Rationale and study design for an Individualized PeriopeRative Open lung VEntilatory approach in Emergency Abdominal Laparotomy/scopy: study protocol for a prospective international randomized controlled trial.

BACKGROUND: Postoperative pulmonary complications (PPC) are the most frequent postoperative complications, with an estimated prevalence in elective surgery ranging from 20% in observational cohort studies to 40% in randomized clinical trials. However, the prevalence of PPCs in patients undergoing emergency abdominal surgery is not well defined. Lung-protective ventilation aims to minimize ventilator-induced lung injury and reduce PPCs. The open lung approach (OLA), which combines recruitment manoeuvres (RM) and positive end-expiratory pressure (PEEP) titration, aims to minimize areas of atelectasis and the development of PPCs; however, there is no conclusive evidence in the literature that OLA can prevent PPCs. The purpose of this study is to compare an individualized perioperative OLA with conventional standardized lung-protective ventilation in patients undergoing emergency abdominal surgery with clinical signs of intraoperative lung collapse. METHODS: Randomized international clinical trial to compare an individualized perioperative OLA (RM plus individualized PEEP and individualized postoperative respiratory support) with conventional lung-protective ventilation (standard PEEP of 5 cmH2O and conventional postoperative oxygen therapy) in patients undergoing emergency abdominal surgery with clinical signs of lung collapse. Patients will be randomised to open-label parallel groups. The primary outcome is any severe PPC during the first 7 postoperative days, including: acute respiratory failure, pneumothorax, weaning failure, acute respiratory distress syndrome, and pulmonary infection. The estimated sample size is 732 patients (366 per group). The final sample size will be readjusted during the interim analysis. DISCUSSION: The Individualized Perioperative Open-lung Ventilatory Strategy in emergency abdominal laparotomy (iPROVE-EAL) is the first multicentre, randomized, controlled trial to investigate whether an individualized perioperative approach prevents PPCs in patients undergoing emergency surgery.

Hemorragia digestiva baja: factores de riesgo de gravedad, necesidad de cirugía de urgencia y mortalidad hospitalaria / Lower gastrointestinal bleeding: risk factors of severity, need for emergency surgery and in-hospital Mortality

RESUMEN Antecedentes: Últimamente creció el interés en poder determinar, en etapas tempranas de las hemorragias digestivas bajas (HDB), aquellos factores de riesgo relacionados con la posibilidad de presentar resultados evolutivos adversos. Objectivo: Determinar los factores de riesgo asociados a sangrados graves, cirugía de urgencia y mortalidad hospitalaria. Material y métodos: Realizamos un estudio observacional y retrospectivo sobre 1.850 pacientes, atendidos en forma consecutiva entre enero de 1999 y diciembre de 2018 por HDB. Para evaluar el riesgo de gravedad analizamos trece variables en las primeras cuatro horas desde la admisión. Para determinar los factores relacionados con la cirugía de urgencia, agregamos la enfermedad diverticular y, para evaluar mortalidad, la cirugía de urgencia y el puntaje (score) preoperatorio de la Sociedad Americana de Anestesiología (ASA). Resultados: De los 1.850 casos, 194 fueron graves y 1656 leves/moderados. Resultaron estadísticamente significativos como factores de mayor gravedad: > 70 años, FC > 120 lat/min., TA < 90 mm Hg, oliguria, hematoquecia masiva, hematocrito < 30%, hemoglobina < 7 g/% y necesidad transfusional. Resultaron predictores significativos de cirugía de urgencia: > 70 años, anti-coagulación, hipotensión arterial, taquicardia, hemoglobina < 7 g/%, oliguria, transfusiones y hematoquecia masiva. Se construyó una fórmula pronóstica de requerimiento de cirugía (sensibilidad 94%, especificidad 74%, valor predictivo positivo 91% y valor predictivo negativo 81%). AUC: 0,89%. Fueron significativos para mortalidad: > 70 años, anticoagulados, hematoquecia masiva, transfusiones y cirugía urgente. De los dieciséis pacientes operados y fallecidos de la serie, quince presentaban un ASA ≥ IV. Conclusiones: Las variables utilizadas resultaron simples, fiables y estadísticamente significativas para predecir gravedad, cirugía de urgencia y mortalidad.

