Manejo perioperatorio óptimo en pacientes sometidos a artroplastia de miembro inferior: conclusiones del análisis POWER 2

Background: total hip and knee replacement surgeries are relatively safe, but their volume represents a high consumption of resources. Accelerated recovery or ERAS protocols attempt to improve outcomes by speeding recovery and decreasing complications. Material and methods: national multicenter prospective observational study, in which hospitals were invited to participate regardless of the existence of an ERAS protocol. During a single 2-month recruitment period in 2018, all adult patients undergoing total hip or knee arthroplasty were included, with a 30-day follow-up. The primary objectives were the association of adherence to ERAS protocols with postoperative complications; to determine the time until mobilization after surgery, and to identify the preoperative hemoglobin level associated with a lower incidence of complications. The secondary objectives were to determine the association between adherence to ERAS protocols and length of stay, readmissions, and mortality; to identify factors associated with early mobilization, and to determine the relationship between preoperative anemia and blood transfusion, readmissions, hospital stay and mortality. Results: 6146 patients were included (3580 women (58.2%); median age 71 [IQR 63 &#8211; 76] years). Of these, 680 (11.1%) presented postoperative complications. The entire cohort was divided into quartiles according to adherence to the individual ERAS elements regardless of the center where they had undergone surgery. Patients in the quartile with the highest adherence had a lower number of total postoperative complications (144 (10.6%) vs. 270 (13.0%); OR 0.80; 95% CI 0.64-0.99; P < 0.001 ), moderate or severe complications (59 (4.4%) vs 143 (6.9%); OR 0.62; 95% CI 0.45-0.84; P< 0.001) and a shorter hospital lenght of stay (4 [IQR 3-5] versus 5 [IQR 4-6] days; OR 0.97; 95% CI 0.96-0.99; P< 0.001) compared to the lowest adherence quartile. The median time to achieve mobilization after surgery was 24 hours [16-30]. 4,222 (69.3%) patients moved &#8804; 24 hours after surgery. Infiltrative local anesthesia (OR = 0.80; 95% CI 0.72-0.90; P = 0.001), surgery in a self-declared ERAS center (OR = 0.57; 95% CI 0.55- 0.60; P <0.001), mean adherence to ERAS elements (OR = 0.93; 95% CI 0.92-0.93; P <0.001) and preoperative hemoglobin (OR = 0.97; CI 0.96-0.98; P<0.001) were associated with a shorter time to mobilization. 8.8% of patients were anemic. Patients with preoperative anemia were more likely to have postoperative complications (111/539 (20.6%) vs 563/5560 (10.1%), P<0.001), and moderate or severe complications (67/539 (12.4%) vs 284/5560 (5.1%), P<0.001). Multivariate analysis showed that preoperative hemoglobin &#8805;14 g/dl was associated with fewer postoperative complications. Conclusions: Greater compliance with the ERAS elements was associated with a decrease in complications and length of stay. The elements associated with less complications were a preoperative Hb, the use of tranexamic acid, less bleeding and early mobilization. The majority of patients were mobilized in the first 24 hours after surgery. Early mobilization was associated with adherence to the protocol, preoperative hemoglobin, use of infiltrative local anesthesia (LIA), absence of urinary catheter, surgical drains or epidural catheter, and postoperative complications. A preoperative hemoglobin &#8805; 14 g/dL was associated with a lower risk of postoperative complications. Preoperative anemia was associated with a higher likelihood of receiving blood transfusions, longer length of hospital stay, and increased readmissions.Antecedentes: Las cirugías de artroplastia de cadera y rodilla son relativamente seguras, pero su volumen supone un alto