Post-discharge impact and cost-consequence analysis of prehabilitation in high-risk patients undergoing major abdominal surgery: secondary results from a randomised controlled trial.

BACKGROUND: Prehabilitation may reduce postoperative complications, but sustainability of its health benefits and impact on costs needs further evaluation. Our aim was to assess the midterm clinical impact and costs from a hospital perspective of an endurance-exercise-training-based prehabilitation programme in high-risk patients undergoing major digestive surgery. METHODS: A cost-consequence analysis was performed using secondary data from a randomised, blinded clinical trial. The main outcomes assessed were (i) 30-day hospital readmissions, (ii) endurance time (ET) during an exercise testing, and (iii) physical activity by the Yale Physical Activity Survey (YPAS). Healthcare use for the cost analysis included costs of the prehabilitation programme, hospitalisation, and 30-day emergency room visits and hospital readmissions. RESULTS: We included 125 patients in an intention-to-treat analysis. Prehabilitation showed a protective effect for 30-day hospital readmissions (relative risk: 6.4; 95% confidence interval [CI]: 1.4-30.0). Prehabilitation-induced enhancement of ET and YPAS remained statistically significant between groups at the end of the 3 and 6 month follow-up periods, respectively (ΔET 205 [151] s; P=0.048) (ΔYPAS 7 [2]; P=0.016). The mean cost of the programme was €389 per patient and did not increment the total costs of the surgical process (€812; CI: 95% -878 - 2642; P=0.365). CONCLUSIONS: Prehabilitation may result in health value generation. Moreover, it appears to be a protective intervention for 30-day hospital readmissions, and its effects on aerobic capacity and physical activity may show sustainability at midterm. CLINICAL TRIAL REGISTRATION: NCT02024776.

Actividad física y fragilidad como indicadores de reserva cardiorrespiratoria y predictores del pronóstico quirúrgico: caracterización de la población quirúrgica en cirugía general y digestiva / Physical activity and frailty as indicators of cardiorespiratory reserve and predictors of surgical prognosis: general and digestive surgery population characterization

Introducción. Una baja reserva cardiorrespiratoria, un bajo nivel de actividad física y la fragilidad se relacionan con una mayor morbimortalidad perioperatoria. Implementar medidas para optimizar estos aspectos es clave para mejorar el pronóstico. Es fundamental conocer la magnitud del problema para dimensionar los programas de optimización preoperatoria. Objetivo. Caracterizar la población quirúrgica de un hospital universitario de nivel terciario. Métodos. Se incluyeron prospectivamente todos los pacientes sometidos a evaluación preoperatoria para cirugía digestiva con ingreso durante 3 meses. Se evaluó el nivel de actividad física, la capacidad funcional, la fragilidad y el estado emocional, y se realizó un test de medición del estado físico (5 Times Sit-to-Stand Test). Se recogieron datos demográficos, clínicos y relacionados con la cirugía. Resultados. Se incluyeron 140 pacientes (60±15 años, 56% varones, 25% ASA III o IV). El 49% estaban propuestos para cirugía oncológica y un 13% había recibido neoadyuvancia. El 70% de los pacientes presentaban una capacidad funcional reducida y eran sedentarios. Un 18% fueron considerados frágiles y más de un 50% completaron el 5 Times Sit-to-Stand Test en un tiempo superior a los valores de referencia. La edad avanzada, el ASA III/IV, el sedentarismo, la fragilidad y un nivel de ansiedad/depresión elevado se relacionaron con una menor capacidad funcional. Conclusiones. La población quirúrgica de nuestro entorno tiene una baja reserva funcional y un elevado índice de sedentarismo y fragilidad, factores asociados a un peor pronóstico quirúrgico. Urge implementar medidas preoperatorias para identificar la población de riesgo y programas de prehabilitación considerados estrategias de optimización preoperatoria con gran potencial (AU)

Introduction. Frailty and low physical activity and cardiorespiratory reserve are related to higher perioperative morbimortality. The crucial step in improving the prognosis is to implement specific measures to optimize these aspects. It is critical to know the magnitude of the problem in order to implement preoperative optimization programmes. Objective. To characterize surgical population in a university hospital. Methods. All patients undergoing preoperative evaluation for abdominal surgery with admission were prospectively included during a 3-month period. Level of physical activity, functional capacity, frailty and emotional state were assessed using score tests. Additionally, physical condition was evaluated using 5 Times Sit-to-Stand Test. Demographic, clinical and surgical data were collected. Results. One hundred and forty patients were included (60±15yr-old, 56% male, 25% ASA III or IV). Forty-nine percent of patients were proposed for oncologic surgery and 13% of which had received neoadjuvant treatment. Seventy percent of patients presented a low functional capacity and were sedentary. Eighteen percent of patients were considered frail and more than 50% completed the 5 Times Sit-to-Stand Test at a higher time than the reference values adjusted to age and sex. Advanced age, ASA III/IV, sedentarism, frailty and a high level of anxiety and depression were related to a lower functional capacity. Conclusions. The surgical population of our area has a low functional reserve and a high index of sedentary lifestyle and frailty, predictors of postoperative morbidity. It is mandatory to implement preoperative measures to identify population at risk and prehabilitation programmes, considered highly promising preventive interventions towards improving surgical outcome (AU)

Physical activity and frailty as indicators of cardiorespiratory reserve and predictors of surgical prognosis: General and digestive surgery population characterization. / Actividad física y fragilidad como indicadores de reserva cardiorrespiratoria y predictores del pronóstico quirúrgico: caracterización de la población quirúrgica en cirugía general y digestiva.