ABSTRACT Background: Background: There has been a growing interest in determining those risk factors associated with adverse outcomes in early stages of lower gastrointestinal bleeding (LGIB). Objective: The aim of our study was to analyze the risk factors associated with severe bleeding, emergency surgery and in-hospital mortality. Material and methods: We conducted an observational and retrospective study on 1850 patients consecutive managed between January 1999 and December 2018 for LGIB. We analyzed thirteen variables within the first four hours of hospitalization to evaluate risk severity. Diverticular disease was considered to determine factors associated with emergency surgery, and the preoperative American Society of Anesthesiologists (ASA) score was used to assess mortality and emergency surgery. Results: Out of 1850 cases, 194 were severe and 1656 were mild/moderate, Patients > 70 years, with HR > 120 beats/min, BP < 90 mm Hg, oliguria, massive hematochezia, hematocrit < 30%, hemoglobin < 7 g% and need for transfusions presented statistically significant associations with severe bleeding. Age > 70 years, anticoagulation, hypotension, tachycardia, hemoglobin < 7 g%, oliguria, need for transfusion and massive hematochezia were significant predictors of emergency surgery. A prognostic formula was constructed to predict the need for surgery (sensitivity 94%, specificity 74%, positive predictive value 91% and negative predictive value 81%). AUC-ROC: 0,89%. Age > 70 years, anticoagulation, massive hematochezia transfusions and emergency surgery were identified as predictors of mortality. Fifteen of the sixteen patients who underwent surgery and died had ASA ≥ grade 4. Conclusions: The variables analyzed are simple, reliable and statistically significant to estimate the risk of severe bleeding, need for emergency surgery and mortality.

Vía aérea difícil no prevista en paciente anunciada para cirugía de urgencia / Difficult airway not foreseen in patient announced for emergency surgery

Introducción: El manejo de la vía aérea, conceptualizado como el conjunto de maniobras y empleo de dispositivos que permiten una ventilación adecuada y segura en pacientes que por diversas condiciones clínicas lo requieren, llega a ser uno de los desafíos más importantes que enfrenta un anestesiólogo en su práctica. Se considera que el resultado final dependerá de las características del paciente, la disponibilidad de equipos, así como de su destreza y habilidades. Cuando no se tienen en cuenta estos aspectos, aumenta la incidencia de morbilidad y mortalidad perioperatoria. Objetivo: Describir la conducta anestesiológica ante una paciente con diagnóstico de vía aérea difícil no prevista durante el perioperatorio. Presentación de caso: Se presenta el caso de una paciente anunciada para cirugía de urgencia, sin antecedentes patológicos personales, con antecedente de anestesia para amigdalotomía en la niñez. A pesar de un interrogatorio y examen físico minucioso, con utilización de herramientas como los test predictivos de vía aérea difícil y el empleo de dispositivos para su abordaje, no fue posible la intubación y se hizo necesario un abordaje quirúrgico de urgencia. Conclusiones: La vía aérea es parte integral del manejo anestésico. En la actualidad no se cuenta con un método clínico capaz de incluir la valoración de todos los parámetros que sugieran la presencia de vía aérea difícil. Una historia preoperatoria detallada y minuciosa evaluación de esta puede identificar factores de riesgos potenciales, pero casos como estos demuestran que a pesar de las medidas que se puedan tomar, no se está exento de fracasar en la permeabilización de la vía aérea(AU)

Introduction: The management of the airway, conceptualized as the set of maneuvers and use of devices that allow adequate and safe ventilation in patients who require it due to various clinical conditions, becomes one of the most important challenges faced by an anesthesiologist in the practice. It is considered that the final result will depend on the characteristics of the patient, the availability of equipment, as well as their dexterity and skills. When these aspects are not taken into account, the incidence of perioperative morbidity and mortality increases. Objective: Describe the anesthesiological behavior in a patient with a difficult airway diagnosis not foreseen during the perioperative period. Case presentation: The case of a patient announced for emergency surgery, without a personal pathological history, with a history of anesthesia for tonsillectomy in childhood is presented. Despite a thorough interrogation and physical examination, with the use of tools such as predictive tests of difficult airway and the use of devices for their approach, intubation was not possible and an emergency surgical approach was necessary. Conclusions: The airway is an comprehensive part of anesthetic management. At present there is no clinical methods capable of including the assessment of all the parameters that suggest the presence of a difficult airway. A detailed preoperative history and thorough evaluation of this can identify potential risk factors, but cases like these show that despite the measures that can be taken, it is not exempt from failing to permeate the airway(AU)

Relationship between the anatomical location and the selective non-operative management of penetrating stab wounds in the abdomen.

