face-to-face consultation? 3) Has been there any information added by the health questionnaire that was missed by face-to-face consultation? For statistical analysis, the paired Student's t-test was used for parametric data and chi-square test for categorical data, with p < 0.05 considered significant. RESULTS: Of the 269 eligible patients there was one refusal, and four agreed to participate but did not complete the questionnaire, in addition to 52 losses, totaling 212 participants. Questionnaire data added to the consultation in 109 cases (51.4%). The screening questionnaire alone was effective for 144 patients (67.93%), with no need for consultation. The anesthesiologist evaluation referred patients for surgery on their fi rst visit in 178 opportunities (84%). In the identification of cases of non-referral to surgery, the questionnaire showed a negative predictive value of 94.4%, positive predictive value of 38.2%, sensitivity of 76.5%, and specificity of 76.4%. Statistically significant (P < 0.05) clinical factors associated with non-referral to surgery were: age over 65 years, BMI > 30, low functional capacity, hypertension, diabetes mellitus, asthma, renal failure, hepatitis, and ischemic heart disease. CONCLUSION: The questionnaire was effective for screening patients who needed further evaluation and/or changes in treatment regimen prior to elective surgery. Moreover, the questionnaire added data not covered by clinical evaluation.

Avaliação pré-operatória: triagem por meio de questionário / Preoperative evaluation: screening using a questionnaire / Evaluación preoperatoria: selección por medio de cuestionario

JUSTIFICATIVA E OBJETIVOS: Antes de cirurgia eletiva é indispensável conhecer com antecedência as condições clínicas do paciente. O objetivo deste estudo foi comparar a avaliação pré-operatória (APO) por meio do preenchimento de um questionário com a consulta realizada pelo anestesiologista. MÉTODO: Antes da consulta pré-operatória, os pacientes responderam a um questionário com informações sobre idade, peso, altura, cirurgia planejada, história médica e cirúrgica pregressa, alergias, medicamentos e doses usadas, história social (drogas ilícitas, álcool, tabagismo), capacidade funcional e tolerância ao exercício. A consulta pré-operatória foi realizada por anestesiologista que não tinha acesso aos dados do questionário nem conhecimento da pesquisa. Os dados obtidos por meio do questionário foram comparados com a consulta pré-operatória por dois pesquisadores independentes, com a finalidade de responder às perguntas: 1) A avaliação pelo questionário foi suficiente - o paciente poderia ser conduzido à cirurgia sem necessidade da avaliação presencial? 2) Houve alguma informação relevante - capaz de mudar a conduta anestésica - que o questionário não aferiu, mas que a consulta presencial avaliou? 3) Houve alguma informação acrescentada pelo questionário de saúde que a consulta presencial não obteve? Para análise estatística usou-se o teste t de Student pareado para dados paramétricos e o teste Qui-quadrado para dados categóricos com P < 0,05. RESULTADOS: Dentre os 269 pacientes elegíveis houve uma recusa, quatro aceitaram participar mas não preencheram o questionário e houve 52 perdas, totalizando 212 participantes. O questionário acrescentou dados à consulta em 109 casos (51,4%). A triagem apenas pelo questionário foi suficiente - não necessitou de consulta presencial - em 144 pacientes (67,93%). A avaliação realizada pelo anestesiologista liberou para a cirurgia na primeira consulta em 178 oportunidades (84%). Na identificação dos casos de não liberação para cirurgia, o questionário apresentou valor preditivo negativo de 94,4%, valor preditivo positivo de 38,2%, sensibilidade de 76,5% e especificidade de 76,4%. Houve fatores clínicos estatisticamente significativos (P < 0,05) associados com não liberação para a cirurgia: idade acima de 65 anos, IMC > 30, baixa capacidade funcional, hipertensão arterial, diabetes mellitus, asma, insuficiência renal, hepatite e cardiopatia isquêmica. CONCLUSÕES: O uso do questionário foi efetivo para triagem de pacientes que necessitam de avaliação complementar e/ou alteração de regime terapêutico previamente ao procedimento eletivo. Além disso, o questionário acrescentou dados não contemplados pela avaliação clínica.

