Evolución de la tasa de amputación en España entre los años 2003 y 2020

Introducción: Las amputaciones de miembros inferiores siguen siendo un problema de salud a pesar de la disminución generalizada de las amputaciones mayores en los países occidentales. Las amputaciones menores presentan variabilidad entre países y sistemas sanitarios. El envejecimiento, la diabetes y la isquemia crítica condicionan su evolución. Hipótesis: Se pretende comprobar la disminución de las tasas de amputación mayor en España. Material y método: Analizamos entre 2003 y 2020 los procedimientos de amputación del Registro de Actividad Especializada, y los procedimientos de revascularización entre 2003 y 2015. Valoramos la evolución de tasas mediante el Cambio Porcentual Anual (CPA), así como la evolución de la comorbilidad, la mortalidad intrahospitalaria, la estancia y su correlación con la revascularización. Resultados: Entre 2003 y 2020 disminuye el número de amputaciones mayores (-0,68% anual), así como las tasas bruta, CPA -1,57% IC 95% [-1,82%;-1,31%] p<0,001, y ajustada por edad y sexo, CPA -3% IC 95% [-3,28%;-2,71%] p<0,001. Las amputaciones menores aumentan un 2,80% anual, así como la tasa bruta, CPA 1,75% IC 95% [1,35%;2,15%] p<0,001, y la ajustada, CPA 0,406% IC 95% [0,0159%;0,798%] p 0,042. La incidencia en hombres es 2,7 veces mayor que en mujeres y aparece 7 años antes (p<0,001). La relación hombres mujeres se incrementa durante el periodo, CPA 2,31% IC 95% [1,99%;2,62%] p<0,001. Los diagnósticos más frecuentes en estos pacientes son la diabetes (77,4%) y la enfermedad arterial periférica (62,2%). El índice de Charlson presenta un incremento a lo largo del periodo. La combinación de diabetes e isquemia es la más frecuente (38,11%, 41,61% respectivamente). Seguido de la combinación de diabetes, isquemia e infección en las amputaciones menores (19,56%) y de la isquemia aislada en las amputaciones mayores (26,06%). La mortalidad intrahospitalaria ha disminuido a lo largo del periodo. CPA -2,89% IC 95% [-3,39%;- 2,39%] p<0,001. 157 La estancia ha disminuido a lo largo del periodo. CPA -1,6% IC 95% [-1,89%;-1,31%] p<0,001. El número de revascularizaciones, la tasa bruta y la tasa ajustada por edad y sexo presentan un incremento a lo largo del periodo, se correlaciona con la reducción de amputaciones mayores y el incremento de amputaciones menores, índice de correlación de Pearson -0,95 y 0,95 respectivamente, p<0,001. El número episodios con alta dada por un Servicio de Cirugía Vascular se correlaciona con las tasas de amputación mayor, índice de correlación de Pearson -0,90 p<0,001. Conclusiones: Se objetiva una disminución de las amputaciones mayores. Encontramos una relación inversa entre las amputaciones mayores y menores. La isquemia y la diabetes son los principales diagnósticos. Ha disminuido la mortalidad intrahospitalaria y la estancia media. Por último, existe una correlación entre las tasas de revascularización, el despliegue de Servicios de Cirugía Vascular y las tasas de amputación.Introduction: Lower limb amputations are still a healthcare problem despite de reduction of major amputations in western countries. Minor amputations rates are variable between countries and healthcare systems. The age, diabetes and critical limb ischaemia are the main factors of its evolution. Hypothesis: We pretend to assess de reduction of the major amputation rates in Spain. Material and method: We analyse the amputation procedures between 2003 and 2020 from the Spanish Registry of Specialized Activity, and the revascularization procedures between 2003 and 2015. The evolution is assessed with Annual Percentage Change (APC), as well as the evolution of the comorbidities, in hospital mortality, average stay and its correlation with revascularizations. Results: Between 2003 and 2020 a reduction of the number of major amputations is observed (-0,68% per year), as well as the gross rate, APC -1,57% IC 95% [-1,82%;-1,31%] p<0,001, and the age and sex adjusted rate, APC -3% IC 95% [-3,28%;-2,71%] p<0,001.Minor amputations grow 2,80% per year, as well as the gross rate, APC 1,75% IC 95% [1,35%;2,15%] p<0,001, and the adjusted rate, APC 0,406% IC 95% [0,0159%;0,798%] p 0,042. The incidence in men is 2,7 fold than in women and appears 7 years earlier (p<0,001). The men/women ratio is increased through the period, APC 2,31% IC 95% [1,99%;2,62%] p<0,001. The most frequent diagnostics in this patients are diabetes (77,4%) and peripheral artery disease (62,2%). The Charlson index increases along the period. The diabetes and ischaemia combination is the most frequent one (minor 38,11%, major 41,61%). Followed by the combination of diabetes, ischaemia and infection in minor amputations (19,56%) and the ischaemia in major amputations (26,06%). In hospital mortality decreases along the period. APC -2,89% IC 95% [-3,39%;- 2,39%] p<0,001. The average stay decreases along the period. CPA -1,6% IC 95% [-1,89%;-1,31%] p<0,001. The number of revascularizations, the gross rate, and the adjusted rate increases along the period, and it is correlated with the reduction of major amputations and the increase of minor amputados, Pearson index -0,95 y 0,95 respectivamente, p<0,001. The number of episodes discharged by a Vascular Surgery Department is correlated with the major amputation rates, Pearson Index -0,90 p<0,001. Conclusions: The study finds a reduction of major amputations, an inverse relation between major and minor amputations. Ischaemia and diabetes are the main diagnostics. In hospital mortality and mean stay present a reduction along the period. And there is a correlation between revascularization rates, Vascular Surgery Departments expansion and amputation rates

The persistent breach between evidence and practice in the prevention of surgical site infection. Qualitative study.

Despite the dissemination of guidelines for surgical site infection (SSI) prevention, a gap between the theoretical measures and their compliance persists. Accurate estimates of the implementation of preventative measures is crucial before planning dissemination strategies. A web-based survey was distributed to members of 11 Associations of operative nurses and surgeons. Questions aimed to determine their awareness of evidence, personal beliefs and actual use of the main preventative measures. Of 1105 responders, 50.5% receive no feed-back of their SSI rate. Responders show a moderate rate of awareness of the recommendations about not removing hair, hair clipping, skin antisepsis with alcoholic solutions, and normothermia. Antibiotic prophylaxis is given for more than 24 h by 18.8% of respondents. Screening for S. aureus is performed by 27.6%. Hair removal by shaving is used by 16.6% of responders. The most common antiseptic solutions are alcoholic chlorhexidine (57.2%) and aqueous povidone (23.3%). 62.8% of surgeons allow the solution to air dry before applying surgical drapes. Adhesive drapes in the surgical field are used routinely in 33.4% of cases. Perioperative normothermia, glucose control and hyperoxia are used in 84.3%, 65.9% and 23.3% of cases. Antimicrobial sutures and negative pressure therapy are used by 20.2% and 43.5% of teams, respectively. Prior to closing the incision, 83.9% replace surgical instruments always or selectively. Wound irrigation before closing is used in 78.1% of cases, mostly with saline. Check-lists, standardized orders, surveillance, feed-back and educational programs were rated most highly by respondents as a means to improve compliance with preventative guidelines, but few of these strategies were in place at their institutions. Gaps in the translation of evidence into practice remain in the prevention of SSI among different surgical specialities. Several areas for improvement have been identified, as some core prevention measures are not in common use