INTRODUCTION: The relationship between the anatomical location of penetrating abdominal stab wounds (SW) and the rate of selective non-operative management (SNOM) based on that location is scarcely reflected in the specialized literature. Our main objective has been to assess this rate based on the anatomical location, and our results. METHODS: Retrospective review of a prospective registry of abdominal trauma from April 1993 to June 2020. The two study groups considered were the Operative Management (OM), and the SNOM, including in this one the use of diagnostic laparoscopy. Penetrating SWs in the abdomen were classified according to anatomical location. RESULTS: We identified 259 patients who fulfilled the inclusion criteria. SNOM was applied in 31% of the patients with a success rate of 96%, and it was more frequent in the lumbar, flank, and thoraco-abdominal regions; within the anterior abdomen it was more applicable in the RH, followed by the LH and epigastrium, respectively. An unnecessary laparotomy was done in 21% of patients, with the highest number in the epigastrium. Taking into account the unnecessary laparotomies and the rates of successful SNOM, 70.5% of lumbar, 66.5% of epigastric, 62% of flank, and 59% of RH penetrating SW could have been managed without a laparotomy. CONCLUSIONS: SNOM of penetrating SW in the abdomen has been safer and more applicable in those located in the lumbar, flank, epigastric, and RH regions.

Relación entre la localización anatómica y el manejo selectivo no operatorio de las heridas por arma blanca penetrantes en abdomen / Relationship between the anatomical location and the selective non-operative management of penetrating stab wounds in the abdomen

Introducción: La localización anatómica de las heridas por arma blanca (HAB) penetrantes en abdomen y su relación con el manejo selectivo no operatorio (MSNO) tiene escaso reflejo en la literatura especializada. Nuestro objetivo principal ha sido valorar la tasa de MSNO en función de esa localización anatómica, y sus resultados. Métodos: Revisión retrospectiva del registro prospectivo de trauma abdominal desde abril de 1993 hasta junio de 2020. Los dos grupos a estudio fueron manejo operatorio (MO) y MSNO, incluyendo en este último grupo el uso de laparoscopias exploradoras como método diagnóstico. Se clasificaron las HAB penetrantes en abdomen en función de su localización anatómica. Resultados: Identificamos 259 pacientes que cumplían los criterios de inclusión. El MSNO se aplicó en el 31% de los pacientes, con una tasa de éxito del 96,5%. En las HAB de las regiones lumbares, flancos y toracoabdominales fue donde se optó más frecuentemente por este manejo; y en el abdomen anterior fue más aplicable en el hipocondrio derecho (HD), seguido del hipocondrio izquierdo (HI) y epigastrio. Se realizó una laparotomía innecesaria en el 21%, con la cifra más alta en el epigastrio. Teniendo en cuenta los porcentajes de MSNO y laparotomías evitables en cada región, el 70,5% de las HAB lumbares, el 66,5% de las epigástricas, el 62% de flancos y el 59% de HD se podrían haber manejado con éxito sin laparotomía. Conclusiones: El MSNO de las HAB penetrantes en abdomen ha resultado más seguro y aplicable en las localizadas en las regiones lumbares, flancos, epigastrio e HD (AU)

Introduction: The relationship between the anatomical location of penetrating abdominal stab wounds (SW) and the rate of selective non-operative management (SNOM) based on that location is scarcely reflected in the specialized literature. Our main objective has been to assess this rate based on the anatomical location, and our results. Methods: Retrospective review of a prospective registry of abdominal trauma from April 1993 to June 2020. The two study groups considered were the Operative Management (OM), and the SNOM, including in this one the use of diagnostic laparoscopy. Penetrating SWs in the abdomen were classified according to anatomical location. Results: We identified 259 patients who fulfilled the inclusion criteria. SNOM was applied in 31% of the patients with a success rate of 96%, and it was more frequent in the lumbar, flank, and thoraco-abdominal regions; within the anterior abdomen it was more applicable in the RUQ, followed by the LUQ and epigastrium, respectively. An unnecessary laparotomy was done in 21% of patients, with the highest number in the epigastrium. Taking into account the unnecessary laparotomies and the rates of successful SNOM, 70,5% of lumbar, el 66,5% of epigastric, 62% of flank, and 59% of RUQ penetrating SWs could have been managed without a laparotomy. Conclusions: SNOM of penetrating SWs in the abdomen has been safer and more applicable in those located in the lumbar, flank, epigastric, and RUQ regions (AU)

Uso de eritromicina como procinético para cesárea con cuatro horas de ayuno / Use of erythromycin as a prokinetic for cesarean section with four hours of fasting