BACKGROUND AND OBJECTIVE: Prior to elective surgery it is essential to know in advance the patient’s clinical condition. The aim of this study was to compare the preoperative evaluation (POE) through questionnaire responses with preanesthetic evaluation by the anesthesiologist. METHOD: Prior to their preoperative evaluation, patients answered a questionnaire with information regarding age, weight, height, scheduled surgery, past medical and surgical history, allergies, medications and doses used, social history (illicit drugs, alcohol, smoking), functional capacity and exercise tolerance. Preoperative evaluation was performed by an anesthesiologist who had no access to the questionnaire data or knowledge about the research. The questionnaire data were compared with the preoperative evaluation by two independent investigators, in order to answer the questions: 1) Was the questionnaire evaluation effective - could the patient undergo surgery without the need for face-to-face consultation? 2) Has been there any relevant information - ability to change the anesthetic approach - not assessed by the questionnaire, but assessed by the face-to-face consultation? 3) Has been there any information added by the health questionnaire that was missed by face-to-face consultation? For statistical analysis, the paired Student’s t-test was used for parametric data and chi-square test for categorical data, with p < 0.05 considered significant. RESULTS: Of the 269 eligible patients there was one refusal, and four agreed to participate but did not complete the questionnaire, in addition to 52 losses, totaling 212 participants. Questionnaire data added to the consultation in 109 cases (51.4%). The screening questionnaire alone was effective for 144 patients (67.93%), with no need for consultation. The anesthesiologist evaluation referred patients for surgery on their first visit in 178 opportunities (84%). In the identification of cases of non-referral to surgery, the questionnaire showed a negative predictive value of 94.4%, positive predictive value of 38.2%, sensitivity of 76.5%, and specificity of 76.4%. Statistically significant (P < 0.05) clinical factors associated with non-referral to surgery were: age over 65 years, BMI > 30, low functional capacity, hypertension, diabetes mellitus, asthma, renal failure, hepatitis, and ischemic heart disease. CONCLUSION: The questionnaire was effective for screening patients who needed further evaluation and/or changes in treatment regimen prior to elective surgery. Moreover, the questionnaire added data not covered by clinical evaluation.

JUSTIFICATIVA Y OBJETIVOS: Antes de iniciar la cirugía electiva se hace indispensable conocer con anterioridad las condiciones clínicas del paciente. El objetivo de este estudio, fue comparar la evaluación preoperatoria (EPO) por medio de la realización de un cuestionario con la consulta realizada por el anestesiólogo. MÉTODO: Antes de la consulta preoperatoria, los pacientes respondieron a un cuestionario con informaciones sobre edad, peso, altura, cirugía planificada, historial médico y quirúrgico anterior, alergias, medicamentos y dosis usadas, historial social (drogas ilícitas, alcohol, tabaquismo), capacidad funcional y tolerancia al ejercicio. La consulta preoperatoria fue realizada por un anestesiólogo que no tenía acceso a los datos del cuestionario ni sabía nada sobre la investigación. Los datos obtenidos por medio del cuestionario se compararon con la consulta preoperatoria por dos investigadores independientes, con la finalidad de responder a las preguntas: 1) ¿La evaluación por el cuestionario fue suficiente y el paciente podría haber sido derivado a la cirugía sin necesidad de la evaluación presencial? 2) ¿Hubo alguna información relevante capaz de cambiar la conducta anestésica que el cuestionario no comprobó, pero que fue tenido en cuenta por la consulta presencial? 3) ¿Hubo alguna información añadida por el cuestionario de salud que la consulta presencial no obtuvo? Para el análisis estadístico se usó el test t de Student pareado para los datos paramétricos, y el test X² para los datos categóricos con P < 0,05. RESULTADOS: De los 269 pacientes elegidos, se produjo una negativa, cuatro aceptaron participar pero no rellenaron el cuestionario, y hubo 52 pérdidas, totalizando 212 participantes. El cuestionario añadió datos a la consulta en 109 casos (51,4%). La selección hecha por el cuestionario fue suficiente y no necesitó consulta presencial en 144 pacientes (67,93%). La evaluación realizada por el anestesiólogo autorizó ya para operación en la primera consulta en 178 oportunidades (84%). En la identificación de los casos de no autorización para la cirugía, el cuestionario tuvo un valor predictivo negativo de un 94,4%, valor predictivo positivo de un 38,2%, sensibilidad del 76,5% y una especificidad de un 76,4%. Hubo factores clínicos estadísticamente significativos (P < 0,05), asociados con la no autorización para la cirugía: edad por encima de los 65 años, IMC > 30, baja capacidad funcional, hipertensión arterial, diabetes mellitus, asma, insuficiencia renal, hepatitis y cardiopatía isquémica. CONCLUSIONES: El uso del cuestionario fue efectivo para la selección de pacientes que necesitan una evaluación complementaria y/o alteración de régimen terapéutico anteriormente al procedimiento electivo. Además, el cuestionario añadió datos no contemplados por la evaluación tradicional.