Protocolo de Higiene Oral para Establecimientos de Larga Estadía para Adultos Mayores en Estado de Pandemia COVID-19. Prevención de Neumonía por Aspiración / Oral Hygiene Protocol for Long-Term Establishments for Older Adults in a State of Pandemic COVID-19. Aspiration Pneumonia Prevention

RESUMEN: ¿Por qué es importante la salud oral en la prevención de enfermedades respiratorias en tiempos de pandemia? La razón es simple, cualquier enfermedad respiratoria en la persona mayor, podría eventualmente activar alarma de COVID-19 positivo, pudiendo ser esta ocasionada por otro motivo, sin mencionar el riesgo aumentado de tener una enfermedad previa de tipo respiratoria en tiempos de pandemia, sobre todo, en una población de riesgo como las personas mayores institucionalizadas. Por esta razón, la prevención en higiene oral de personas mayores mediante un Protocolo que proponga lineamientos a seguir en Establecimientos de Larga Estadía para Adultos Mayores, es fundamental en la prevención de Neumonía por aspiración. Cabe mencionar, que desde antes de surgir el COVID-19, ya la Neumonía se considera la principal causa de muerte por enfermedades infecciosas en la población chilena, y la primera causa específica de muerte en los mayores de 80 años.

ABSTRACT: Why is oral health important in the prevention of respiratory diseases in times of pandemic? The reason is simple, any respiratory disease in the elderly could eventually trigger a positive COVID-19 alarm, and this could be caused by another reason, not to mention the increased risk of having a previous respiratory-type illness in times of pandemic, over everything, in a population of risk like the institutionalized older people. For this reason, the prevention of oral hygiene in older people through a Protocol that proposes guidelines to be followed in long-stay establishments for older adults, is essential in the prevention of aspiration Pneumonia. It is worth mentioning that, before the emergence of COVID-19, Pneumonia was considered the main cause of death from infectious diseases in the Chilean population and the first specific cause of death in those over 80 years of age.

Uso de pulseira de identificação para risco de broncoaspiração em ambiente hospitalar / Use of silicone bracelet to signal risk of bronchoaspiration in a hospital setting

RESUMO Objetivo apresentar o Protocolo de Prevenção de Broncoaspiração (PPB), visando estabelecer um fluxo padronizado para o manejo do paciente com risco de broncoaspiração. Esse protocolo, de aplicabilidade multiprofissional, estabelece um padrão assistencial de práticas clínicas para garantir a segurança do paciente em unidades de terapia intensiva (UTI), unidades de internação (UI) e pronto-socorro (PS). Métodos na admissão do paciente, ou durante sua permanência hospitalar, a equipe multiprofissional deverá observar se o paciente se encaixa em, pelo menos, UM dos critérios de inclusão do PPB. Caso o paciente seja identificado como em risco de broncoaspiração, a equipe de enfermagem deverá sinalizá-lo com a Pulseira do Risco de Broncoaspiração (cor cinza/prata). Resultados o PPB já foi aprovado pela Comissão de UTI Cirúrgica e pelo Serviço de Controle de Infecção Hospitalar (SCCIH) do Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICHCFMUSP). Com isso, o PPB mostrou-se factível, de baixo custo e efetivo em sua proposta. Conclusão a aplicabilidade do PPB nas Unidades de Terapia Intensiva, Unidades de Internação e Pronto-Socorro do ICHCFMUSP é uma iniciativa pioneira. O uso do protocolo e da pulseira é uma conquista para a Fonoaudiologia e a consolidação da sua existência nas unidades de internação hospitalar.

ABSTRACT Purpose To present the Bronchoaspiration Prevention Protocol (PPB) for the management of patients at risk of brochoaspiration. This protocol has a multidisciplinary approach and aims to standardize clinical practice in order to ensure patients' safety in Inpatient, Emergency and Intensive Care Units (ICUs). Methods Upon admission or during patients' hospital stay, the multidisciplinary team must observe if the patient presents at least one of the inclusion criteria for the PPB. In case the patient is classifies as at risk of bronchoaspiration, the nursing team will identify the patient with the silicone Bracelet for Risk of Bronchoaspiration (grey/silver color). Results The PPB has already been approved by the Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICHC FMUSP) ICU Commission and Hospital Infection Control Service (HICS). The PPB proved to fulfil its purpose in a viable, low-cost and effective manner. Conclusion Applicability of the PPB in Inpatient, Emergency and Intensive Care Units (ICUs) is a pioneer initiative. The use of the protocol and bracelet is an achievement for the Speech-Language and Hearing Sciences and consolidates our existence in the inpatient hospital setting.