Resumen: El ayuno preoperatorio es fundamental como requisito previo a la mayoría de cirugías tanto para las electivas como para las urgencias relativas. Sin embargo, no siempre se cumplen las condiciones idóneas al momento de abordar a un paciente y la falta de ayuno es una condición que puede poner en riesgo la vida del mismo, siendo un factor de riesgo mayúsculo para la broncoaspiración del contenido gástrico. Hasta el momento se cuenta con un reducido arsenal farmacológico de medicamentos que con distinta función e intensidad aceleran el vaciamiento gástrico; la eritromicina no se encuentra en esta lista de manera oficial. A pesar de que ya ha sido utilizada ampliamente con este fin en el ámbito de los procedimientos endoscópicos, no existen aún suficientes reportes en los que se haya puesto a prueba su eficacia procinética en cirugía de urgencia, específicamente una cesárea. Este artículo, además de ofrecer un breve sumario de dicho macrólido, presenta el caso de una paciente embarazada con ingesta alimenticia reciente, en la cual se obtuvieron las condiciones idóneas para cirugía tan sólo cuatro horas después de la administración de la eritromicina.

Abstract: Preoperative fasting is essential as a prerequisite for most surgeries, either elective procedures or relative emergencies. However, the ideal conditions for surgery are not always fulfilled at the time of approaching a patient, and the lack of fasting is a factor that could endanger patient's life, being a major risk factor for bronchoaspiration of gastric content. Until now there is a small pharmacological list of medications that with different function and intensity accelerate gastric emptying, erythromycin is not officially on this list. Despite the fact that it has already been widely used for this purpose in the field of endoscopic procedures, there are not enough reports about its efficacy in emergency surgery, specifically C-section. This article, in addition to offering a brief summary of this macrolide, presents a case in which after erythromycin administration to a pregnant patient with a recent food intake, the ideal conditions for surgery were obtained only four hours later.

Relationship between the anatomical location and the selective non-operative management of penetrating stab wounds in the abdomen. / Relación entre la localización anatómica y el manejo selectivo no operatorio de las heridas por arma blanca penetrantes en abdomen.

INTRODUCTION: The relationship between the anatomical location of penetrating abdominal stab wounds (SW) and the rate of selective non-operative management (SNOM) based on that location is scarcely reflected in the specialized literature. Our main objective has been to assess this rate based on the anatomical location, and our results. METHODS: Retrospective review of a prospective registry of abdominal trauma from April 1993 to June 2020. The two study groups considered were the Operative Management (OM), and the SNOM, including in this one the use of diagnostic laparoscopy. Penetrating SWs in the abdomen were classified according to anatomical location. RESULTS: We identified 259 patients who fulfilled the inclusion criteria. SNOM was applied in 31% of the patients with a success rate of 96%, and it was more frequent in the lumbar, flank, and thoraco-abdominal regions; within the anterior abdomen it was more applicable in the RUQ, followed by the LUQ and epigastrium, respectively. An unnecessary laparotomy was done in 21% of patients, with the highest number in the epigastrium. Taking into account the unnecessary laparotomies and the rates of successful SNOM, 70,5% of lumbar, el 66,5% of epigastric, 62% of flank, and 59% of RUQ penetrating SWs could have been managed without a laparotomy. CONCLUSIONS: SNOM of penetrating SWs in the abdomen has been safer and more applicable in those located in the lumbar, flank, epigastric, and RUQ regions.

Validez de tres procedimientos para la predicción de reoperación en cirugía abdominal: estudio de cohorte / Validity of three procedures for predicting reoperation in abdominal surgery: a cohort study

Introducción: Resulta difícil diagnosticar con certeza la necesidad de reoperar a un paciente después de cirugía abdominal mayor. Objetivo: Evaluar la validez de tres procedimientos para la predicción de la reoperación en cirugía abdominal. Métodos: Estudio explicativo, de cohorte, prospectivo, realizado de noviembre de 2016 a abril de 2017; 146 pacientes en posoperatorio de cirugía abdominal mayor, ingresados consecutivamente en la unidad de cuidados intensivos del Hospital Militar Central Dr. Carlos J. Finlay. Para ser reoperados, los pacientes fueron evaluados según criterios clínicos, de laboratorio e imágenes. De forma independiente, se estimó la probabilidad de requerir una reoperación mediante el Acute Re-intervention Predictive Index, el Sistema de Ayuda al Pronóstico de Reoperación en Cirugía Abdominal (SAPRCA) y la presión intraabdominal. Se aplicó la curva característica operativa del receptor y se seleccionó el mejor punto de corte con sus indicadores de validez. Resultados: Fueron reoperados 23 pacientes (15,8 por ciento). El área bajo la curva característica operativa del receptor (ABC) de los tres puntajes fue > 0,8, con excelente capacidad de discriminación, pero con diferencias significativas entre ellas (p < 0,001). El SAPRCA tuvo mejor desempeño (ABC = 0,965; CI 0,933 - 0,997), seguido de la presión intraabdominal (ABC = 0,939; CI 0,892 - 0,987) y el Acute Re-intervention Predictive Index (ABC = 0,863, CI 0,789 - 0,938). Conclusiones: El SAPRCA mostró un excelente desempeño y una eficacia superior a la demostrada por los otros dos procedimientos, que lo hace recomendable para pronosticar la necesidad de reoperar después de cirugía abdominal mayor(AU)

