Is the severe pain after Milligan-Morgan hemorrhoidectomy still currently remaining a major postoperative problem despite being one of the oldest surgical techniques described? A case series of 117 consecutive patients.

INTRODUCTION: Surgery is the only curative method of hemorrhoidal disease. Currently the Milligan-Morgan hemorrhoidectomy is still considered the "gold standard", since it is the best performing technique. However, postoperative pain remains a major problem. We analize the postoperative analgesic requirements for this procedure in 117 patients. PRESENTATION OF CASES: Between 2012 and 2013, 117 consecutive patients undergoing Milligan-Morgan hemorroidectomy, with an analysis of sex, age, total vascular anal cushions removed, hospital stay, complications, and relation with postoperative analgesic requirements. Patients with documented allergy to NSAIDs or pyrazolones were excluded. Additionally 23 patients undergoing Milligan-Morgan hemorrhoidectomy associated to internal lateral sphincterotomy were also analyzed. RESULTS: The mean age of patients was 51.7 years. The 50.8% were women and 49.2% men. In 33.3% of cases, one vascular anal cushion was removed, 2 in 39.3%, and 3 in 27.4%. The average stay for the 3 groups was 2.0days. An analgesic dose average of 4.1 by day was given, with opioid requirements in 22.2% of cases. It was statistically significant that as more anal cushions were eliminated was higher the opioids need. No significant difference of opioids use was found regarding patients undergoing sphincterotomy as additional procedure. DISCUSSION: Postoperative pain after a Milligan-Morgan hemorrhoidectomy currently remains a problem for colorectal surgery teams. This involves the use of opioids comparable to other major surgeries, finally causing not negligible days of admission charge. A protocolized analgesic treatment, as we actually do in our center, should be implemented after a Milligan-Morgan hemorrhoidectomy for improving the postoperative period pain management.

Cuidados e implicaciones en los cuidadores de pacientes quirúrgicos en el domicilio / Care and implications for caregivers of surgical patients at home

OBJETIVO: Identificar el tipo de cuidados que prestaban los cuidadores de pacientes intervenidos de cirugía abdominal en el Consorcio Hospitalario de Vic, Vic (Barcelona), comparar la intensidad que suponían estos cuidados durante el proceso quirúrgico, conocer las repercusiones del cuidar sobre su salud, e identificar los factores que contribuían a la necesidad de prestación de cuidados y aparición de repercusiones en los cuidadores, en sus domicilios. METODOLOGÍA: Estudio observacional longitudinal con seguimiento al ingreso, al alta y a los 10 días en cuidadores informales no remunerados, de pacientes con patología quirúrgica abdominal. Se estudiaron las características de los cuidadores y de los pacientes quirúrgicos que cuidaban. Para identificar los cuidados que prestaba el cuidador y las repercusiones desencadenadas por cuidar en su salud, se utilizó el cuestionario ICUB97-R, basado en el modelo de Virginia Henderson. RESULTADOS: La mayoría de los cuidadores eran mujeres, de 52,9 ± 13,7 años y sin experiencia previa como cuidadoras. La mayor intensidad de cuidados y repercusiones se objetivó en el momento de llegar a casa, tras el alta hospitalaria (p < 0,05). Las variables predictivas de repercusiones fueron ser paciente dependiente antes de la intervención quirúrgica (β = 2,93, p = 0,007), diagnóstico de neoplasia (β = 2,87, p < 0,001) y tiempo de dedicación al cuidado (β = 0,07, p = 0,018). CONCLUSIONES: Los cuidadores durante el proceso quirúrgico prestan numerosos cuidados en el domicilio, dependiendo de las características de los pacientes que cuidan y ello repercute sobre su calidad de vida

OBJECTIVE: To identify the care given by informal caregivers to patients who underwent abdominal surgery in the Consorci Hospitalari of Vic (Barcelona). To compare the responsibility burden for those caregivers in all the different stages of the surgical process. To determine the consequences of the care itself on the caregiver's health and to identify the factors that contribute to the need of providing care and the appearance of consequences for the caregivers in the home. METHODOLOGY: A longitudinal observational study with follow-up at admission, at discharge and 10 days, of 317 non-paid caregivers of patients who suffer underwent surgery. The characteristics of caregivers and surgical patients were studied. The validated questionnaire, ICUB97-R based on the model by Virginia Henderson, was used to measure the care provided by informal caregivers and its impact on patient quality of life. RESULTS: Most of the caregivers were women, with an average age of 52.9 ± 13.7 years without any previous experience as caregivers. The greater intensity of care and impact was observed in the time when they arrived home after hospital discharge (p < 0.05). The predictive variables of repercussions were being a dependent patient before the surgical intervention (β = 2.93, p = 0.007), having a cancer diagnosis (β = 2.87, p < .001) and time dedicated to the care process (β= 0.07, p = 0.018). CONCLUSIONS: Caregivers involved in the surgical process provide a great amount of care at home depending on the characteristics of patients they care for, and it affects their quality of life

[Care and implications for caregivers of surgical patients at home]. / Cuidados e implicaciones en los cuidadores de pacientes quirúrgicos en el domicilio.