Qualitative and quantitative ultrasound assessment of gastric content.

OBJECTIVE:: Pulmonary aspiration of the gastric contents is one of the most feared complications in anesthesia. Its prevention depends on preoperative fasting as well as identification of risky patients. A reliable diagnostic tool to assess gastric volume is currently lacking. The aim of this study performed on volunteers was to evaluate the feasibility of ultrasonography to identify qualitative and quantitative gastric content. METHOD:: A standardized gastric scanning protocol was applied on 67 healthy volunteers to assess the gastric antrum in four different situations: fasting, after ingesting clear fluid, milk and a solid meal. A qualitative and quantitative assessment of the gastric content in the antrum was performed by a blinded sonographer. The antrum was considered either as empty, or containing clear or thick fluid, or solids. Total gastric volume was predicted based on a cross-sectional area of the antrum. A p-value less than 0.05 was considered statistically significant. RESULTS:: For each type of gastric content, the sonographic characteristics of the antrum and its content were described and illustrated. Sonographic qualitative assessment allowed to distinguish between an empty stomach and one with different kinds of meal. The predicted gastric volume was significantly larger after the consumption of any food source compared to fasting. CONCLUSION:: Bedside sonography can determine the nature of gastric content. It is also possible to estimate the difference between an empty gastric antrum and one that has some food in it. Such information may be useful to estimate the risk of aspiration, particularly in situations when prandial status is unknown or uncertain.

Qualitative and quantitative ultrasound assessment of gastric content / Avaliação qualitativa e quantitativa do conteúdo gástrico através da ultrassonografia

Summary Objective: Pulmonary aspiration of the gastric contents is one of the most feared complications in anesthesia. Its prevention depends on preoperative fasting as well as identification of risky patients. A reliable diagnostic tool to assess gastric volume is currently lacking. The aim of this study performed on volunteers was to evaluate the feasibility of ultrasonography to identify qualitative and quantitative gastric content. Method: A standardized gastric scanning protocol was applied on 67 healthy volunteers to assess the gastric antrum in four different situations: fasting, after ingesting clear fluid, milk and a solid meal. A qualitative and quantitative assessment of the gastric content in the antrum was performed by a blinded sonographer. The antrum was considered either as empty, or containing clear or thick fluid, or solids. Total gastric volume was predicted based on a cross-sectional area of the antrum. A p-value less than 0.05 was considered statistically significant. Results: For each type of gastric content, the sonographic characteristics of the antrum and its content were described and illustrated. Sonographic qualitative assessment allowed to distinguish between an empty stomach and one with different kinds of meal. The predicted gastric volume was significantly larger after the consumption of any food source compared to fasting. Conclusion: Bedside sonography can determine the nature of gastric content. It is also possible to estimate the difference between an empty gastric antrum and one that has some food in it. Such information may be useful to estimate the risk of aspiration, particularly in situations when prandial status is unknown or uncertain.

Resumo Objetivo: A aspiração pulmonar do conteúdo gástrico é uma das complicações mais temidas em anestesia. A sua prevenção depende do jejum pré-operatório e da identificação dos pacientes de risco. Não há um método diagnóstico que possa acessar o conteúdo gástrico a qualquer momento. O objetivo deste estudo realizado em voluntários foi fazer uma avaliação qualitativa e quantitativa do conteúdo gástrico utilizando a ultrassonografia. Método: O estudo foi realizado em 67 voluntários utilizando uma técnica já descrita de avaliação do antro gástrico, em quatro diferentes situações: jejum, após a ingestão de líquido claro, leite ou refeição sólida. Foi feita uma avaliação qualitativa e quantitativa do conteúdo gástrico por um radiologista que desconhecia o estado gástrico do voluntário. O antro foi considerado vazio, contendo líquido claro ou espesso, ou sólido. O volume total do estômago foi calculado com base na área seccional do antro. Um valor de p<0,05 foi considerado estatisticamente significativo. Resultados: Para cada tipo de conteúdo gástrico, as características ultrassonográficas do antro e de seu conteúdo foram descritas e ilustradas. A avaliação qualitativa pode distinguir um estômago vazio de outros com diferentes conteúdos. O volume gástrico calculado foi significativamente maior após a ingestão de qualquer alimento em comparação com o jejum. Conclusão: A ultrassonografia à beira do leito pode determinar a natureza do conteúdo gástrico. Também foi possível diferenciar um antro vazio daquele com algum volume. Essas informações podem ser úteis na determinação do risco de aspiração gástrica, principalmente se a condição gástrica é desconhecida ou incerta.

