Compliance with Enhanced Recovery After Surgery (ERAS) protocol recommendations for bariatric surgery in an obesity treatment center

Abstract Introduction The higher risk of perioperative complications associated with obesity has made anesthesiologists increasingly concerned with the management of obese patients. Measures that improve bariatric surgery patient safety have become essential. The implementation of ERAS protocols in several surgical specialties has made it possible to achieve appropriate outcomes as to surgery safety. The aim of this study was to evaluate patient compliance with the recommendations of an ERAS protocol for Bariatric Surgery (ERABS) at a hospital specialized in obesity treatment. Methods Cross-sectional study, using a medical record database, in a hospital certified as an International Center of Excellence in Bariatric and Metabolic Surgery. The definition of the variables to be assessed was based on the most recent ERABS proposed by Thorell et al. Results were analyzed using descriptive epidemiology. Results The study evaluated all patients undergoing bariatric surgery in 2019. Mean compliance with the recommendations per participant was 42.8%, with a maximum of 55.5%, and was distributed as follows: 22.6% of compliance with preoperative recommendations, 60% to intraoperative recommendations, and 58.1% to postoperative recommendations. The anesthesiologist is the professional who provides most measures for the perioperative optimization of bariatric surgery patients. In our study we found that anesthesiologists complied with only 39.5% of ERABS recommendations. Conclusions Mean compliance with ERABS recommendations per participant was 42.8%. Considering that the study was carried out at a hospital certified as an international center of excellence, the need for introducing improvements in the care of patients to be submitted to bariatric surgery is evident.

Compliance with Enhanced Recovery After Surgery (ERAS) protocol recommendations for bariatric surgery in an obesity treatment center.

INTRODUCTION: The higher risk of perioperative complications associated with obesity has made anesthesiologists increasingly concerned with the management of obese patients. Measures that improve bariatric surgery patient safety have become essential. The implementation of ERAS protocols in several surgical specialties has made it possible to achieve appropriate outcomes as to surgery safety. The aim of this study was to evaluate patient compliance with the recommendations of an ERAS protocol for Bariatric Surgery (ERABS) at a hospital specialized in obesity treatment. METHODS: Cross-sectional study, using a medical record database, in a hospital certified as an International Center of Excellence in Bariatric and Metabolic Surgery. The definition of the variables to be assessed was based on the most recent ERABS proposed by Thorell et al. Results were analyzed using descriptive epidemiology. RESULTS: The study evaluated all patients undergoing bariatric surgery in 2019. Mean compliance with the recommendations per participant was 42.8%, with a maximum of 55.5%, and was distributed as follows: 22.6% of compliance with preoperative recommendations, 60% to intraoperative recommendations, and 58.1% to postoperative recommendations. The anesthesiologist is the professional who provides most measures for the perioperative optimization of bariatric surgery patients. In our study we found that anesthesiologists complied with only 39.5% of ERABS recommendations. CONCLUSIONS: Mean compliance with ERABS recommendations per participant was 42.8%. Considering that the study was carried out at a hospital certified as an international center of excellence, the need for introducing improvements in the care of patients to be submitted to bariatric surgery is evident.

Avaliação de ansiedade e depressão pré-operatória nas cirurgias realizadas em um ospital do Sul de Santa Catarina / Evaluation of preoperative anxiety and depression in surgeries performed at a hospital in South of Santa Catarina

Introdução: O estresse do período pré-operatório pode ser capaz de aumentar os níveis de ansiedade e depressão. Essas patologias provocam uma liberação de mediadores que prejudicam a anestesia, cirurgia e recuperação pós-operatória. Objetivo: Verificar a prevalência de ansiedade e depressão no pré-operatório em pacientes internados que foram submetidos a procedimentos cirúrgicos eletivos realizados em um hospital do sul de Santa Catarina. Métodos: O presente estudo analisou 279 indivíduos que se encontravam internados, que iriam realizar procedimentos cirúrgicos eletivos e procurou identificar a prevalência destas patologias utilizando a escala HADS e um questionário de perfil sociodemográfico. Resultados: Evidenciou-se uma prevalência de 35,1% de ansiedade e 23,3% de depressão. Foi observado um predomínio dessas patologias em pacientes do sexo feminino (p=0,004 para ansiedade e p=0,012 para depressão) e indivíduos que faziam uso de medicamentos ansiolíticos. Também se constatou maiores índices de depressão em pacientes com experiência cirúrgica prévia, história de tabagismo e com 8 anos ou menos de estudo. Conclusão: Houve uma prevalência de 35,1% de ansiedade e 23,3% de depressão no período pré-operatório, sendo ambas mais comuns em mulheres. Com estes dados, torna-se recomendado a utilização de medidas para prevenção e tratamento desses distúrbios, objetivando uma maior segurança no peri e pós-operatório.