Introduction: It is difficult to diagnose with certainty the need to reoperate a patient after major abdominal surgery. Objective: To assess the validity of three procedures for predicting reoperation in abdominal surgery. Method: Explanatory, cohort, prospective study, from November 2016 to April 2017, 146 patients in postoperative period of major abdominal surgery, consecutively admitted to the intensive care unit of the Hospital "Carlos J Finlay". To decide on reoperation, patients were evaluated according to clinical, laboratory and imaging criteria. Independently, the probability of requiring a reoperation was estimated using the Acute Re-intervention Predictive Index, the Abdominal Surgery Reoperation Prognosis Aid System and intra-abdominal pressure. To analyse their usefulness, the Receiver Operating Characteristic curve was applied and the best cut-off point with its validity indicators was selected. Results: 23 patients (15.8 percent) were reoperated. The area under the receiver operator curve (AUC) of the three scores was above 0.8, with an excellent ability to discriminate between patients who really required reoperation and those who did not, but with significant differences between them (p <0.001). The Abdominal Surgery Reoperation Prognosis Aid System had the best performance, with an AUC = 0.965 (CI 0.933-0.997), followed by the intra-abdominal pressure (AUC = 0.939, CI 0.892-0.987) and the Acute Re-intervention Predictive Index (AUC = 0.863, CI 0.789-0.938). Conclusions: The Abdominal Surgery Reoperation Prognosis Aid System shows an excellent performance and an efficiency superior to that demonstrated by the other two procedures, which makes it recommendable to predict the need to reoperate after major abdominal surgery(AU)

The Acute Care Surgery model in the world, and the need for and implementation of trauma and emergency surgery units in Spain. / El modelo Acute Care Surgery en el mundo y la necesidad e implantación de unidades de trauma y cirugía de urgencia en España.

The Acute Care Surgery model groups trauma and emergency surgery with surgical critical care. Conceived and extended during the last 2 decades throughout North America, the magnitude and clinical idiosyncrasy of emergency general surgery have determined that this model has been expanded to other parts of the world. In our country, this has led to the introduction and implementation of the so-called trauma and emergency surgery units, with common objectives as those previously published for the original model: to decrease the rates of emergency surgery at night, to allow surgeons linked to elective surgery to develop their activity in their own disciplines during the daily schedule, and to become the perfect link and reference for the continuity of care. This review summarizes how the original model was born and how it expanded throughout the world, providing evidence in terms of results and a description of the current situation in our country.

Uso de la anestesia local en la cirugía mayor de urgencia / Use of local anesthesia for major surgery in emergency

Introducción: la presencia de enfermos de alto riesgo con necesidad de una intervención quirúrgica de urgencia es un grave problema. En estos casos, la anestesia local podría ser una alternativa. Objetivo: mostrar la experiencia del Hospital Universitario Comandante Manuel Fajardo con el uso de la anestesia local en la cirugía de urgencia en enfermos de alto riesgo. Métodos: se realizó un estudio observacional, descriptivo, de corte trasversal tipo serie de casos. Incluyó 72 pacientes de alto riesgo quirúrgico que necesitaron un procedimiento quirúrgico de urgencia en que por su estado fisco y riesgo fue necesario utilizar anestesia local. Resultados: más de la mitad de los pacientes fueron del sexo masculino, mayores de 65 años, con enfermedades concomitantes. Las enfermedades más frecuentes fueron la HTA y la Diabetes Mellitus. Todos los enfermos eran ASA III y IV, predominó el riesgo quirúrgico malo. Las indicaciones de cirugía de urgencia fueron variadas siendo las frecuente la disfagia severa por cáncer, estenosis por cáusticos o esclerosis lateral amiotrofica, la oclusión intestinal por cáncer de colon izquierdo y la colecistitis aguda. Se apoyó con sedación en 14 enfermos, no se presentaron reacciones adversas ni complicaciones. Conclusiones: la anestesia local en la cirugía de urgencia ofrece resultados favorables y escazas reacciones adversas. Es una opción eficaz en el enfermo con ASA III y IV y riesgo quirúrgico malo(AU)

