WHO Safety Surgical Checklist implementation evaluation in public hospitals in the Brazilian Federal District.

The World Health Organization (WHO) created the WHO Surgical Safety Checklist to prevent adverse events in operating rooms. The aim of this study was to analyze WHO checklist implementation in three operating rooms of public hospitals in the Brazilian Federal District. A prospective cross-sectional study was performed with pre- (Period I) and post (Period II)-checklist intervention evaluations. A total of 1141 patients and 1052 patients were studied in Periods I and II for a total of 2193 patients. Period I took place from December 2012 to March 2013, and Period II took place from April 2013 to August 2014. Regarding the pre-operatory items, most surgeries were classified as clean-contaminated in both phases, and team attire improved from 19.2% to 71.0% in Period II. Regarding checklist adherence in Period II, "Patient identification" significantly improved in the stage "Before induction of anesthesia". "Allergy verification", "Airway obstruction verification", and "Risk of blood loss assessment" had low adherence in all three hospitals. The items in the stage "Before surgical incision" showed greater than 90.0% adherence with the exception of "Anticipated critical events: Anesthesia team review" (86.7%) and "Essential imaging display" (80.0%). Low adherence was noted in "Instrument counts" and "Equipment problems" in the stage "Before patient leaves operating room". Complications and deaths were low in both periods. Despite the variability in checklist item compliance in the surveyed hospitals, WHO checklist implementation as an intervention tool showed good adherence to the majority of the items on the list. Nevertheless, motivation to use the instrument by the surgical team with the intent of improving surgical patient safety continues to be crucial.

Preadmission Application of 2% Chlorhexidine Gluconate (CHG): Enhancing Patient Compliance While Maximizing Skin Surface Concentrations.

OBJECTIVE: Surgical site infections (SSIs) are responsible for significant morbidity and mortality. Preadmission skin antisepsis, while controversial, has gained acceptance as a strategy for reducing the risk of SSI. In this study, we analyze the benefit of an electronic alert system for enhancing compliance to preadmission application of 2% chlorhexidine gluconate (CHG). DESIGN, SETTING, AND PARTICIPANTS: Following informed consent, 100 healthy volunteers in an academic, tertiary care medical center were randomized to 5 chlorhexidine gluconate (CHG) skin application groups: 1, 2, 3, 4, or 5 consecutive applications. Participants were further randomized into 2 subgroups: with or without electronic alert. Skin surface concentrations of CHG (µg/mL) were analyzed using a colorimetric assay at 5 separate anatomic sites. INTERVENTION: Preadmission application of chlorhexidine gluconate, 2% RESULTS: Mean composite skin surface CHG concentrations in volunteer participants receiving EA following 1, 2, 3, 4, and 5 applications were 1,040.5, 1,334.4, 1,278.2, 1,643.9, and 1,803.1 µg/mL, respectively, while composite skin surface concentrations in the no-EA group were 913.8, 1,240.0, 1,249.8, 1,194.4, and 1,364.2 µg/mL, respectively (ANOVA, P<.001). Composite ratios (CHG concentration/minimum inhibitory concentration required to inhibit the growth of 90% of organisms [MIC90]) for 1, 2, 3, 4, or 5 applications using the 2% CHG cloth were 208.1, 266.8, 255.6, 328.8, and 360.6, respectively, representing CHG skin concentrations effective against staphylococcal surgical pathogens. The use of an electronic alert system resulted in significant increase in skin concentrations of CHG in the 4- and 5-application groups (P<.04 and P<.007, respectively). CONCLUSION: The findings of this study suggest an evidence-based standardized process that includes use of an Internet-based electronic alert system to improve patient compliance while maximizing skin surface concentrations effective against MRSA and other staphylococcal surgical pathogens.

Antibiotic prophylaxis in bariatric surgery with continuous infusion of cefazolin: determination of concentration in adipose tissue.