Pre-operative fasting guidelines: an update

Liberal pre-operative fasting routines have been implemented in most countries. In general, clear fluids are allowed up to 2 h before anaesthesia, and light meals up to 6 h. The same recommendations apply for children and pregnant women not in labour. In children <6 months, most recommendations now allow breast- or formula milk feeding up to 4 h before anaesthesia.Recently, the concept of pre-operative oral nutrition using a special carbohydrate-rich beverage has also gained support and been shown not to increase gastric fluid volume or acidity. Based on the available literature, our Task Force has produced new consensus-based Scandinavian guidelines for pre-operative fasting. What is still not clear is to what extent the new liberal fasting routines should apply to patients with functional dyspepsia or systematic diseases such as diabetes mellitus. Other still controversial areas include the need for and effect of fasting in emergency patients, women in labour and in association with procedures done under ‘deep sedation’. We think more research on the effect of various fasting regimes in subpopulations of patients is needed before we can move one step further towards completely evidence-based pre-operative fasting guidelines.

Prevenção da aspiração pulmonar do conteúdo gástrico / Prevention of pulmonary gastric contents aspiration

JUSTIFICATIVA E OBJETIVOS: Apesar da baixa incidência, a aspiração pulmonar do conteúdo gástrico pode ter conseqüências devastadoras para o indivíduo. A diminuição na função do esfíncter esofágico e dos reflexos protetores das vias aéreas causadas pela depressão da consciência, predispõe os pacientes a esta grave complicação. Neste artigo, foi realizada uma revisão dos aspectos fisiológicos associados ao refluxo gastroesofágico, bem como os métodos utilizados para preveni-lo. CONTEUDO: São feitos comentários sobre os mecanismos envolvidos na aspiração do conteúdo gástrico, suas conseqüências e métodos de prevenção, incluindo recentes guias de jejum pré-operatório elaborados após revisão da literatura, o uso racional de drogas que atuam no pH e volume gástrico e, finalmente, o efeito de diferentes métodos de manutenção da via aérea na prevenção da aspiração pulmonar. CONCLUSÕES: A aspiração pulmonar do conteúdo gástrico, apesar de pouco freqüente, exige cuidados especiais para sua prevenção. Guias de jejum pré-operatório elaborados recentemente sugerem períodos menores de jejum, principalmente para líquidos, permitindo mais conforto aos pacientes e menor risco de hipoglicemia e desidratação, sem aumentar a incidência de aspiração pulmonar perioperatória. O uso rotineiro de drogas que diminuem a acidez e volume gástrico parece estar indicado apenas para pacientes de risco. O melhor método de proteção da via aérea contra a aspiração continua sendo a intubação traqueal. Outros métodos de manutenção da via aérea vêm sendo adotados, mas a eficácia na prevenção da aspiração ainda é inferior, embora representem importante alternativa em casos de falha de intubação traqueal.

Omeprazol para la reducción del riesgo de desarrollo de sindrome de Mendelson en pacientes coordinados para cirugía abdominal / Omeprazole in the prophylaxis of Mendelson syndrome in patients coordinated for abdominal surgery

El objetivo de este estudio fue determinar la reducción del volumen y la acidez gástrica producida por la administración preoperatoria de Omeprazol vía oral. Realizamos un estudio prospectivo, randomizado, doble ciego en pacientes coordinados para cirugía abdominal con anestesia general. Se seleccionaron 22 pacientes de ambos sexos, ASA I-III, de 18 años o mayores, asignados de manera aleatoria para recibir Omeprazol 40 mg o placebo la noche previa a la cirugía. Luego de la intubación traqueal se determinó el pH y volumen gástrico. El pH hallado en el grupo Omeprazol fue 4.86 + 2.37 (media + SD) y en el grupo placebo 2.19 + 1.77 (p = 0.004). La incidencia de pacientes con pH <= 2.5 en el grupo Omeprazol fue 27 por ciento y en el grupo Placebo fue 80 por ciento (Riesgo Relativo (RR) = 0.34 IC 95 por ciento= 0.12-0.94). El volumen gástrico medio obtenido en el grupo Omeprazol fue 24.18 ml + 18.03 ml y en el placebo 30.45 ml + 25.54 ml (p = 0.26). La incidencia de pacientes con volumen >= 25 ml fue similar en ambos grupos (RR = 0.91 IC 95 por ciento= 0.37-2.23). Concluimos que la administración preoperatoria de Omeprazol 40 mg V/O redujo en forma efectiva la acidez gástrica y por lo tanto los riesgos de desarrollo de Síndrome de Mendelson, con una reducción significativa del número de pacientes con pH <= 2.5 (Reducción del RR (RRR)=66 por ciento IC95 por ciento=88 por ciento-6 por ciento). Con respecto al volumen gástrico, si bien el promedio fue algo mayor para el grupo placebo, no hubo una diferencia estadísticamente significativa entre ambos grupos. Tampoco hubo una reducción significativa del número de pacientes con volumen >= 25 ml (AU)

