Análisis de la utilización de un protocolo de profilaxis antibiótica en cirugía mamaria / Analysis of the use of a protocol of antibiotic prophylaxis in breast surgery

Introducción y Objetivos. El concepto de profilaxis antibiótica en cirugía tiene como objetivo la reducción de la incidencia de infección postquirúrgica, con mínima morbilidad para el paciente. Es habitual encontrar protocolos teóricos diseñados para optimizar, unificar, facilitar y estandarizar los procesos clínicos. Sin embargo cuando estos son llevados a la práctica, se cometen errores de ejecución que menguan su efectividad. En el presente trabajo valoramos de forma objetiva la aplicación del protocolo de profilaxis antibiótica durante la cirugía mamaria en el Complejo Hospitalario Universitario de A Coruña, España, así como los errores más frecuentes que se presentan durante la ejecución del proceso, con la idea de que nuestras conclusiones puedan ser también válidas para su aplicación en otros centros. Material y Método. Revisamos retrospectivamente el porcentaje de cumplimiento adecuado en la administración de la profilaxis antibiótica prequirúrgica en cirugía mamaria (tanto benigna como maligna), analizando 5 variables objetivas consideradas como estándares de calidad. Resultados. Recogimos de la base de datos hospitalaria todas las cirugías mamarias realizadas entre 2008 y 2012, obteniendo una muestra representativa de 45 casos/año que fue objeto de estudio mediante la cualificación de 5 variables de calidad: 1.- indicación de la profilaxis, 2.- elección adecuada del antibiótico, 3.- dosis y vía de administración, 4.- momento de administración de la primera dosis, y 5.- duración de la profilaxis. Quedó reflejado un porcentaje de correcta aplicación superior al 90% en todos los indicadores de calidad, excepto en el 4, momento de administración de la primera dosis antibiótica. Conclusiones. Detectamos que los errores más frecuentes en la administración de la profilaxis antibiótica en nuestro centro radican en que se realiza en un momento inadecuado, siendo el ideal entre 2 horas y 15 minutos antes del inicio de la cirugía, según el antibiótico que se utilice. Toda mejora en el circuito organizativo durante la administración de la profilaxis, redundará en una mejoría en la aplicación de la misma y por supuesto en su mayor eficacia (AU)

Background and Objectives. The concept of antibiotic prophylaxis in surgery aims to reduce the incidence of postoperative infection, with minimal patient morbidity. It is common to find theoretical protocols designed to optimize, unify, facilitate and standarize clinical processes. However when they are put into practice, execution errors that diminish their effectiveness, are made. In this paper we value objectively the application of protocol antibiotic prophylaxis during breast surgery at the University Hospital of A Coruña, Spain, and the most frequent errors that occur during the execution of the process, with the idea that our findings may be also valid for application in other centers. Methods. We retrospectively reviewed the percentage of adequate compliance in the administration of preoperative antibiotic prophylaxis in breast surgery (both benign and malignant), analyzing variables considering 5 objective quality standards. Results.All breast surgeries performed between 2008 and 2012 were collected from the hospital database, obtaining a representative sample of 45 cases / year that was studied through the qualification of 5 quality variables: 1. indication of prophylaxis, 2. appropriate choice of antibiotic, 3. dose and route of administration, 4. time of administration of the first dose, and 5. duration of prophylaxis. It was reflected a higher percentage of correct application to 90% in all quality indicators, except in 4, time of administration of the first antibiotic dose. Conclusions.We found that the most frequent errors in the administration of antibiotic prophylaxis in our center is that it is done at the wrong time, being the ideal between 2 hours and 15 minutes before the start of surgery, depending on the antibiotic used. Any improvement in the organizational circuit during the administration of prophylaxis, results in an improvement in its application and of course, in a better effective (AU)

Prognostic value of mitral regurgitation assessment during exercise echocardiography in patients with left ventricular dysfunction: a follow-up study of 1.7 +/- 1.5 years.