Background: Preoperative stress may be able to increase levels of anxiety and depression. These pathologies cause a release of mediators that impair the anesthesia, surgery and postoperative recovery. Objective: To verify the prevalence of preoperative anxiety and depression in hospitalized patients who performed elective surgical procedures at a hospital in south of Santa Catarina. Methods: The present study analyzed 279 individuals who were hospitalized, who would perform elective surgical procedures and sought to identify the prevalence of these pathologies using the HADS scale and a sociodemographic profile questionnaire. Results: It was found a prevalence of 35,1% of anxiety and 23,3% of depression. It was observed a predominance of these pathologies in female patients (p=0,004 for anxiety and p=0,012 for depression) and individuals who were users of anxiolytic drugs. It was also found higher rates of depression in patients with previous surgical experience, smoking history and with 8 years or less of study. Conclusion: There was a prevalence of 35,1% of anxiety and 23,3% of depression in the preoperative period, both being more common in women. With this data, it is recommended to take measures for prevention and treatment of these disorders, aiming for more safety in the perioperative and postoperative period.

Frequência de via aérea difícil em pacientes submetidos à anestesia geral em um hospital do Sul de Santa Catarina / Frequency of difficult airway tract in pacients submitted to general anesthesia in South Santa Catarina hospital

Justificativa e Objetivos: Avaliar via aérea difícil nos pacientes submetidos à ventilação e intubação orotraqueal sob anestesia geral para operações eletivas. Método: Estudo observacional com desenho transversal. Foram estudados um total de 163 pacientes, de 18 a 80 anos submetidos à ventilação sob máscara facial e intubação traqueal em operações com uso de anestesia geral. Os dados foram coletados na consulta pré-anestésica através de questionário que continha os parâmetros antropométricos e clínicos para intubação difícil. Resultados e Conclusões: Foram investigados 163 pacientes. Houve a presença de via aérea difícil em 19% dos pacientes, e a grande maioria não teve complicações. Ainda, houve uma maior frequência de via aérea difícil em pacientes com maior IMC e maior circunferência cervical, sendo ambos estatisticamente significativos. Foi observado também que quanto maior a classe do Mallampati maior a prevalência de encontrar-se uma classe maior que três na classificação de Cormack e Lehane, assim como maior a chance de se ter uma via aérea difícil, sendo significativo. Por fim, a prevalência de via aérea difícil encontrada é baixa, e quando presente geralmente está relacionado com fatores que podem ser prevenidos. As classificações quando utilizadas juntas tem maior chance de prever a via aérea difícil.

Rationale and Objectives: To evaluate difficult airway in patients submitted to ventilation and orotracheal intubation under general anesthesia for elective operations. Method: Observational study with cross-sectional design. A total of 163 patients, 18 to 80 years old undergoing ventilation under face mask and tracheal intubation in operations using general anesthesia were studied. The data were collected in the pre-anesthetic consultation through a questionnaire that contained the anthropometric and clinical parameters for difficult intubation. Results and Conclusions: 163 patients were investigated. There was a difficult airway presence in 19% of the patients, and the vast majority had no complications. Also, there was a higher frequency of difficult airway in patients with higher BMI and greater cervical circumference, both of which were statistically significant. It was also observed that the higher the Mallampati class the higher the prevalence of finding a class higher than three in the classification of Cormack and Lehane, as well as the greater the chance of having a difficult airway, being significant. Finally, the prevalence of difficult airways found is low, and when present geographically it is related to factors that can be prevented. Classifications when used together have a greater chance of predicting difficult airway.