Preoperative starvation and pulmonary aspiration. New perspectives and guidelines

The fear of aspiration of gastric contents and its life-threatening consequences in patients(aspiration pneumonitis and respiratory failure), has caused many medical practitioners, particularly anaesthetists, to rigidly follow conservative (i.e. prolonged) preoperative fasting standards. This is the nil per os (NPO) order for clear fluids/liquids and solids overnight or six to eight hours preceding the induction of anaesthesia. This practice neither takes into account the differences in the rate of gastric emptying for solid food (which may exceed six hours) and clear liquids (which is one to two hours), nor the differences in scheduled times of surgery. Long-term prospective studies and retrospective reviews have shown that the incidence of significant clinical aspiration is low: 1.4-6.0 per 100,00 anaesthetics for elective general surgery. Risk factors for pulmonary aspiration include: a high American Society of Anaesthesiologists (ASA) physical status score; emergency surgery; difficult airway management; increased gastric volume and acidity; increased intra-abdominal pressure; gastro-oesophageal reflux; oesophageal disease; head injury with impaired consciousness and extremes of age. Experimental studies and reviews have consistently shown the safety of clear liquid ingestion up to two hours before induction of anaesthesia in healthy patients without risk factors, and the fact that a longer fluid fast does not necessarily offer any added protection against pulmonary aspiration. The conservative pre-operative fasting standard causes discomfort and in some cases, suffering of patients and is therefore unnecessary for patients without risk factor(s). Anecdotal reports at the University Hospital of the West Indies (UHWI) have shown that application of the liberalized guidelines for preoperative fasting and fluid intake has not resulted in increased pulmonary aspiration, morbidity or mortality. Instead it has resulted in decreased irritability, anxiety, thirst and hunger in the peri-operative period. Patients, especially children are more comfortable and the perioperative period is better tolerated. It is therefore time that all medical personnel adopt the liberalized guidelines

Preoperative starvation and pulmonary aspiration. New perspectives and guidelines.

The fear of aspiration of gastric contents and its life-threatening consequences in patients(aspiration pneumonitis and respiratory failure), has caused many medical practitioners, particularly anaesthetists, to rigidly follow conservative (i.e. prolonged) preoperative fasting standards. This is the nil per os (NPO) order for clear fluids/liquids and solids overnight or six to eight hours preceding the induction of anaesthesia. This practice neither takes into account the differences in the rate of gastric emptying for solid food (which may exceed six hours) and clear liquids (which is one to two hours), nor the differences in scheduled times of surgery. Long-term prospective studies and retrospective reviews have shown that the incidence of significant clinical aspiration is low: 1.4-6.0 per 100,00 anaesthetics for elective general surgery. Risk factors for pulmonary aspiration include: a high American Society of Anaesthesiologists (ASA) physical status score; emergency surgery; difficult airway management; increased gastric volume and acidity; increased intra-abdominal pressure; gastro-oesophageal reflux; oesophageal disease; head injury with impaired consciousness and extremes of age. Experimental studies and reviews have consistently shown the safety of clear liquid ingestion up to two hours before induction of anaesthesia in healthy patients without risk factors, and the fact that a longer fluid fast does not necessarily offer any added protection against pulmonary aspiration. The conservative pre-operative fasting standard causes discomfort and in some cases, suffering of patients and is therefore unnecessary for patients without risk factor(s). Anecdotal reports at the University Hospital of the West Indies (UHWI) have shown that application of the liberalized guidelines for preoperative fasting and fluid intake has not resulted in increased pulmonary aspiration, morbidity or mortality. Instead it has resulted in decreased irritability, anxiety, thirst and hunger in the peri-operative period. Patients, especially children are more comfortable and the perioperative period is better tolerated. It is therefore time that all medical personnel adopt the liberalized guidelines.