AIMS: The value of exercise echocardiography (EE) over resting echocardiography when this last incorporates information on mitral regurgitation (MR) is only partially known. Furthermore, limited data exist regarding the value of MR worsening during exercise in patients with left ventricular (LV) dysfunction. We investigate whether EE has incremental value over a resting echo-Doppler study; and whether post-exercise MR increments the value of EE for predicting outcome in patients with LV dysfunction. METHODS AND RESULTS: Three hundred and twenty-three consecutive patients with LV dysfunction (LV ejection fraction < or =45%) referred for EE were followed for 1.7 +/- 1.5 years. There were 43 hard events (myocardial infarction in 9 and cardiac death in 34). Resting MR, peak heart rate x blood pressure, and number of involved territories at exercise were independently associated to hard events (incremental P-value of EE =0.02). Independent variables associated to cardiac death were resting MR, peak heart rate x blood pressure, peak wall motion score index, and MR worsening (incremental P-value of MR worsening = 0.04). CONCLUSIONS: EE maintains its prognostic value over resting echocardiography even when this last incorporates information on MR. Exercise-induced MR worsening has independent prognostic value for cardiac death in patients with LV dysfunction.

Risk stratification by treadmill exercise echocardiography in patients with excellent exercise capacity.

BACKGROUND: The incremental value of exercise echocardiography (EE) has been demonstrated to be maximal in patients with moderate pretest probability for coronary artery disease, but there is a lack of data in patients with low pretest probability or patients with good functional capacity. METHODS: To investigate whether such incremental value is maintained in patients with excellent exercise capacity, we studied 1,433 patients who had excellent exercise capacity (>or=8 METs for women, >or=10 METs for men). RESULTS: During a follow-up of 2.3 +/- 1.5 years, 42 hard events occurred (cardiac death or nonfatal myocardial infarction). Variables independently associated to hard events were male gender (P = 0.04), % of the age-predicted maximum heart rate (P = 0.02), chronotropic reserve (P = 0.002), and abnormal EE (P = 0.03; incremental P value of EE = 0.03). CONCLUSIONS: EE has incremental value over clinical variables, resting echocardiography, and exercise testing variables in patients with excellent exercise capacity. EE may be preferable to ECG exercise testing even in patients expected to have good exercise capacity.

[Value of resting and exercise mitral regurgitation during exercise echocardiography to predict outcome in patients with left ventricular dysfunction]. / Valor pronóstico de la regurgitación mitral en reposo y ejercicio durante la ecocardiografía de ejercicio en pacientes con disfunción ventricular izquierda.

INTRODUCTION AND OBJECTIVES: The relative value of exercise echocardiography (EE) over resting echocardiography when this last incorporates information on mitral regurgitation (MR) is unknown. Furthermore, limited data exists regarding to the value of MR worsening during exercise in patients with LV dysfunction. We investigated whether: a) EE has incremental value over a resting echo-Doppler study; and b) post-exercise MR increments the value of EE for predicting outcome in patients with LV dysfunction. METHODS: 388 consecutive patients with LV dysfunction (LV ejection fraction <50%) were followed for 2.1 (1.5) years. There were 46 hard events (myocardial infarction in 10 and cardiac death in 36). RESULTS: There were 43 events in 319 patients with abnormal EE vs 3 events in 69 patients with normal EE (13% vs 4%, P=.04), whereas there were 20 events in the 103 patients with at least moderate resting MR vs 26 events in the 288 with no/mild MR (19% vs 9%, P=.006). Resting MR, peak heart rate x blood pressure, and n masculine of diseased territories on EE were independently associated to hard events. The same variables and MR worsening were independently associated to cardiac death. CONCLUSIONS: EE maintains its higher prognostic value over resting echocardiography even when this last incorporates information on MR. MR worsening increments the value of EE for predicting cardiac death in patients with LV dysfunction.