Introduction: high risk patients requiring surgery in emergency is a serious problem. In this situation, the local anesthesia might be an alternative. Objective: to show the experience of Comandante Manuel Fajardo hospital in using the local anesthesia for emergency surgery in high risk patients. Methods: a case series-type, cross-sectional observational and descriptive study was carried out with 72 high surgical risk patients who required emergency surgical procedure and whose physical condition and risk demanded using local anesthesia. Results: over half of the patients were males, aged over 65 years with underlying diseases. The most frequent of them were hypertension and diabetes mellitus. All the patients were classified as ASA III and IV, being bad surgical risk predominant. The indications for emergency surgery varied and the most common ones included severe dysphagia caused by cancer, stenosis from caustic substances or amiotrophic lateral sclerosis, intestinal occlusion from cancer in left colon and acute cholecystitis. Surgical procedure supported on sedation in 14 patients; there were neither adverse reactions nor complications. Conclusions: local anesthesia for emergency surgery provides favorable results and few adverse reactions. It is an effective option to treat ASA III and IV and bad surgical risk patients(AU)

Uso de la anestesia local en la cirugía mayor de urgencia / Use of local anesthesia for major surgery in emergency

Introducción: la presencia de enfermos de alto riesgo con necesidad de una intervención quirúrgica de urgencia es un grave problema. En estos casos, la anestesia local podría ser una alternativa. Objetivo: mostrar la experiencia del Hospital Universitario Comandante Manuel Fajardo con el uso de la anestesia local en la cirugía de urgencia en enfermos de alto riesgo. Métodos: se realizó un estudio observacional, descriptivo, de corte trasversal tipo serie de casos. Incluyó 72 pacientes de alto riesgo quirúrgico que necesitaron un procedimiento quirúrgico de urgencia en que por su estado fisco y riesgo fue necesario utilizar anestesia local. Resultados: más de la mitad de los pacientes fueron del sexo masculino, mayores de 65 años, con enfermedades concomitantes. Las enfermedades más frecuentes fueron la HTA y la Diabetes Mellitus. Todos los enfermos eran ASA III y IV, predominó el riesgo quirúrgico malo. Las indicaciones de cirugía de urgencia fueron variadas siendo las frecuente la disfagia severa por cáncer, estenosis por cáusticos o esclerosis lateral amiotrofica, la oclusión intestinal por cáncer de colon izquierdo y la colecistitis aguda. Se apoyó con sedación en 14 enfermos, no se presentaron reacciones adversas ni complicaciones. Conclusiones: la anestesia local en la cirugía de urgencia ofrece resultados favorables y escazas reacciones adversas. Es una opción eficaz en el enfermo con ASA III y IV y riesgo quirúrgico malo(AU)

Introduction: high risk patients requiring surgery in emergency is a serious problem. In this situation, the local anesthesia might be an alternative. Objective: to show the experience of Comandante Manuel Fajardo hospital in using the local anesthesia for emergency surgery in high risk patients. Methods: a case series-type, cross-sectional observational and descriptive study was carried out with 72 high surgical risk patients who required emergency surgical procedure and whose physical condition and risk demanded using local anesthesia. Results: over half of the patients were males, aged over 65 years with underlying diseases. The most frequent of them were hypertension and diabetes mellitus. All the patients were classified as ASA III and IV, being bad surgical risk predominant. The indications for emergency surgery varied and the most common ones included severe dysphagia caused by cancer, stenosis from caustic substances or amiotrophic lateral sclerosis, intestinal occlusion from cancer in left colon and acute cholecystitis. Surgical procedure supported on sedation in 14 patients; there were neither adverse reactions nor complications. Conclusions: local anesthesia for emergency surgery provides favorable results and few adverse reactions. It is an effective option to treat ASA III and IV and bad surgical risk patients(AU)

Self-expanding metallic stent as a bridge to surgery in the treatment of left colon cancer obstruction: Cost-benefit analysis and oncologic results. / Stents metálicos autoexpandibles como puente a la cirugía en el tratamiento del cáncer de colon izquierdo en oclusión. Análisis coste-beneficio y resultados oncológicos.