consumo de recursos. Los protocolos de recuperación acelerada o ERAS intentan mejorar los resultados acelerando la recuperación y disminuyendo las complicaciones. Material y métodos: estudio observacional prospectivo multicéntrico a nivel nacional, al que fueron invitados a participar hospitales independientemente de la existencia de un protocolo ERAS. Durante un periodo único de reclutamiento de 2 meses en 2018 se incluyeron todos los pacientes adultos intervenidos de artroplastia total de cadera o rodilla, con un seguimiento a 30 días. Los objetivos primarios fueron la asociación de la adherencia a los protocolos ERAS con las complicaciones postoperatorias; determinar el tiempo hasta la movilización tras la cirugía, e identificar el nivel de hemoglobina preoperatoria asociado con una menor incidencia de complicaciones. Los objetivos secundarios fueron determinar la asociación entre la adherencia a los protocolos ERAS y la estancia, los reingresos y la mortalidad; identificar los factores asociados con la movilización precoz, y determinar la relación entre la anemia preoperatorios y la transfusión sanguínea, los reingresos, la estancia hospitalaria y la mortalidad. Resultados: se incluyeron 6146 pacientes, (3580 mujeres (58,2%); mediana de edad 71 [RIQ 63 &#8211; 76] años). De estos, 680 (11,1%) presentaron complicaciones postoperatorias. Se dividió toda la cohorte en cuartiles según la adherencia a los elementos individuales ERAS independientemente del centro donde hubieran sido intervenidos. Los pacientes del cuartil con mayor adherencia tuvieron un menor número de complicaciones postoperatorias totales (144 (10,6%) frente a 270 (13,0%); OR 0.80; IC 95% 0,64-0,99; P< 0,001), moderadas o graves (59 (4,4%) frente a 143 (6,9%); OR 0,62; IC 95% 0,45-0,84; P< 0,001) y una menor estancia hospitalaria (4 [RIQ 3-5] frente a 5 [RIQ 4-6] días; OR 0,97; IC 95% 0,96-0,99; P< 0,001) en comparación al cuartil de menor adherencia. La mediana de tiempo para lograr la movilización tras la cirugía fueron 24h [16-30]. 4.222 (69,3%) pacientes se movieron en &#8804; 24h tras la cirugía. La anestesia local infiltrativa (OR = 0,80; IC 95% 0,72-0,90; P = 0,001), la cirugía en un centro auto-declarado ERAS (OR = 0,57; IC 95% 0,55-0,60; P <0,001), la adherencia media a los elementos ERAS (OR = 0,93; IC 95% 0,92-0,93; P<0,001) y la hemoglobina preoperatoria (OR = 0,97; IC 0,96-0,98; P<0,001) se asociaron con un menor tiempo hasta la movilización. Un 8,8% de pacientes estaban anémicos. Los pacientes con anemia preoperatoria tenían mayor probabilidad de sufrir complicaciones postoperatorias (111/539 (20,6%) frente a 563/5560 (10,1%), P<0,001), y complicaciones moderadas o graves (67/539 (12,4%) frente a 284/5560 (5,1%), P<0,001). El análisis multivariable mostró que la hemoglobina preoperatoria &#8805;14 g/dl se asociaba con menos complicaciones postoperatorias. Un mayor cumplimiento de los elementos ERAS se asoció a una disminución de complicaciones y estancia. Los elementos asociados con una disminución de las complicaciones fueron una Hb preoperatoria, el uso de ácido tranexámico, un menor sangrado y la movilización precoz. La mayoría de pacientes se movilizaron en las primeras 24h tras la cirugía. La movilización precoz se asoció a la adherencia al protocolo, al valor de hemoglobina preoperatoria, al uso de anestesia local infiltrativa (LIA), a la ausencia de sondaje vesical, drenaje quirúrgico o catéter epidural, y a las complicaciones postoperatorias. Una hemoglobina preoperatoria &#8805; 14 g/dL se asoció con un menor riesgo de complicaciones postoperatorias. La anemia preoperatoria se asoció con una mayor probabilidad de recibir transfusiones de sangre, una mayor duración de la estancia hospitalaria y un aumento de los reingresos.Escuela de DoctoradoDoctorado en Investigación en Ciencias de la Salu