OBJECTIVE: To identify the care given by informal caregivers to patients who underwent abdominal surgery in the Consorci Hospitalari of Vic (Barcelona). To compare the responsibility burden for those caregivers in all the different stages of the surgical process. To determine the consequences of the care itself on the caregiver's health and to identify the factors that contribute to the need of providing care and the appearance of consequences for the caregivers in the home. METHODOLOGY: A longitudinal observational study with follow-up at admission, at discharge and 10 days, of 317 non-paid caregivers of patients who suffer underwent surgery. The characteristics of caregivers and surgical patients were studied. The validated questionnaire, ICUB97-R based on the model by Virginia Henderson, was used to measure the care provided by informal caregivers and its impact on patient quality of life. RESULTS: Most of the caregivers were women, with an average age of 52.9±13.7 years without any previous experience as caregivers. The greater intensity of care and impact was observed in the time when they arrived home after hospital discharge (p<0.05). The predictive variables of repercussions were being a dependent patient before the surgical intervention (ß=2.93, p=0.007), having a cancer diagnosis (ß=2.87, p<.001) and time dedicated to the care process (ß=0.07, p=0.018). CONCLUSIONS: Caregivers involved in the surgical process provide a great amount of care at home depending on the characteristics of patients they care for, and it affects their quality of life.

[Surgical patients hospital home care program: two years evaluation]. / Programa de hospitalización domiciliara de pacientes quirúrgicos: evaluación de los dos años de funcionamiento.

OBJECTIVE: To evaluate the results after two years of the implementation of surgical patients' hospital home care program in Consort. Hospitalari de Vic. METHOD: Longitudinal study conducted between January 2011 and December 2012 on patients enrolled in hospital home care program patients. Sociodemographic, clinical, financial, management and patients experience variables were analysed. Data were obtained from hospital home care program records and Hospital Information Systems in addition to telephone surveys. We performed a univariate descriptive analysis using the statistical package SPSS Statistics 19. RESULTS. 691 patients were assessed, and 80.75% were included in hospital home care program. The average hospital length of stay was 5.01 days, with a 3.05% of readmission rate. A higher number of male patients were treated; patients under general surgery, orthopaedics and urology specialties were the more prevalence in the program. 82% of patients were assigned to the care plan "surgical patient", and the most recorded potential complications were pain (539) and infection (436). The mean overall satisfaction score with care was 8.67 +/- 1.37 out of 10. CONCLUSIONS: The results objectively reflect the impact of hospital home care program in our context. Moreover, it highlights the importance of the advanced nursing role.

Programa de hospitalización domiciliaria de pacientes quirúrgicos. Evaluación de los dos años de funcionamiento / Surgical patients hospital home care program: two years evaluation

Objetivo. Evaluar los resultados obtenidos con la implantación del programa de Hospitalización Domiciliaria Quirúrgica (HDQ) en el Consorci Hospitalari de Vic durante un periodo de dos años. Método. Estudio longitudinal realizado entre enero de 2011 y diciembre de 2012, sobre los pacientes incluidos en el programa de HDQ. Se estudiaron variables sociodemográficas, clínicas, económicas, de gestión y de percepción del usuario. Los datos se obtuvieron de los registros del programa HDQ, de la Unidad de Planificación y de los sistemas de información, y mediante encuestas telefónicas. Se realizó un análisis descriptivo univariado con el paquete estadístico IBM SPSS Statistics 19. Resultados. Se valoraron 691 pacientes. El 80.75 % se incluyó en el programa HDQ, su estancia media global fue de 5.01 días y la tasa de reingreso del 3.05 %. Destacó un mayor número de pacientes tratados de sexo masculino; las especialidades que aportaron más pacientes al programa fueron cirugía general, traumatología y urología. Se asignó el plan de cuidados del «paciente quirúrgico intervenido» al 82 % de los pacientes, y las complicaciones potenciales enfermeras más registradas fueron el dolor (539) y la infección (436). La puntuación media de satisfacción global sobre la atención recibida y el funcionamiento de HDQ fue de 8.67 ± 1.37 sobre 10. Conclusiones. Los resultados objetivan el impacto de la HDQ en nuestro ámbito y ponen de manifiesto la relevancia del rol de la atención enfermera especializada en el domicilio (AU)

