LITOTRICIA EXTRACORPOREA POR ONDAS DE CHOQUE GUIADA POR ECOGRAFIA: SEMIOLOGIA DE LOS SIGNOS ECOGRAFICOS DE FRAGMENTACION

INTRODUCCIÓN Desde diciembre de 2007, en nuestro servicio se ha empleado el ecógrafo como método de focalización de la litiasis renal para el tratamiento con litotricia extracorpórea por ondas de choque (LEOC). Se observó la aparición, en los mismos, de una serie de signos litiásicos que han sido sometidos a estudio. OBJETIVOS La caracterización y la semiología de los signos ecográficos de fragmentación litiásica mediante la focalización ecográfica, durante LEOC y la creación de un modelo probabilístico de fragmentación, en función de la cantidad de signos encontrados. MATERIAL Y METODOS Se diseñó un estudio de cohortes retrospectivo sobre una base de datos de recogida prospectiva de todos los pacientes sometidos a tratamiento de LEOC sobre litiasis renal con focalización ecográfica entre enero de 2012 a diciembre de 2016 en un hospital de tercer nivel. Finalizado el tratamiento, se practicó control ecográfico entre los 20 y 30 días siguientes, considerando la existencia de fragmentación ante la desaparición del cálculo o generación de fragmentos múltiples (de un tamaño igual o menor de 2 mm), proponiendo nuevo tratamiento en el caso de que los fragmentos litiásicos superen los 3 mm de diámetro. RESULTADOS Se define como signo ecográfico todo cambio con respecto al aspecto inicial de la litiasis a tratar que aparece durante dicho tratamiento. A lo largo del tratamiento, se anotó una o varias de las seis posibilidades, apreciadas por el urólogo, en la ficha de trabajo, siendo cinco los signos observados que se describen ("Dispersión", "Aumento de Ecogenicidad", "Medallón", "Aumento de Sombra Posterior"y "Salto"). CONCLUSIONES La descripción y monitorización de estos signos durante el tratamiento es una buena referencia a la hora de valorar el éxito o fracaso del mismo y predecir la fragmentación de las litiasis

Implementation of an ERAS program in patients undergoing thoracic surgery at a third-level university hospital: an ambispective cohort study

Objective: To analyze the effects of an ERAS program on complication rates, readmission, and length of stay in patients undergoing pulmonary resection in a tertiary university hospital. Methods: Ambispective cohort study with a prospective arm of 50 patients undergoing thoracic surgery within an ERAS program (ERAS group) versus a retrospective arm of 50 patients undergoing surgery before the protocol was implemented (Standard group). The primary outcome was the number of patients with 30-day surgical complications. Secondary outcomes included ERAS adherence, non-surgical complications, mortality, readmission, reintervention rate, pain, and hospital length of stay. We performed a multivariate logistic analysis to study the correlation between outcomes and ERAS adherence. Results: In the univariate analysis, we found no difference between the two groups in terms of surgical complications (Standard 18 [36%] vs. ERAS 12 [24%], p = 0.19). In the ERAS group, only the readmission rate was significantly lower (Standard 15 [30%] vs. ERAS 6 [12%], p = 0.03). In the multivariate analysis, ERAS adherence was the only factor associated with a reduction in surgical complications (OR [95% CI] = 0.02 [0.00, 0.59], p = 0.03) and length of stay (HR [95% CI] = 18.5 [4.39, 78.4], p < 0.001). Conclusions: The ERAS program significantly reduced the readmission rate at our hospital. Adherence to the ERAS protocol reduced surgical complications and length of stay

Intraoperative goal directed hemodynamic therapy in noncardiac surgery: a systematic review and meta-analysis

Abstract Background: The goal directed hemodynamic therapy is an approach focused on the use of cardiac output and related parameters as end-points for fluids and drugs to optimize tissue perfusion and oxygen delivery. Primary aim: To determine the effects of intraoperative goal directed hemodynamic therapy on postoperative complications rates. Methods: A meta-analysis was carried out of the effects of goal directed hemodynamic therapy in adult noncardiac surgery on postoperative complications and mortality using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. A systematic search was performed in Medline PubMed, Embase, and the Cochrane Library (last update, October 2014). Inclusion criteria were randomized clinical trials in which intraoperative goal directed hemodynamic therapy was compared to conventional fluid management in noncardiac surgery. Exclusion criteria were trauma and pediatric surgery studies and that using pulmonary artery catheter. End-points were postoperative complications (primary) and mortality (secondary). Those studies that fulfilled the entry criteria were examined in full and subjected to quantifiable analysis, predefined subgroup analysis (stratified by type of monitor, therapy, and hemodynamic goal), and predefined sensitivity analysis. Results: 51 RCTs were initially identified, 24 fulfilling the inclusion criteria. 5 randomized clinical trials were added by manual search, resulting in 29 randomized clinical trials in the final analysis, including 2654 patients. A significant reduction in complications for goal directed hemodynamic therapy was observed (RR: 0.70, 95% CI: 0.62-0.79, p < 0.001). No significant decrease in mortality was achieved (RR: 0.76, 95% CI: 0.45-1.28, p = 0.30). Quality sensitive analyses confirmed the main overall results. Conclusions: Intraoperative goal directed hemodynamic therapy with minimally invasive monitoring decreases postoperative complications in noncardiac surgery, although it was not able to show a significant decrease in mortality rate