INTRODUCTION: The use of a self-expanding metallic stent as a bridge to surgery in acute malignant left colonic obstruction has been suggested as an alternative treatment to emergency surgery. The aim of the present study was to compare the morbi-mortality, cost-benefit and long-term oncological outcomes of both therapeutic options. METHODS: This is a prospective, comparative, controlled, non-randomized study (2005-2010) performed in a specialized unit. The study included 82 patients with left colon cancer obstruction treated by stent as a bridge to surgery (n=27) or emergency surgery (n=55) operated with local curative intention. The main outcome measures (postoperative morbi-mortaliy, cost-benefit, stoma rate and long-term oncological outcomes) were compared based on an "intention-to-treat" analysis. RESULTS: There were no significant statistical differences between the two groups in terms of preoperative data and tumor characteristics. The technically successful stenting rate was 88.9% (11.1% perforation during stent placement) and clinical success was 81.4%. No difference was observed in postoperative morbi-mortality rates. The primary anastomosis rate was higher in the bridge to surgery group compared to the emergency surgery group (77.8% vs. 56.4%; P=.05). The mean costs in the emergency surgery group resulted to be €1,391.9 more expensive per patient than in the bridge to surgery group. There was no significant statistical difference in oncological long-term outcomes. CONCLUSIONS: The use of self-expanding metalllic stents as a bridge to surgery is a safe option in the urgent treatment of obstructive left colon cancer, with similar short and long-term results compared to direct surgery, inferior mean costs and a higher rate of primary anastomosis.

Morbilidad y mortalidad del paciente geriátrico intervenido de urgencia / Morbidity and mortality in geriatric patients undergoing emergency surgery

Introducción: la elevación de la expectativa de vida de la población se deduce por el aumento de pacientes que se operan en edades superiores a los 60 años, y una gran cantidad lo hace de manera urgente. Objetivo: describir la morbilidad y la mortalidad anestésicas de origen cardiovascular, en el paciente geriátrico intervenido quirúrgicamente de urgencia. Métodos: se realizó un estudio descriptivo, prospectivo y longitudinal de 123 pacientes mayores de 60 años en el Hospital General Docente Leopoldito Martínez, durante el período comprendido entre enero de 2010 y diciembre de 2011. Los datos fueron recogidos de las historias clínicas y los protocolos de anestesia. Resultados: se presentaron antecedentes patológicos cardiovasculares en 34,1 por ciento de los pacientes y predominó la hipertensión arterial en 15,4 por ciento. El factor de riesgo más frecuente fue el hábito de fumar (26,8 por ciento), y la herniorrafia fue la intervención más practicada en urgencia (33,3 por ciento). El método anestésico más empleado fue la anestesia general, en 68,3 por ciento de los casos, y dentro de ella, la anestesia general orotraqueal. Las complicaciones cardiovasculares fueron más frecuentes y ocurrieron en el período transoperatorio. Fallecieron 5 pacientes (4,1 por ciento) y ninguna muerte fue imputable al proceder anestésico. Conclusiones: la morbilidad anestésica de origen cardiovascular en el paciente geriátrico intervenido quirúrgicamente de urgencia tuvo relación directa con la mortalidad((AU)

Introduction: as a result of the increase in life expectancy, more patients aged over 60 undergo surgery, and a large number of them undergo emergency surgery. Objective: describe anesthetic morbidity and mortality of cardiovascular origin in geriatric patients undergoing emergency surgery. Methods: a prospective longitudinal descriptive study was conducted of 123 patients aged over 60 at Leopoldito Martínez General Teaching Hospital from January 2010 to December 2011. The data were collected from medical records and anesthesia protocols. Results: 34.1 percent of the patients had a history of cardiovascular disease, and arterial hypertension was predominant in 15.4 percent. Smoking was the most frequent risk factor (26.8 percent), and herniorrhaphy was the most common emergency intervention (33.3 percent). The anesthetic method most frequently used was general anesthesia (68.3 percent), with a predominance of general orotracheal anesthesia. Most cardiovascular complications appeared during the transoperative period. Five patients died (4.1 percent), with no death attributable to the anesthetic procedure applied. Conclusions: a direct relationship was found between anesthetic morbidity of cardiovascular origin and mortality in geriatric patients undergoing emergency surgery(AU)

Morbilidad y mortalidad del paciente geriátrico intervenido de urgencia / Morbidity and mortality in geriatric patients undergoing emergency surgery