Complicações pós-operatórias imediatas na SRPA em um hospital geral do sul de Santa Catarina / Immediate postoperative complications in the SRPA ia general hospital do sul de Santa Catarina

Introdução: Apesar de haver rigorosas determinações para avaliação pré-anestésica do paciente cirúrgico, bem como cuidados no transoperatório e no pós-operatório, ainda se verifica a permanência de complicações pós-operatórias. Objetivo: Identificar complicações pós-operatórias imediatas ocorridas na Sala de Recuperação Pós-Anestésica (SRPA) em um Hospital Geral do Sul de Santa Catarina. Métodos: Estudo transversal que incluiu pacientes submetidos à anestesia geral em cirurgias eletivas e de urgência. Foram coletados dados acerca do perfil do paciente e do procedimento cirúrgico. Também foram registrados dados dos monitores cardíacos à beira leito do paciente, assim como temperatura axilar, frequência cardíaca e saturação de oxigênio. Prontuários médicos foram revisados. Foram considerados como complicação os sintomas referidos pelo paciente no momento de aplicação do questionário, além de distúrbios da temperatura corporal, da frequência cardíaca ou da saturação de oxigênio. Resultados: Considerando os 350 pacientes incluídos no estudo, a prevalência de complicações pós-operatórias imediatas foi de 74,0%. A complicação mais comum verificada foi dor no local cirúrgico (56,9%), seguido de tontura (21,4%). A maioria dos pacientes apresentou apenas uma complicação (47,9%), sendo que apenas um paciente (0,4%) apresentou seis complicações. Houve uma tendência de associação entre o tipo de cirurgia e a ocorrência de complicações (p=0,059), e houve associação estatisticamente significante entre tipo de anestesia e a ocorrência de complicações (p<0,001). Conclusão: Houve incidência de 74,0% de complicações pós-operatórias, e a dor de fraca intensidade foi a complicação mais comum. Estes dados permitem conhecimento mais abrangente pelos anestesiologistas das principais complicações pós-operatórias, possibilitando condutas mais direcionadas às complicações que são mais comuns entre os pacientes.

Background: Although there are rigorous determinations for pre-anesthetic evaluation of the surgical patient, as well as transoperative and postoperative care, the permanence of postoperative complications is still verified. Objective: To identify immediate postoperative complications occurred in the Post-Anesthesia Care Unit (PACU) at a General Hospital in the South of Santa Catarina. Methods: Cross-section study with patients undergoing general anesthesia in elective and emergency surgeries. Data on patients' profile and their surgical procedure were collected. Cardiac monitors data at the patients' bedside were also registered, as well as the axillary temperature, heart rate and oxygen saturation. The medical records were reviewed. Another symptoms reported by the patient at the time of the application of the questionnaire were considered as complications, besides the body temperature, heart rate and oxygen saturation. Results: Considering the 350 patients included in the study, the prevalence of immediate postoperative complications was 74.0%. The most common complication verified was pain at the surgical site (56.9%), followed by dizziness (21.4%). The majority of patients presented only one complication (47.9%), and just one (0.4%) had six complications. There was a tendency of association between the type of surgery and the occurrence of complications (p = 0.059), and there was a statistically significant association between the type of anesthesia and the occurrence of complications (p <0.001). Conclusion: There was an incidence of 74.0% of postoperative complications, and the pain of low intensity was the most common complication. These data allow a more comprehensive knowledge of the main prostoperative complications by the anesthesiologists, enabling more directed conducts to the complications that are more common among the patients.