Estudio en doble ciego con famotidina: pH y volumen gástrico / Study in double blind with famotidine: pH and gastric volume

Estudio prospectivo, aleatorio y en doble ciego. Noventa pacientes sometidos a cirugía abdominal recibieron preoperatoriamente 20 mg de famotidina intravenosa o un placebo. Se midió el pH y volumen gástrico postintubación traqueal (T1), al momento del vaciamiento total del estómago (T2) y antes de la extubación (T3). El pH gástrico fue significativamente superior en el grupo de pacientes que recibió famotidina en los tres tiempos de medición. El volumen gástrico fue significativamente inferior en el grupo con famotidina en el tiempo 1, no habiendo diferencia entre los dos grupos en los tiempos 2 y 3. La población "en riesgo" (pH < 3 y volumen > 25 ml) fue significativamente inferior en el grupo que recibió famotidina en los tres tiempos de medición

Ayuno preoperatorio en niños, contenido gástrico al momento de la inducción anéstesica y sus modificaciones con el uso del citrato de sodio / Preoperative fasting in children, gastric contents to the moment of the anesthesic induction and your modifications with the use of the citrate of sodium

Se estudiaron 166 pacientes con una edad promedio ñ ES 61 ñ 3,6 meses y un peso de 19,8 ñ 1,2 kg, ASAI-II hospitalizados, no premedicados y sin patología gastrointestinal concomitante, con los objetivos de: a) cuantificar con qué pH y volumen gástrico llegan los pacientes pediátricos a pabellón para ser intervenidos en forma electiva; b) correlacionar el tiempo de ayuno, la edad y el peso con el pH y el volumen gástrico obtenidos, y c) evaluar las modificacionesde estos parámetros con el uso del citrato de sodio en el preoperatorio inmediato. En forma aleatoria, 43 niños recibieron citrato de sodio 0,3 M en dosis de 0,5 ml/kg por vía oral 25 a135 minutos antes de la medición del pH; los 123 restantes no recibieron antiácidos, constituyendo el grupo control. Ambos grupos fueron similares en edad, peso, tiempo de ayuno y patología de base. Después de anestesiados se obtuvo el jugo gástrico a través de una sonda nasogástrica, se les midió pH y volumen. El grupo control tuvo un pH 2,37 ñ 0,1 y un volumen de 5,9 ñ 0,5 ml. Hubo una correlación significativa entre edad y pH (r=0,211 p<0,02) y entre edad y volumen(r=0,49 p<0,001). No hubo correlación entre el pH volumen, tiempo de ayuno y el peso. El pH del grupo que recibió citrato fue de 4,24 ñ 0,22 (p<0,001), con respecto al grupo control y el volumen fue de 14,4 ñ 3,1 ml (p<0,001) con respecto al grupo control. Se concluye que el pH gástrico con que llegan a pabellón los niños controles es de riesgo y que éste se relaciona inversamente con la edad. El citrato de sodio aumenta el pH gástrico sobre los llamados valores de riesgo y a su vez eleva el volumen gástrico

Revisión retrospectiva de 278 casos de accidentes cerebrovasculares en mujeres internadas en el Hospital General Nacional Arzobispo Loayza / A retrospective review of 278 cases of strokes in internal women in the Hospital General Nacional Arzobispo Loayza (Lima-Perú)

El presente estudio es una revisión retrospectiva de 278 casos de accidentes cerebrovasculares en mujeres internas en el Hospital General Nacional Arzobispo Loayza entre los años 1983-1988. Tiene como objetivo el incentivar el interés de los médicos en general, y no sólo de los neurólogos, en el conocimiento de los accidentes cerebrovasculares, patología de manejo frecuente en nuestro ambiente hospitalario. En nuestro trabajo hemos hallado una incidencia hospitalaria de accidentes cerebrovasculares de 6/1000 casos en población femenina. El 79.5 por ciento de los diagnósticados fue clínico. El 64.4 por ciento de las pacientes presentó complicaciones médicas durante su hospitalización. las más frecuentes fueron las infecciones del tracto urinario (37.1 por ciento), las neumonías aspirativas (29.1 por ciento) y las sepsis (13.3 por ciento). La letalidad general hospitalaria fue de 34.9 por ciento. El 59.6 por ciento de los cuáles falleció durante la primera semana de hospitalización. Clínicamente el enclavamiento por hipertensión endocraneana (40.2 por ciento) y la sepsis (34.0 por ciento) fueron las 2 causas de muerte más frecuentes. El 44.2 por ciento de los pacientes que sobrevivieron fue dado de alta con algún déficit neurológico. Los más frecuentes fueron los motores puros (19.9 por ciento) y los combinados con disartria (13.8 por ciento)