Perioperative Use of Clevidipine: A Systematic Review and Meta-Analysis

<div><p>Background</p><p>Clevidipine is an ultrashort-acting drug for rapid reduction of blood pressure by selectively acting on the L-type Ca2+ channels on arteriolar smooth muscle. The drug’s ultrashort action in reducing the blood pressure is due to its rapid hydrolysis by blood and extravascular tissue esterases, which does not depend on hepato-renal metabolism and excretion. An analysis of the perioperative management of blood pressure should be considered to compare with other intravenous antihypertensive agents.</p><p>Methods</p><p>Analyses of the available evidence in randomized clinical trials following the PRISMA methodology as well as clinical significance according to the GRADE system were conducted. Placebo versus other antihypertensive drugs studies were included. Statistical assessments were done using the X2 and I2 tests.</p><p>Results</p><p>Clevidipine was more effective in maintaining the blood pressure within pre-specified ranges compared with other antihypertensive drugs (MD, -17.87 CI 95%: -29.02 to -6.72; p = 0.02). The use of Clevidipine versus placebo and rescue antihypertensive intravenous drug showed a clear reduction in rates of treatment failure (RR 0.10; IC 95%; 0.05–0.18; p <0.0001). There was no difference in the incidence of adverse events compared with placebo (RR 1.47; 95% CI 0.89 to 2.43, p = 0.14) and with other antihypertensive drugs (RR 0.78, 95% CI 0.45 to 1.35; p = 0.37). In addition, there was no difference in the incidence of atrial fibrillation (AF) between clevidipine and control groups (RR 1.09, IC del 95%: 0.65 a 1.83; p = 0.73).</p><p>Conclusions</p><p>Clevidipine is an ultrafast-acting drug that is highly effective for management of perioperative arterial hypertension. It is devoid of adverse effects associated with the use of other IV antihypertensives. Its favorable pharmacodynamic and pharmacokinetic properties make clevidipine the drug of choice for the management of acute perioperative hypertension. It is important to emphasize the need for further studies with a larger number of patients to confirm these findings and increase the degree of evidence.</p></div

Complications.

<p>Complications.</p

Enhanced recovery after surgery protocol versus conventional perioperative care in colorectal surgery. A single center cohort study

Background: Enhanced recovery after surgery (ERAS) protocols consist of a set of perioperative measures aimed at improving patient recovery and decreasing length of stay and postoperative complications. We assess the implementation and outcomes of an ERAS program for colorectal surgery. Methods: Single center observational study. Data were collected from consecutive patients undergoing open or laparoscopic colorectal surgery during 2 time periods, 3 years before (Pre-ERAS) and 2 years after (Post-ERAS) the implementation of an ERAS protocol. Baseline characteristics of both groups were compared. The primary outcome was the number of patients with 180 days follow-up with moderate or severe complications; secondary outcomes were postoperative length of stay, and specific complications. Data were extracted from patient records. Results: There were 360 patients in the Pre-ERAS group and 319 patients in the Post-ERAS Group. 214 (59.8%) patients developed at least one complication in the pre ERAS group, versus 163 patients in the Post-ERAS group (51.10%). More patients in the Pre-ERAS group developed moderate or severe complications (31.9% vs. 22.26%, p = 0.009); and severe complications (15.5% vs. 5.3%; p < 0.0001). The median length of stay was 13 (17) days in Pre-ERAS Group and 11 (10) days in the Post-ERAS Group (p = 0.034). No differences were found on mortality rates (4.7% vs. 2.5%; p = 0.154), or readmission (6.39% vs. 4.39%; p = 0.31). Overall ERAS protocol compliance in the Post-ERAS cohort was 88%. Conclusions: The implementation of ERAS protocol for colorectal surgery was associated with a significantly reduction of postoperative complications and length of stay. Resumo: Justificativa: O protocolo ERAS — do Inglês Enhanced Recovery After Surgery — consiste em um conjunto de medidas perioperatórias destinadas a melhorar a recuperação do paciente e diminuir o tempo de internação e as complicações pós-operatórias. Avaliamos a implementação e os resultados de um protocolo ERAS para cirurgia colorretal. Métodos: Estudo observacional em centro único. Os dados foram coletados de pacientes consecutivos submetidos à cirurgia colorretal aberta ou laparoscópica durante dois períodos: três anos antes (pré-ERAS) e dois anos após (pós-ERAS) a implementação de um protocolo ERAS. As características basais de ambos os grupos foram comparadas. O desfecho primário foi o número de pacientes com 180 dias de acompanhamento com complicações moderadas ou graves. Os desfechos secundários foram tempo de internação pós-cirurgia e complicações específicas. Os dados foram extraídos de prontuários dos pacientes. Resultados: O grupo pré-ERAS foi composto por 360 pacientes e o grupo pós-ERAS por 319. No grupo pré ERAS, 214 pacientes (59,8%) desenvolveram pelo menos uma complicação versus 163 pacientes (51,10%) no grupo pós-ERAS. Um número maior de pacientes do grupo pré-ERAS desenvolveu complicações moderadas ou graves (31,9% vs. 22,26%, p = 0,009); e complicações graves (15,5% vs. 5,3%; p < 0,0001). A mediana do tempo de internação foi de 13 (17) dias no grupo Pré-ERAS e de 11 (10) dias no grupo pós-ERAS (p = 0,034). Não houve diferença nas taxas de mortalidade (4,7% vs. 2,5%; p = 0,1554) ou de reinternação (6,39% vs. 4,39%; p = 0,31). A conformidade geral do protocolo ERAS na coorte pós-ERAS foi de 88%. Conclusões: A implantação do protocolo ERAS para cirurgia colorretal foi associada a uma redução significativa das complicações pós-operatórias e do tempo de internação. Keywords: Perioperative, Enhanced recovery after surgery, Postoperative complications, Palavras-chave: Perioperatório, Aceleração da recuperação pós-operatória, Complicações pós-operatória

Forest Plot.

<p>Atrial Fibrillation. Forest plot considering p < 0.05 as statistically significant. One χ2 test was conducted for heterogeneity, considering p value of < 0.10 as statistically significant. NIC, denotes nicardipine.</p