Reação anafilática induzida por látex em paciente submetido à apendicectomia aberta: relato de caso / Latex-induced anaphylactic reaction in a patient undergoing open appendectomy: case report / Reacción anafiláctica inducida por el látex en paciente sometido a la apendicectomía abierta: relato de caso

JUSTIFICATIVA E OBJETIVOS: Embora crescente a incidência de alergia ao látex na população em geral, eventos graves de anafilaxia durante alguns procedimentos cirúrgicos felizmente ainda são raros, porém com morbidade e mortalidade elevados. Não apenas a prevenção, mas o diagnóstico, o pronto tratamento e o acompanhamento dos pacientes acometidos por esse evento representam um desafio para o anestesiologista. O presente relato teve por objetivo descrever um caso de anafilaxia grave ao látex e discutir seu diagnóstico e tratamento. RELATO DO CASO: Paciente do sexo feminino, 39 anos, branca com suspeita diagnóstica de apendicite, é levada para procedimento de urgência sob raquianestesia. Aproximadamente 30 minutos após o início da cirurgia, apresentou quadro de anafilaxia com parada cardiorrespiratória, revertida após tratamento. Um dos cuidados foi o isolamento de eventuais agentes causais, sendo que, posteriormente, a paciente foi encaminhada para unidade de terapia intensiva e evoluiu sem sequelas. A dosagem de IgE-RAST (Radioallergosorbent Test) específico para o látex mostrou-se positiva. A paciente foi encaminhada para acompanhamento com o alergologista. CONCLUSÕES: O anestesiologista deve concentrar esforços na anamnese, mesmo em procedimentos de urgência, estando consciente das limitações que se apresentam nessas ocasiões. O prognóstico de anafilaxia depende do pronto início do tratamento adequado e o diagnóstico não se limita ao momento do evento, mas sim à determinação do fator causal. Criar um meio de acompanhar esses pacientes, a exemplo de outros centros internacionais, parece ser o caminho a ser seguido.

BACKGROUND AND OBJECTIVE: Despite the increase of latex allergy in general population, severe anaphylactic events during some surgical procedures are still rare; however, they are associated with increased morbidity and mortality. Prevention, diagnosis, treatment, and follow-up of patients affected by this event represent a challenge for anesthesiologists. The objective of this report was to describe a case of severe latex-induced anaphylactic reaction and discuss its diagnosis and treatment. CASE REPORT: This is a 39-year-old Caucasian female patient, with a diagnostic suspicion of appendicitis, who underwent an emergency surgery under spinal anesthesia. Approximately 30 minutes after beginning the surgery, the patient developed an anaphylactic reaction with cardiorespiratory arrest, which was reversed after treatment. Possible causative agents were isolated and, posteriorly, the patient was transferred to the intensive care unit, evolving without sequelae. Latex-specific IgE-RAST (Radioallergosorbent Test) was positive. The patient was referred to an allergist for follow-up. CONCLUSIONS: Anesthesiologists should focus on patient's history, even in urgent procedures, being aware of the limitations arising on these situations. The prognosis of anaphylaxis depends on prompt initiation of adequate treatment; diagnosis is not limited to the event occasion, but to the determination of the causative factor. Creating the means of following-up these patients, similar to other international centers, seems to be the example to be followed.

JUSTIFICATIVA Y OBJETIVOS: Aunque exista un aumento en la incidencia de alergia al látex en la población en general, los eventos graves de anafilaxia durante algunos procedimientos quirúrgicos por suerte todavía son raros, aunque con un nivel de morbilidad y mortalidad elevados. La prevención, el diagnóstico, el rápido tratamiento y el seguimiento de los pacientes afectados por ese evento, representan un reto para el anestesiólogo. El presente relato intentó describir un caso de anafilaxia grave al látex y discutir su diagnóstico y tratamiento. RELATO DEL CASO: Paciente del sexo femenino, 39 anos, blanca y con sospecha diagnóstica de apendicitis, que fue derivada a quirófano para un procedimiento urgente bajo raquianestesia. Aproximadamente 30 minutos después del inicio de la cirugía, presentó un cuadro de anafilaxia con parada cardiorrespiratoria, revertida posteriormente al tratamiento. Uno de los cuidados tomados fue el aislamiento de eventuales agentes causales, siendo que, posteriormente, la paciente fue derivada a la Unidad de Cuidados Intensivos y evolucionó sin secuelas. La dosificación de IgE-RAST (Radioallergosorbent Test), específico para el látex fue positiva. La paciente fue derivada para seguimiento con el alergista. CONCLUSIONES: El anestesiólogo debe concentrar sus esfuerzos en la anamnesis, aunque en los procedimientos de urgencia, sea consciente de las limitaciones que se presentan en esas ocasiones. El pronóstico de anafilaxia depende del rápido inicio del tratamiento adecuado, y el diagnóstico no se restringe al momento del evento, sino a la determinación del factor causal. Crear un medio de seguimiento para esos pacientes, como lo hacen otros centros internacionales, parece ser el camino que debe ser secundado.