Relationship between ABO Blood Group Distribution and COVID-19 Infection in Patients Admitted to the ICU: A Multicenter Observational Spanish Study

ABO blood-group system; Coronavirus infections; Multivariate analysis.Sistema de grups sanguinis ABO; Infeccions per coronavirus; Anàlisi multivariantSistema de grupos sanguíneos ABO; Infecciones por coronavirus; Análisis multivariableSince the beginning of the COVID-19 pandemic in December 2019, a relationship between the ABO blood group type and the novel coronavirus SARS-CoV-2, the etiological agent of COVID-19, has been reported, noting that individuals with the O blood group are the least likely to be infected. Spain is one of the most badly affected countries worldwide, with high rates of patients diagnosed, hospitalized, and deceased due to COVID-19 infection. The present study aimed to analyze the possible relationship of ABO in COVID-19 patients hospitalized in different Spanish centers during the first wave of the COVID-19 pandemic, for which the ABO group was available. Physicians from the transfusion services of different Spanish hospitals, who have developed a multicenter retrospective observational study, were invited to participate voluntarily in the research and 12,115 patients with COVID-19 infection were admitted to the nine participating hospitals. The blood group was known in 1399 cases (11.5%), of which 365 (26.1%) were admitted to the ICU. Regarding the distribution of ABO blood groups, a significant increase in the non-O blood groups and reduction for the O blood group was observed in patients hospitalized due to COVID-19, compared to the reference general population. Among the patients admitted to the ICU, after multivariate analysis, adjusted for the rest of the confounding variables, patients with the O blood group presented a significantly lower risk for admission to the ICU. We conclude that an association was observed between patients with the O blood group and their lower susceptibility to SARS-CoV-2 infection, both for those admitted to the hospitalization ward and for those who required admission to the ICU

Association between use of enhanced recovery after surgery protocol and postoperative complications in colorectal surgery: the postoperative outcomes within enhanced recovery after surgery protocol (power) study

Importance: enhanced Recovery After Surgery (ERAS) care has been reported to be associated with improvements in outcomes after colorectal surgery compared with traditional care. Objective: to determine the association between ERAS protocols and outcomes in patients undergoing elective colorectal surgery. Design, setting, and participants: the Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol (POWER) Study is a multicenter, prospective cohort study of 2084 consecutive adults scheduled for elective colorectal surgery who received or did not receive care in a self-declared ERAS center. Patients were recruited from 80 Spanish centers between September 15 and December 15, 2017. All patients included in this analysis had 1 month of follow-up. Exposures: colorectal surgery and perioperative management were the exposures. Twenty-two individual ERAS items were assessed in all patients, regardless of whether they were included in an established ERAS protocol. Main outcomes and measures: the primary study outcome was moderate to severe postoperative complications within 30 days after surgery. Secondary outcomes included ERAS adherence, mortality, readmissions, reoperation rates, and hospital length of stay. Results: between September 15 and December 15, 2017, 2084 patients were included in the study. Of these, 1286 individuals (61.7%) were men; mean age was 68 years (interquartile range [IQR], 59-77). A total of 879 patients (42.2%) presented with postoperative complications and 566 patients (27.2%) developed moderate to severe complications. The number of patients with moderate or severe complications was lower in the ERAS group (25.2% vs 30.3%; odds ratio [OR], 0.77; 95% CI, 0.63-0.94; P¿=¿.01). The overall rate of adherence to the ERAS protocol was 63.6% (IQR, 54.5%-77.3%), and the rate for patients from hospitals self-declared as ERAS was 72.7% (IQR, 59.1%-81.8%) vs non-ERAS institutions, which was 59.1% (IQR, 50.0%-63.6%; P¿<¿.001). Adherence quartiles among patients receiving the highest and lowest ERAS components showed that the patients with the highest adherence rates had fewer moderate to severe complications (OR, 0.34; 95% CI, 0.25-0.46; P¿<¿.001), overall complications (OR, 0.33; 95% CI, 0.26-0.43; P¿<¿.001), and mortality (OR, 0.27; 95% CI, 0.07-0.97; P¿=¿.06) compared with those who had the lowest adherence rates. Conclusions and relevance: an increase in ERAS adherence appears to be associated with a decrease in postoperative complications

Early mobilization after total hip or knee arthroplasty: a substudy of the POWER.2 study