Valor pronóstico de la regurgitación mitral en reposo y ejercicio durante la ecocardiografía de ejercicio en pacientes con disfunción ventricular izquierda / Value of resting and exercise mitral regurgitation during exercise echocardiography to predict outcome in patients with left ventricular dysfunction

Introducción y objetivos. El valor relativo de la ecocardiografía de ejercicio (EE) sobre la ecocardiografía basal cuando esta última incorpora información sobre la regurgitación mitral (RM) es desconocido. Además, hay poca información sobre el valor del empeoramiento de la RM durante el ejercicio en pacientes con disfunción ventricular. El objetivo fue investigar: a) si la EE incrementa el valor pronóstico de la ecocardiografía Doppler basal, y b) si la RM posterior al ejercicio incrementa el valor pronóstico de la EE en pacientes con disfunción ventricular. Métodos. Se realizó el seguimiento de un grupo de 388 pacientes consecutivos con disfunción ventricular durante 2,1 ± 1,5 años. Hubo 46 eventos (infarto de miocardio en 10 y muerte cardiaca en 36). Resultados. Hubo 43 eventos en 319 pacientes con EE anormal frente a 3 eventos en 69 pacientes con EE normal (el 13 frente al 4%; p = 0,04), mientras que hubo 20 eventos en 103 pacientes con RM ≥ moderada basal frente a 26 eventos en los 288 con RM ligera o sin RM (el 19 frente al 9%; p = 0,006). La RM basal, el doble producto pico y el número de territorios afectos en la EE estaban independientemente asociados con eventos. Las mismas variables junto con el empeoramiento de la RM estaban independientemente asociadas con muerte cardiaca. Conclusiones. La EE mantiene su valor pronóstico sobre la ecocardiografía basal incluso cuando ésta incorpora información sobre la RM en pacientes con disfunción ventricular. El empeoramiento de la RM aumenta el valor predictivo de la EE para muerte cardiaca en pacientes con disfunción ventricular

Introduction and objectives. The relative value of exercise echocardiography (EE) over resting echocardiography when this last incorporates information on mitral regurgitation (MR) is unknown. Furthermore, limited data exists regarding to the value of MR worsening during exercise in patients with LV dysfunction. We investigated whether: a) EE has incremental value over a resting echo-Doppler study; and b) post-exercise MR increments the value of EE for predicting outcome in patients with LV dysfunction. Methods. 388 consecutive patients with LV dysfunction (LV ejection fraction <50%) were followed for 2.1 (1.5) years. There were 46 hard events (myocardial infarction in 10 and cardiac death in 36). Results. There were 43 events in 319 patients with abnormal EE vs 3 events in 69 patients with normal EE (13% vs 4%, P=.04), whereas there were 20 events in the 103 patients with at least moderate resting MR vs 26 events in the 288 with no/mild MR (19% vs 9%, P=.006). Resting MR, peak heart rate x blood pressure, and nº of diseased territories on EE were independently associated to hard events. The same variables and MR worsening were independently associated to cardiac death. Conclusions. EE maintains its higher prognostic value over resting echocardiography even when this last incorporates information on MR. MR worsening increments the value of EE for predicting cardiac death in patients with LV dysfunction

Prognostic value of mitral regurgitation assessment during exercise echocardiography in patients with known or suspected coronary artery disease.