Introducción: la elevación de la expectativa de vida de la población se deduce por el aumento de pacientes que se operan en edades superiores a los 60 años, y una gran cantidad lo hace de manera urgente. Objetivo: describir la morbilidad y la mortalidad anestésicas de origen cardiovascular, en el paciente geriátrico intervenido quirúrgicamente de urgencia. Métodos: se realizó un estudio descriptivo, prospectivo y longitudinal de 123 pacientes mayores de 60 años en el Hospital General Docente "Leopoldito Martínez", durante el período comprendido entre enero de 2010 y diciembre de 2011. Los datos fueron recogidos de las historias clínicas y los protocolos de anestesia. Resultados: se presentaron antecedentes patológicos cardiovasculares en 34,1 % de los pacientes y predominó la hipertensión arterial en 15,4 %. El factor de riesgo más frecuente fue el hábito de fumar (26,8 %), y la herniorrafia fue la intervención más practicada en urgencia (33,3 %). El método anestésico más empleado fue la anestesia general, en 68,3 % de los casos, y dentro de ella, la anestesia general orotraqueal. Las complicaciones cardiovasculares fueron más frecuentes y ocurrieron en el período transoperatorio. Fallecieron 5 pacientes (4,1 %) y ninguna muerte fue imputable al proceder anestésico. Conclusiones: la morbilidad anestésica de origen cardiovascular en el paciente geriátrico intervenido quirúrgicamente de urgencia tuvo relación directa con la mortalidad.

Introduction: as a result of the increase in life expectancy, more patients aged over 60 undergo surgery, and a large number of them undergo emergency surgery. Objective: describe anesthetic morbidity and mortality of cardiovascular origin in geriatric patients undergoing emergency surgery. Methods: a prospective longitudinal descriptive study was conducted of 123 patients aged over 60 at Leopoldito Martínez General Teaching Hospital from January 2010 to December 2011. The data were collected from medical records and anesthesia protocols. Results: 34.1 % of the patients had a history of cardiovascular disease, and arterial hypertension was predominant in 15.4 %. Smoking was the most frequent risk factor (26.8 %), and herniorrhaphy was the most common emergency intervention (33.3 %). The anesthetic method most frequently used was general anesthesia (68.3 %), with a predominance of general orotracheal anesthesia. Most cardiovascular complications appeared during the transoperative period. Five patients died (4.1 %), with no death attributable to the anesthetic procedure applied. Conclusions: a direct relationship was found between anesthetic morbidity of cardiovascular origin and mortality in geriatric patients undergoing emergency surgery.

Consentimiento nnformado en cirugía ortopédica / Informed consent in orthopedics

Esta revisión pretende ser un alto en el camino para quienes ejercen la ortopedia y el trauma en Colombia -y en otras latitudes-, un espacio de reflexión para afrontar el diario vivir, con estudiantes y residentes, pacientes y familiares, colegas y administradores de la salud, al establecer y hacer vida una cultura ética desde la cirugía ortopédica, de tal manera que no se estén recordando principios éticos fundamentales solo cuando aparezcan las quejas de los pacientes o los requerimientos judiciales. Con el hilo central del Consentimiento Informado, su historia, su sentido y momento apropiado de aplicación, se repasan conceptos bioéticos nucleares, partiendo de la buena comunicación, pilar de la relación médico-paciente, que deriva en la necesaria confianza que perfecciona dicha relación. Se ofrecen comentarios, principalmente en el campo de los conflictos de intereses, a la reglamentación que la Asociación Americana de Cirujanos Ortopedistas tiene para regular la práctica profesional de sus asociados.

The present review is intended as a wake-up call for those who work with orthopedics and trauma in Colombia and in other parts of the world. It is an opportunity to reflect on daily practice with students and residents, patients and their families, colleagues and health administrators by establishing and making life an ethical culture from the standpoint of orthopedic surgery, so that we are reminded of fundamental ethical principles at all times, not just when complaints from patients or injunctions arise. Informed consent, its history, meaning and appropriate moment of application are the basis on which nuclear bioethical concepts are reviewed, beginning with good communication, which is the backbone of the physician-patient relationship and from which the confidence necessary to perfect that relationship is derived. Comments are put forth, primarily with respect to conflicts of interest in light of the regulations adopted by the American Association of Orthopedic Surgeons to standardize the professional practice of its members.

Esta revisão deseja ser um alto no caminho dos que exercem a ortopedia e o trauma em Colômbia (e nos outros países), um sitio de reflexão para afrontar o diário viver com estudantes y residentes, pacientes e familiares, colegas e administradores da saúde, ao fixar e fazer viva uma cultura ética desde a cirurgia ortopédica; assim, os princípios éticos básicos no somente se recordarão quando cheguem as queixas dos pacientes ou os requerimentos judiciais. Neste artigo, repassam-se conceitos bioéticos fundamentais -tindo como eixo o consentimento informado, a sua história e o momento apropriado de aplicação- partindo da adequada comunicação, apoio da relação médico-paciente, que leva à confiança necessária que aperfeiçoa esta relação. No campo dos conflitos de interesse, fazem-se comentários à regulamentação da Associação Americana de Cirurgiões Ortopedistas.