Objective. To evaluate the results after two years of the implementation of surgical patients’ hospital home care program in Consorci Hospitalari de Vic. Method. Longitudinal study conducted between January 2011 and December 2012 on patients enrolled in hospital home care program patients. Sociodemographic, clinical, financial, management and patients experience variables were analysed. Data were obtained from hospital home care program records and Hospital Information Systems in addition to telephone surveys. We performed a univariate descriptive analysis using the statistical package SPSS Statistics 19. Results. 691 patients were assessed, and 80.75 % were included in hospital home care program. The average hospital length of stay was 5.01 days, with a 3.05 % of readmission rate. A higher number of male patients were treated; patients under general surgery, orthopaedics and urology specialties were the more prevalence in the program. 82 % of patients were assigned to the care plan «surgical patient», and the most recorded potential complications were pain (539) and infection (436). The mean overall satisfaction score with care was 8.67 ± 1.37 out of 10. Conclusions. The results objectively reflect the impact of hospital home care program in our context. Moreover, it highlights the importance of the advanced nursing role (AU)

Pacientes quirúrgicos e intervenciones enfermeras estandarizadas. Estudio descriptivo sobre resultados / Descriptive study of the results of nursing interventions applied to surgical patients

Objetivos: conocer la evolución de los resultados de salud de los pacientes quirúrgicos durante su estancia hospitalaria, evaluando criterios de resultado NOC al ingreso y alta. Método: estudio prospectivo observacional realizado en las plantas de hospitalización quirúrgica del Hospital General de Vic, con pacientes que precisaron una intervención quirúrgica de cualquier especialidad, a partir de 18 añ;os, con niveles de riesgo anestésico I, II o III. Las variables principales de resultado fueron indicadores asociados a cada NOC de un plan de cuidados estandarizado, basado en el concepto «paciente tipo». Resultados: participaron 460 pacientes, de ellos 69(15%) fueron intervenidos de operaciones del sistema musculoesquelético y 391(85%) de operaciones del aparato digestivo, urinario y órganos genitales masculinos y femeninos, de operaciones de la piel, tegumentos y/o sistema endocrino. Las puntuaciones NOC al alta de todos los pacientes se mantuvieron o mejoraron, nunca empeoraron y en todos los pacientes el número de caídas y de infecciones recurrentes fue una constante. Prácticamente ningún enfermo se cayó, ni se infectó. Conclusiones: la mayoría de los pacientes quirúrgicos en el momento de recibir el alta hospitalaria mejoran o mantienen sus condiciones de ingreso y los que empeoran nunca lo hacen sustancialmente(AU)

Objectives: Knowing the evolution of health outcomes of surgical patients during their hospital stay, evaluating NOC outcome criteria at admission and discharge. Material and methods: Prospective observational study conducted in the surgical hospital wards of the Hospital General de Vic, with patients who required surgical intervention of any specialty, of 18 or more years old and anesthetic risk levels I, II or III. The main outcome variables were indicators associates with each NOC of a standard of care based on the "patient type" concept. Results: Four hundred and six patients participated. Of these, 69 (15%) were operated of the musculoskeletal system and 391 (85%) were operated on the digestive or urinary systems, male/female genitalia, skin, integuments, and endocrine system. NOC scores high of all patients were maintained or improved, never worse and in all patients the number of falls and recurrent infections was constant, virtually no patient fell or became infected. Conclusions: The majority of surgical patients at the time of hospital discharge improves or maintain their conditions of admission and patients who never worse substantially(AU)

[Descriptive study of the results of nursing interventions applied to surgical patients]. / Pacientes quirúrgicos e intervenciones enfermeras estandarizadas. Estudio descriptivo sobre resultados.