BACKGROUND: The aim of this study was to evaluate the concentration of cefazolin in adipose tissue of patients undergoing bariatric surgery. METHODS: Eighteen patients undergoing bariatric surgery were evaluated during the period from October 2011 to May 2012. All patients had a dosage schedule of antibiotic prophylaxis with cefazolin administered as follows: first, 2 g in anesthetic induction, followed by continuous infusion of 1 g diluted in 250 ml of saline solution. Adipose samples, collected soon after the incision (initial) and before the skin synthesis (final), were analyzed using reverse phase high-pressure liquid chromatography. The level of significance adopted was 5 %. RESULTS: The cefazolin concentration in the adipose tissue samples at the beginning of surgery was an average of 6.66 ± 2.56 ug/ml. The mean concentration before the skin synthesis was 7.93 ± 2.54 ug/ml. Patients with BMI < 40 kg/m(2) had higher initial and final sample concentrations of cefazolin than patients with BMI ≥ 40 kg/m(2). There was no surgical site infection (SSI) in any of the patients. CONCLUSIONS: In bariatric surgeries, addition of a 1 g increase of cefazolin, administered through continuous intravenous infusion, to the currently recommended dose of 2 g administered in anesthetic induction provided a concentration in the adipose tissue above the minimum inhibitory concentration (MIC) of the main causal agents of SSI. An inverse correlation between BMI and concentration of cefazolin in adipose tissue was observed.

Food tolerance in patients submitted to gastric bypass: the importance of using an integrated and interdisciplinary approach.

BACKGROUND: Under the restrictive component, patients undergoing gastric bypass may have food intolerance with or without complications. METHODS: This study used quantitative, analytical, observational methodology with patients submitted to Roux-en-Y gastric bypass without the placement of a ring at Hospital Universitário do Rio Grande do Norte in the city of Natal, Brazil between July 2005 and August 2010. Out of 176 patients monitored after surgery by the interdisciplinary team, 47 took part in the study. Two questionnaires were applied to participants: one elaborated by Suter et al. and previously validated for assessment of food tolerance and another to characterize schooling and socioeconomic status. Evaluation of food tolerance considered patient satisfaction with eating, most accepted food types, and frequency of vomiting and/or regurgitation. After application of the first questionnaire, a score was generated, characterizing food intolerance. RESULTS: Of the 47 patients evaluated, 85.1% classified their degree of food satisfaction as good or excellent. Red meat was the most cited as being difficult to ingest (38.3%), representing a significant impact on overall tolerance level (P < 0.001); 48.9% of participants exhibited rare episodes of vomiting, which resulted in a mean food tolerance score of 23.02 (2.87 ± SD). Moreover, socioeconomic status showed a significant correlation with tolerance level (P = 0.032). CONCLUSIONS: The degree of food tolerance observed in the study sample was better than that obtained in other investigations using similar methodology. The questionnaire proved to be useful in evaluating food quality and comparing postoperative results. Socioeconomic status was correlated with food tolerance level.

Gastric bypass in the treatment of type 2 diabetes in patients with a BMI of 30 to 35 kg/m2.

BACKGROUND: Type 2 diabetes mellitus (T2DM) and class I obesity, which are pandemics of considerable socioeconomic importance, require new treatment modalities due to inadequate control through normal clinical conduct. The aim of the present study was to assess the efficacy and safety of Roux-en-Y gastric bypass (RYGB) in the control of T2DM in patients with a body mass index (BMI) of 30 to 35 kg/m(2). METHODS: An observational, retrospective study was carried out at the Universidade Federal de Pernambuco-Brazil. Between 2002 and 2008, 27 patients were submitted to RYGB for the treatment of uncontrolled T2DM, with a mean follow-up period of 20 months. An assessment was performed of the complete resolution of T2DM [HbA(1c) < 6%/fasting plasma glucose (FPG) < 100 mg/dL/no diabetes medication] and glycemic control. The ethics committee of the university approved the study. RESULTS: RYGB led to the following results: (1) 23% weight reduction (p < 0.001), BMI stabilized at 25.6 kg/m(2) in a mean of 12 months; (2) 46% reduction in glycemia and 27% reduction in HbA(1c) (p < 0.001); (3) 100% improvement in glycemia and 48% resolution of T2DM; (4) glycemic control was 74% without medication and 93% with medication and five patients required medication in addition to RYGB; (5) mean current FPG is 93 mg/dL and HbA(1c) is 6%; and (6) there were no severe complications or deaths. CONCLUSIONS: RYGB is a safe and effective option in the treatment of uncompensated T2DM associated to class I obesity.