BACKGROUND: Although mitral regurgitation (MR) may be assessed during exercise echocardiography (EE) there are no data regarding its value for predicting outcome in large series of patients. We sought to determine whether the predictive value of EE is maintained over clinical variables and resting echocardiography when the latter included information on MR, and to verify whether postexercise MR may improve the value of EE for predicting outcome. METHODS: In all, 1916 patients (mean age +/- 1SD = 62 +/- 11 years; mean left ventricular ejection fraction +/- 1SD = 56 +/- 11) referred for EE were followed up for 1.9 +/- 1.4 years. RESULTS: There were 87 cardiac events before revascularization: 67 events occurred in 948 patients with abnormal EE and 20 events occurred in 968 patients with normal EE (P < .0001), whereas there were 24 events in the 218 patients with moderate or higher resting MR and 63 events in the 1698 patients with no or mild MR (P < .0001). Previous myocardial infarction, resting MR, peak double product, and peak left ventricular ejection fraction were independently associated to hard events (chi2 model = 144, P < .0001). The same variables were associated to cardiac death (chi2 model = 141, P < .0001). Predictors of cardiac events in patients with abnormal EE were resting MR, resting wall-motion score index, metabolic equivalents, peak double product, and MR worsening (incremental P value of MR worsening = .03). Predictors of cardiac death were resting MR, peak double product, peak left ventricular ejection fraction, and MR worsening (incremental P value of MR worsening = .03). CONCLUSIONS: EE maintains its higher prognostic value over resting echocardiography even when the latter incorporates information on resting MR. MR worsening provides significant incremental prognostic information in patients with abnormal EE.

Risk stratification by treadmill exercise echocardiography.

BACKGROUND: Although exercise echocardiography (EE) has value for the diagnosis of coronary artery disease (CAD), it's not clear whether it may be useful for risk assessment in all categories of patients. To determine whether: 1) there is an incremental value of EE over clinical, exercise and resting echocardiographic variables for the prediction of events according to the pre-test probability of CAD; and 2) the number, location of the diseased territories, and nature of the disease affect the risk stratification, we studied 2436 patients referred for EE that were followed for 2.1 +/- 1.5 years. METHODS: Based on a pre-test score, previous myocardial infarction (MI) or revascularizations, 1242 patients were considered as having high, 1038 moderate, and 156 low pre-test probability. RESULTS: There were 89 hard events (myocardial infarction or cardiovascular death) in the 1203 patients with abnormal EE vs. 31 events in the 1233 with normal EE (p < 0.0001). Gender, Mets, heart rate x blood pressure, resting wall motion score index and number of involved territories at exercise were independently associated to hard events (final Chi-square = 170, incremental p value of exercise echo <0.0001). The incremental value of exercise echo over other variables was found in patients with the different pre-test probabilities. CONCLUSIONS: Exercise echocardiography has incremental value over clinical, exercise and resting echocardiographic variables in patients with different pre-test probabilities of CAD.

Comparison of exercise echocardiography and the Duke treadmill score for risk stratification in patients with known or suspected coronary artery disease and normal resting electrocardiogram.

BACKGROUND: Although exercise echocardiography (EE) is not clearly indicated in patients with normal electrocardiogram (ECG) as the first evaluation, there is a lack of data regarding its superiority over the Duke score for prognosis. We investigate whether EE has incremental value over the Duke score for predicting outcome in patients with normal ECG. METHODS: One thousand six hundred forty-seven patients with interpretable ECG referred for EE were followed up for 2.5 +/- 1.4 years. There were 58 hard events (myocardial infarction or cardiovascular death). RESULTS: There were 38 events in 735 patients with abnormal EE versus 20 events in 912 with normal EE (P < .0001). The Duke score, resting wall motion score index, and ischemia were independently associated to events (incremental P value of EE = .03). The Duke score allowed stratification of patients with abnormal EE (P = .001) or ischemia (P = .01) into different risk categories but did not stratify patients without these characteristics. Exercise echocardiography variables stratified patients with the low Duke score (left anterior descending artery territory P = .04, left anterior descending artery ischemia P = .03) and with the intermediate Duke score (abnormal EE P = .005, necrosis P = .0009, ischemia P = .004, resting ejection fraction P < .00001, resting wall motion score index P < .00001, peak ejection fraction P < .00001, peak wall motion score index P < .0001, number of territories P = .002, left anterior descending artery territory P = .001, and left anterior descending artery ischemia P = .002) but did not with the high Duke score. CONCLUSIONS: Exercise echocardiography has incremental value over clinical variables, the Duke score, and resting echocardiography for the prediction of hard cardiovascular events in patients with normal resting ECG.