OBJECTIVES: Knowing the evolution of health outcomes of surgical patients during their hospital stay, evaluating NOC outcome criteria at admission and discharge. MATERIAL AND METHODS: Prospective observational study conducted in the surgical hospital wards of the Hospital General de Vic, with patients who required surgical intervention of any specialty, of 18 or more years old and anesthetic risk levels I, II or III. The main outcome variables were indicators associates with each NOC of a standard of care based on the "patient type" concept. RESULTS: Four hundred and six patients participated. Of these, 69 (15%) were operated of the musculoskeletal system and 391 (85%) were operated on the digestive or urinary systems, male/ female genitalia, skin, integuments, and endocrine system. NOC scores high of all patients were maintained or improved, never worse and in all patients the number of falls and recurrent infections was constant, virtually no patient fell or became infected. CONCLUSIONS: The majority of surgical patients at the time of hospital discharge improves or maintain their conditions of admission and patients who never worse substantially.

[A study on surgical dressings and the uses associated to them]. / Apósitos quirúrgicos factores asociados con su uso.

OBJECTIVE: To identify the variability in the surgical dressing practices and to assess the factors of their use. METHOD: A prospective study on surgical dressings was carried out. Data was collected on some post surgery patients who, once outside the operating room in a general hospital, they were still wearing a surgical dressing. A non-random sample was included. Socio demographic data, pre operative and intra operative data inside the operating room were collected as well as post surgical tests in the surgical inpatient wards. Tests chi2 were carried out for the category variables, tau Student for the continuous ones and the variant analysis. RESULTS: 315 patients were put into groups of 5 according to the surgical proceedings. All dressings were realized with non-woven gauze dressings (more absorbent) and mostly removed every 24 to 48 hours. Two groups showed more exuded dressings. The highest percentage of lesions appeared when dressings were removed between 24 and 48 hours. 50% of the removed ones before the first 24 hours had been over dressed and the chance of having skin lesion was increased 7 times with the reinforcement. Patients showed a medium average of comfort of 6,09 (EVA 0-10) to the dressings. CONCLUSIONS: The use of the traditional dry dressings to cover surgical wounds and the technique to apply a dressing over the existing one are here confirmed. A direct relation is observed between the reapplication of dressings to the same wound and the skin lesions.

Apósitos quirúrgicos. Factores asociados con su uso / A study on surgical dressings and the uses associated to them

Objetivo: identificar la variabilidad en la práctica de los apósitos quirúrgicos y los factores asociados con su uso. Método: se realizó un estudio transversal sobre los apósitos quirúrgicos. Se estudió una población de pacientes quirúrgicos de un hospital general que al salir del quirófano eran portadores de dicho apósito. Se incluyó una muestra no aleatoria. Se recogieron datos sociodemográficos y clínicos preoperatorios e intraoperatorios en el quirófano y postoperatorios en las plantas de hospitalización quirúrgica. Se efectuaron pruebas de alpha2 para las variables categóricas y para las continuas la ? de Student y el análisis de la varianza. Resultados: 315 pacientes se agruparon en cinco grupos, según el procedimiento quirúrgico. Todos los apósitos se realizaron con gasas hidrófilas de algodón, fijados con apósito de tejido sin tejer y la mayoría cambiados entre las 24-48 horas. Dos grupos presentaron más apósitos manchados. El mayor porcentaje de lesiones aparecía cuando se cambiaban entre las 24 y las 48 horas. El 50% de los cambiados antes de las 24 horas había sido reforzado y la probabilidad de que se lesionara la piel se multiplicaba por siete con el refuerzo. Los pacientes manifestaron un confort medio de 6,09 (EVA 0- 10) respecto al apósito. Conclusiones: se constata el uso del apósito tradicional de gasa seca para cubrir las heridas operatorias y la técnica de refuerzo de los apósitos. Se observa una relación directa entre el refuerzo y las lesiones en la piel(AU)

Objective: To identify the variability in the surgical dressing practices and to assess the factors of their use. Method: A prospective study on surgical dressings was carried out. Data was collected on some post surgery patients who, once outside the operating room in a general hospital, they were still wearing a surgical dressing. A non-random sample was included. Socio demographic data, pre operative and intra operative data inside the operating room were collected as well as post surgical tests in the surgical inpatient wards. Tests alpha2 were carried out for the category variables, ? Student for the continuous ones and the variant analysis. Results: 315 patients were put into groups of 5 according to the surgical proceedings. All dressings were realized with non-woven gauze dressings (more absorbent) and mostly removed every 24 to 48 hours. Two groups showed more exuded dressings. The highest percentage of lesions appeared when dressings were removed between 24 and 48 hours. 50% of the removed ones before the first 24 hours had been over dressed and the chance of having skin lesion was increased 7 times with the reinforcement. Patients showed a medium average of comfort of 6,09 (EVA 0-10) to the dressings. Conclusions: The use of the traditional dry dressings to cover surgical wounds and the technique to apply a dressing over the existing one are here confirmed. A direct relation is observed between the reapplication of dressings to the same wound and the skin lesions(AU)