Treatment of ring slippage after gastric bypass: long-term results after endoscopic dilation with an achalasia balloon (with videos).

BACKGROUND: Silastic rings are used in gastric bypass procedures for the treatment of obesity, but ring slippage may lead to gastric pouch outlet stenosis (GPOS). Conventional management has been ring removal through abdominal surgery. OBJECTIVE: To describe a novel, safe, minimally invasive, endoscopic technique for the treatment of GPOS caused by ring slippage after gastric bypass. DESIGN: Case series. SETTING: Federal University of Pernambuco and São Paulo University. PATIENTS: This study involved 39 consecutive patients who were screened for inclusion. INTERVENTION: Endoscopic dilation with an achalasia balloon. MAIN OUTCOME MEASUREMENTS: Technical success and safety of the procedure. RESULTS: Among the 39 patients, 35 underwent endoscopic dilation at the ring slippage site for the relief of GPOS. The 4 patients who did not undergo endoscopic dilation underwent surgical removal of the ring, based on the exclusion criteria. The endoscopic approach was successful in 1 to 4 sessions in 100% of cases with radioscopic control (n = 12). The duration of the procedures ranged from 5 to 30 minutes, and the average internment was 14.4 hours. Dilation promoted either rupture (65.7%) or stretching (34.3%) of the thread within the ring, thereby increasing the luminal diameter of the GPOS. Complications included self-limited upper digestive tract hemorrhage (n = 1) and asymptomatic ring erosion (n = 4). There were no recurrences of obstructive symptoms during the follow-up period (mean of 33.3 months). LIMITATIONS: This was not a randomized, comparison study, and the number of patients was relatively small. CONCLUSION: The technique described promotes the relief of GPOS with low overall morbidity and avoids abdominal reoperation for ring removal.

Translumenal endoscopic drainage of abdominal abscess due to early migration of adjustable gastric band.

We describe the case of early band migration that developed into intraabdominal infection treated by natural orifice translumenal endoscopic surgery. A 40-year-old man was seen 4 years after gastric band placement. He complained of epigastric pain and fever. Gastroscopy revealed minimal gastric fundus erosion and a bulging of the antrum wall. Abdominal CT scan showed perigastric abscess surrounding the band tube. Antibiotic therapy was initiated, and endoscopic transgastric abscess drainage was performed. The endoscope was guided into the abscess cavity, and the band tubing was brought into the gastric lumen to serve as a stent to drain the infection, which ceased 5 days later. During the follow-up, the mucosa covering the band was incised in two more sessions to hasten the erosion process. Endoscopic removal was done 7 months after the drainage.

Evaluation of splenomegaly in the hepatosplenic form of mansonic schistosomiasis.

This study was aimed to evaluate splenomegaly in patients with the hepatosplenic (HS) form of mansonic schistosomiasis (MS), analyzing the size and weight of the spleen and their relationships with patients' gender and age. Between October, 1993 to July, 1998, 78 patients with the HS form of MS had undergone splenectomy as treatment of choice for bleeding due to portal hypertension, at Hospital das Clínicas, Pernambuco, Brazil. By means of abdominal palpation, the excess spleen felt below the left costal edge was measured, and the weight was obtained after splenectomy along with the histopathological analysis. Liver biopsy was performed intraoperatively in order to confirm MS and to rule out other liver diseases. The mean age of the 78 patients were 45 years and 41 of them (53%) were female. The average spleen weight was 912g and the mean spleen size palpable below the left costal edge was 9.1cm. There was a positive relationship between size and weight (p<0.001). Spleen weight and size were larger in males (p=0.007 and p=0.001, respectively). An inverse correlation between age and spleen weight was observed (p<0.001). A classification based upon spleen weight showed 53% of patients presenting a moderate (501-1000g) and 33% a severe (>1001g) splenomegaly. As for the spleen size, the classification showed 64% of patients presenting moderate (4.1-10cm below the left costal edge) and 21% severe (>10cm) splenomegaly. In conclusion, splenomegaly may be considered a key physical finding in patients with HS form of MS, and we found a good correlation between the spleen sizes clinically evaluated with its weight. The majority of cases presents a moderate to severe splenomegaly and spleen size is larger in men and it seems to decrease with aging.