Background Early mobilization after surgery is a cornerstone of the Enhanced Recovery After Surgery (ERAS) programs in total hip arthroplasty (THA) or total knee arthroplasty (TKA). Our goal was to determine the time to mobilization after this surgery and the factors associated with early mobilization. Methods This was a predefined substudy of the POWER.2 study, a prospective cohort study conducted in patients undergoing THA and TKA at 131 Spanish hospitals. The primary outcome was the time until mobilization after surgery as well as determining those perioperative factors associated with early mobilization after surgery. Results A total of 6093 patients were included. The median time to achieve mobilization after the end of the surgery was 24 hours [16–30]. 4,222 (69.3%) patients moved in ≤ 24 hours after surgery. Local anesthesia [OR = 0.80 (95% confidence interval [CI]: 0.72–0.90); p = 0.001], surgery performed in a self-declared ERAS center [OR = 0.57 (95% CI: 0.55–0.60); p < 0.001], mean adherence to ERAS items [OR = 0.93 (95% CI: 0.92–0.93); p < 0.001], and preoperative hemoglobin [OR = 0.97 (95% CI: 0.96–0.98); p < 0.001] were associated with shorter time to mobilization. Conclusions Most THA and TKA patients mobilize in the first postoperative day, early time to mobilization was associated with the compliance with ERAS protocols, preoperative hemoglobin, and local anesthesia, and with the absence of a urinary catheter, surgical drains, epidural analgesia, and postoperative complications. The perioperative elements that are associated with early mobilization are mostly modifiable, so there is room for improvement

Blood donations and transfusions during the COVID-19 pandemic in Spain: Impact according to autonomous communities and hospitals

Worldwide, the COVID-19 pandemic has caused a decline in blood donations, between 30% and 70% in some of the most affected countries. In Spain, during the initial eight weeks after the State of Emergency was decreed on 14 March 2020, in the weekly reports of the Health Ministry, an average decrease of 20% was observed between 11 and week 25 compared with the 2018 donation. We aimed to investigate the impact of the COVID-19 pandemic on blood donations and blood distribution in four autonomous communities, and to explore the evolution of the consumption of blood components (BCs) in ten hospitals of six autonomous communities. We performed a prospective study of grouped cohorts on the donation and distribution of blood in four regional transfusion centers in four autonomous communities in Spain, and a retrospective study of the consumption of blood components in ten hospitals in six autonomous communities. Regarding donations, there was no significant decrease in donations, with differences between autonomous communities, which started between 1 and 15 March 2020 (−11%). The increase in donations in phase II (from 26 May 2020) stands out. Regarding consumption, there was a significant reduction in the consumption of packed red blood cells (RBCs) (24.5%), plasma (45.3%), and platelets (25.3%) in the central period (16 March–10 May). The reduction in the consumption of RBCs was significant in the period from 1–15 March. Conclusions: The COVID-19 pandemic has affected the donation and consumption of BCs

Surgical treatment for colorectal cancer: Analysis of the influence of an enhanced recovery programme on long-term oncological outcomes-a study protocol for a prospective, multicentre, observational cohort study

Introduction The evidence currently available from enhanced recovery after surgery (ERAS) programmes concerns their benefits in the immediate postoperative period, but there is still very little evidence as to whether their correct implementation benefits patients in the long term. The working hypothesis here is that, due to the lower response to surgical aggression and lower rates of postoperative complications, ERAS protocols can reduce colorectal cancer-related mortality. The main objective of this study is to analyse the impact of an ERAS programme for colorectal cancer on 5-year survival. As secondary objectives, we propose to analyse the weight of each of the predefined items in the oncological results as well as the quality of life. Methods and analysis A multicentre prospective cohort study was conducted in patients older than 18 years of age who are scheduled to undergo surgery for colorectal cancer. The study involved 12 hospitals with an implemented enhanced recovery protocol according to the guidelines published by the Spanish National Health Service. The intervention group includes patients with a minimum implementation level of 70%, and the control group includes those who fail to reach this level. Compliance will be studied using 18 key performance indicators, and the results will be analysed using cancer survival indicators, including overall survival, cancer-specific survival and relapse-free survival. The time to recurrence, perioperative morbidity and mortality, hospital stay and quality of life will also be studied, the latter using the validated EuroQol Five questionnaire. The propensity index method will be used to create comparable treatment and control groups, and a multivariate regression will be used to study each variable. The Kaplan-Meier estimator will be used to estimate survival and the log-rank test to make comparisons. A p value of less than 0.05 (two-tailed) will be considered to be significant. Ethics and dissemination Ethical approval for this study was obtained from the Aragon Ethical Committee (C.P.-C.I. PI20/086) on 4 March 2020. The findings of this study will be submitted to peer-reviewed journals (BMJ Open, JAMA Surgery, Annals of Surgery, British Journal of Surgery). Abstracts will be submitted to relevant national and international meetings.The present research study was awarded a Ministerio de Ciencia e Innovación health research project grant (PI19/00291) from the Carlos III Institute of the Spanish National Health Service as part of the 2019 call for Strategic Action in Health