[Latex-induced anaphylactic reaction in a patient undergoing open appendectomy. Case report]. / Reacción anafiláctica inducida por el látex en pacientesometido a la apendicectomía abierta. relato de caso.

BACKGROUND AND OBJECTIVE: Despite the increase of latex allergy in general population, severe anaphylactic events during some surgical procedures are still rare; however, they are associated with increased morbidity and mortality. Prevention, diagnosis, treatment, and follow-up of patients affected by this event represent a challenge for anesthesiologists. The objective of this report was to describe a case of severe latex induced anaphylactic reaction and discuss its diagnosis and treatment. CASE REPORT: This is a 39-year-old Caucasian female patient, with a diagnostic suspicion of appendicitis, who underwent an emergency surgery under spinal anesthesia. Approximately 30 minutes after beginning the surgery, the patient developed an anaphylactic reaction with cardiorespiratory arrest, which was reversed after treatment. Possible causative agents were isolated and, posteriorly, the patient was transferred to the intensive care unit, evolving without sequelae. Latex-specific IgE-RAST (Radioallergosorbent Test) was positive. The patient was referred to an allergist for follow-up. CONCLUSIONS: Anesthesiologists should focus on patient's history, even in urgent procedures, being aware of the limitations arising on these situations. The prognosis of anaphylaxis depends on prompt initiation of adequate treatment; diagnosis is not limited to the event occasion, but to the determination of the causative factor. Creating the means of following-up these patients, similar to other international centers, seems to be the example to be followed.

[Spinal anesthesia with 0.5% hyperbaric ropivacaine and 0.5% hyperbaric bupivacaine: a comparative study.]. / Estudo comparativo entre ropivacaína a 0,5% e bupivacaína a 0,5% ambas hiperbáricas, na raquianestesia.

BACKGROUND AND OBJECTIVES: Spinal anesthesia with ropivacaine has been proven safe both in experimental and clinical studies. On the other hand, ropivacaine is approximately half as potent as bupivacaine in spinal anesthesia when both drugs are used in hyperbaric solutions. This study aimed at comparing clinical spinal block features obtained with hyperbaric ropivacaine or bupivacaine in equipotent doses. METHODS: Twenty ASA I or II patients, aged 20 to 60 years, scheduled for elective surgeries of lower limbs, perineum and inguinal hernioplasty, were randomly allocated into two groups . Group R (n = 10) were given 4 ml 0.5% hyperbaric ropivacaine and Group B (n = 10) were given 2 ml of 0.5% hyperbaric bupivacaine intratecally. Puncture was performed with a 25G needle in the sitting position. Monitoring consisted of SBP, DBP, MBP, HR, ECG and SpO2. Sensory and motor block onset and recovery times, hemodynamic and respiratory changes, and the incidence of adverse effects were recorded. RESULTS: There were no differences between groups in demographics data, sensory block onset (174.4 +/- 75.9 vs. 191 +/- 51.7 s), motor block onset (373.6 +/- 214.6 vs. 240 +/- 60 s), upper level of sensory block T8 - T10 (90% of group R patients vs. 70% of group B), motor block grade 3 (50% of group R patients vs. 30% of group B), time to total sensory block recovery (178.5 +/- 65.2 vs. 181 +/- 26.9 minutes), time to total motor block recovery (192 +/- 50.7 vs. 162.5 +/- 37.8 minutes), and time for first spontaneous pain complaint (183.9 +/- 37.1 vs. 206.5 +/- 46.6 minutes). CONCLUSIONS: No differences in spinal block clinical features were observed between hyperbaric 0.5% ropivacaine and 0.5% bupivacaine, when administered in equipotent doses. Data seem to confirm previous observations that in these conditions, ropivacaines potency is approximately half bupivacaines potency.