Concepto «paciente tipo»: utilidad para el cuidado de los pacientes quirúrgicos / The concept of “patient type”: utility for the care of surgical patients

Objetivo. Identificar y describir las necesidades y las características de los pacientes intervenidos de patología quirúrgica y describir un modelo de «paciente tipo» quirúrgico. Método. Se realizó un estudio transversal para describir un paciente tipo quirúrgico, formado por una o más tipologías con características y/o necesidades similares. La población de estudio fueron los pacientes ingresados en las plantas de hospitalización quirúrgicas de un hospital general, en un período de 10 meses. Se recogieron variables sociodemográficas, clínicas, grado de autonomía y necesidades según V. Henderson mediante una entrevista llevada a cabo durante el postoperatorio. Se realizaron análisis univariante, descriptivo estratificado y de correspondencias múltiples. Resultados. Participaron 270 pacientes de mediana o de baja complejidad, de diferentes especialidades quirúrgicas. Durante el proceso quirúrgico (preoperatorio y postoperatorio) casi la mitad de los pacientes se hipotensaban, la frecuencia cardíaca no sufría cambios significativos y no variaba el riesgo de sufrir úlceras por presión según la escala de Norton. Un primer análisis estadístico clasificó a los pacientes quirúrgicos en 5 grupos y mostró la relación existente entre el grado de autonomía mediante el índice de Barthel, y el número de problemas personales de los pacientes según el modelo de Henderson. Posteriormente, el análisis de conglomerados clasificó a los pacientes quirúrgicos en 4 clases o tipos que explicaban el 70% de la varianza total. Conclusiones. Se ha identificado mediante el modelo de Henderson un «paciente tipo» formado por 4 clases. Se plantea su uso para facilitar el cuidado de los pacientes de mediana o de baja complejidad quirúrgica de diferentes especialidades(AU)

Objective. To describe a model of surgical “patient type” by identifying the needs and characteristics of surgical patients. Method. We performed a cross-sectional study of surgical patients with one or more diseases and similar needs and/or characteristics admitted to the surgical wards of a general hospital over a 10-month period. The variables analyzed were sociodemographic and clinical data, degree of autonomy, and Virginia Henderson′s needs, which were identified through an interview performed in the postoperative period. Univariate analysis, stratified descriptive statistics and multiple correspondence analysis were performed. Results. A total of 270 medium- or low-complexity patients from different surgical specialities took part in the analysis. During the surgical process (pre- and post-operative), almost a half of the patients suffered from hypotension, heart rate showed no significant changes and the risk of developing a pressure ulcer was unmodified according to Norton's scale. The first statistical analysis classified the surgical patients into five groups and showed the relationship between the degree of autonomy (measured through Barthel's index) and the number of personal problems (assessed according to the Henderson model). A subsequent statistical analysis classified the patients into four groups or types, explaining 70% of the total variance. Conclusions. Through the use of Virginia Henderson's model, a surgical patient type composed of four different groups was identified. The results of this study may be useful in the care of low- and medium-complexity patients in distinct surgical specialities(AU)

[The concept of "patient type": utility for the care of surgical patients]. / Concepto <>: utilidad para el cuidado de los pacientes quirúrgicos.

OBJECTIVE: To describe a model of surgical "patient type" by identifying the needs and characteristics of surgical patients. METHOD: We performed a cross-sectional study of surgical patients with one or more diseases and similar needs and/or characteristics admitted to the surgical wards of a general hospital over a 10-month period. The variables analyzed were sociodemographic and clinical data, degree of autonomy, and Virginia Henderson's needs, which were identified through an interview performed in the postoperative period. Univariate analysis, stratified descriptive statistics and multiple correspondence analysis were performed. RESULTS: A total of 270 medium- or low-complexity patients from different surgical specialties took part in the analysis. During the surgical process (pre- and post-operative), almost a half of the patients suffered from hypotension, heart rate showed no significant changes and the risk of developing a pressure ulcer was unmodified according to Norton's scale. The first statistical analysis classified the surgical patients into five groups and showed the relationship between the degree of autonomy (measured through Barthel's index) and the number of personal problems (assessed according to the Henderson model). A subsequent statistical analysis classified the patients into four groups or types, explaining 70% of the total variance. CONCLUSIONS: Through the use of Virginia Henderson's model, a surgical patient type composed of four different groups was identified. The results of this study may be useful in the care of low- and medium-complexity patients in distinct surgical specialties.