Early mobilisation in critically ill COVID-19 patients: a subanalysis of the ESICM-initiated UNITE-COVID observational study

Background Early mobilisation (EM) is an intervention that may improve the outcome of critically ill patients. There is limited data on EM in COVID-19 patients and its use during the first pandemic wave. Methods This is a pre-planned subanalysis of the ESICM UNITE-COVID, an international multicenter observational study involving critically ill COVID-19 patients in the ICU between February 15th and May 15th, 2020. We analysed variables associated with the initiation of EM (within 72 h of ICU admission) and explored the impact of EM on mortality, ICU and hospital length of stay, as well as discharge location. Statistical analyses were done using (generalised) linear mixed-effect models and ANOVAs. Results Mobilisation data from 4190 patients from 280 ICUs in 45 countries were analysed. 1114 (26.6%) of these patients received mobilisation within 72 h after ICU admission; 3076 (73.4%) did not. In our analysis of factors associated with EM, mechanical ventilation at admission (OR 0.29; 95% CI 0.25, 0.35; p = 0.001), higher age (OR 0.99; 95% CI 0.98, 1.00; p ≤ 0.001), pre-existing asthma (OR 0.84; 95% CI 0.73, 0.98; p = 0.028), and pre-existing kidney disease (OR 0.84; 95% CI 0.71, 0.99; p = 0.036) were negatively associated with the initiation of EM. EM was associated with a higher chance of being discharged home (OR 1.31; 95% CI 1.08, 1.58; p = 0.007) but was not associated with length of stay in ICU (adj. difference 0.91 days; 95% CI − 0.47, 1.37, p = 0.34) and hospital (adj. difference 1.4 days; 95% CI − 0.62, 2.35, p = 0.24) or mortality (OR 0.88; 95% CI 0.7, 1.09, p = 0.24) when adjusted for covariates. Conclusions Our findings demonstrate that a quarter of COVID-19 patients received EM. There was no association found between EM in COVID-19 patients' ICU and hospital length of stay or mortality. However, EM in COVID-19 patients was associated with increased odds of being discharged home rather than to a care facility. Trial registration ClinicalTrials.gov: NCT04836065 (retrospectively registered April 8th 2021)

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Intraoperative haemodynamic optimisation using the Hypotension Prediction Index and its impact on tissular perfusion: a protocol for a randomised controlled trial.

Intraoperative arterial hypotension is associated with poor postoperative outcomes. The Hypotension Prediction Index (HPI) developed using machine learning techniques, allows the prediction of arterial hypotension analysing the arterial pressure waveform. The use of this index may reduce the duration and severity of intraoperative hypotension in adults undergoing non-cardiac surgery. This study aims to determine whether a treatment protocol based on the prevention of arterial hypotension using the HPI algorithm reduces the duration and severity of intraoperative hypotension compared with the recommended goal-directed fluid therapy strategy and may improve tissue oxygenation and organ perfusion. We will conduct a multicentre, randomised, controlled trial (N=80) in high-risk surgical patients scheduled for elective major abdominal surgery. All participants will be randomly assigned to a control or intervention group. Haemodynamic management in the control group will be based on standard haemodynamic parameters. Haemodynamic management of patients in the intervention group will be based on functional haemodynamic parameters provided by the HemoSphere platform (Edwards Lifesciences), including dynamic arterial elastance, dP/dtmax and the HPI. Tissue oxygen saturation will be recorded non-invasively and continuously by using near-infrared spectroscopy technology. Biomarkers of acute kidney stress (cTIMP2 and IGFBP7) will be obtained before and after surgery. The primary outcome will be the intraoperative time-weighted average of a mean arterial pressure Ethics committee approval was obtained from the Ethics Committee of Hospital Gregorio Marañón (Meeting of 27 July 2020, minutes 18/2020, Madrid, Spain). Findings will be widely disseminated through peer-reviewed publications and conference presentations. NCT04301102