INTRODUCTION: Frailty and low physical activity and cardiorespiratory reserve are related to higher perioperative morbimortality. The crucial step in improving the prognosis is to implement specific measures to optimize these aspects. It is critical to know the magnitude of the problem in order to implement preoperative optimization programmes. OBJECTIVE: To characterize surgical population in a university hospital. METHODS: All patients undergoing preoperative evaluation for abdominal surgery with admission were prospectively included during a 3-month period. Level of physical activity, functional capacity, frailty and emotional state were assessed using score tests. Additionally, physical condition was evaluated using 5 Times Sit-to-Stand Test. Demographic, clinical and surgical data were collected. RESULTS: One hundred and forty patients were included (60±15yr-old, 56% male, 25% ASA III or IV). Forty-nine percent of patients were proposed for oncologic surgery and 13% of which had received neoadjuvant treatment. Seventy percent of patients presented a low functional capacity and were sedentary. Eighteen percent of patients were considered frail and more than 50% completed the 5 Times Sit-to-Stand Test at a higher time than the reference values adjusted to age and sex. Advanced age, ASA III/IV, sedentarism, frailty and a high level of anxiety and depression were related to a lower functional capacity. CONCLUSIONS: The surgical population of our area has a low functional reserve and a high index of sedentary lifestyle and frailty, predictors of postoperative morbidity. It is mandatory to implement preoperative measures to identify population at risk and prehabilitation programmes, considered highly promising preventive interventions towards improving surgical outcome.

Ascorbic acid PEG-2L is superior for early morning colonoscopies in colorectal cancer screening programs: A prospective non-randomized controlled trial

BACKGROUND: The quality of colon cleansing and the tolerability of anterograde preparation are essential to the success of colorectal cancer screening. AIM: To compare the tolerability and efficacy of low-volume preparations vs the standard regimen in individuals scheduled for an early morning colonoscopy. Study: Participants in a population-based colorectal cancer screening program using the fecal immunochemical test who were scheduled for a colonoscopy from 09:00 a.m. to 10:20 a.m. were prospectively included and assigned to: (1) control group (PEG-ELS 4L): PEG 4L and electrolytes; (2) group AscPEG-2L: a combination of PEG and ascorbic acid 2L; and (3) group PiMg: sodium picosulfate and magnesium citrate 500 mL plus 2 L of clear fluids. Tolerability was evaluated with a questionnaire and the quality of bowel preparation with the Boston Bowel Preparation Scale. RESULTS: A total of 292 participants were included: 98 in the PEG-ELS 4L control group, 96 in the AscPEG-2L study group and 98 in the PiMg study group. Low-volume treatments were better tolerated than the standard solution (AscPEG-2L 94.8% and PiMg 93.9% vs PEG-ELS 4L 75.5%; p < 0.0001). The effectiveness of AscPEG-2L was superior to that of PEG-ELS 4L and PiMg (p = 0.011 and p = 0.032, respectively). Patient acceptance was higher for single-dose than for split-dose administration but efficacy was higher with the split dose than with other doses. CONCLUSIONS: In early morning colonoscopies, ascPEG-2L appears to be the best option, especially when administered in a split-dose

ANTECEDENTES: La calidad de la limpieza del colon y la tolerancia a la preparación anterógrada son claves para el éxito de un programa de cribado de cáncer colorrectal. OBJETIVO: Comparar la tolerancia y eficacia de las preparaciones de volumen reducido frente a la preparación estándar en pacientes programados para colonoscopia a primera hora de la mañana. Estudio: Individuos del programa de cribado poblacional con test de sangre oculta en heces programados para colonoscopia entre las 09:00 y 10:20 a.m fueron prospectivamente asignados a: 1) Grupo Control (PEG-ELS 4L): PEG con electrolitos 4 litros; 2) Grupo AscPEG-2L: PEG más ácido ascórbico 2 litros; y 3) Groupo PiMg: picosulfato sódico más citrato de magnesio 500 ml seguido de 2 litros de líquidos claros. Se evaluó la tolerancia mediante cuestionario y la calidad mediante la Boston Bowel Preparation Scale. RESULTADOS: Se incluyeron 292 sujetos: 98 en el grupo control PEG-ELS 4L, 96 en el grupo a estudio AscPEG-2L y 98 en el grupo a estudio PiMg. Las soluciones de volumen reducido fueron mejor toleradas que la solución estándar (AscPEG-2L 94.8% y PiMg 93.9% vs PEG-ELS 4L 75.5%; p < 0.0001). La calidad de la preparación fue superior en el grupo AscPEG-2L que en el grupo control PEG-ELS 4L y grupo PiMg (p = 0.011 and p = 0.032, respectivamente). Las dosis partidas fueron peor aceptadas por los sujetos pero resultaron en una mayor calidad de la preparación. CONCLUSIONES: AscPEG-2L es la mejor opción para las colonoscopias programadas a primera hora de la mañana, especialmente cuando se administra en dosis partida

Ascorbic acid PEG-2L is superior for early morning colonoscopies in colorectal cancer screening programs: a prospective non-randomized controlled trial.

BACKGROUND: The quality of colon cleansing and the tolerability of anterograde preparation are essential to the success of colorectal cancer screening. AIM: To compare the tolerability and efficacy of low-volume preparations vs the standard regimen in individuals scheduled for an early morning colonoscopy. STUDY: Participants in a population-based colorectal cancer screening program using the fecal immunochemical test who were scheduled for a colonoscopy from 09:00 a.m. to 10:20 a.m. were prospectively included and assigned to: (1) control group (PEG-ELS 4L): PEG 4L and electrolytes; (2) group AscPEG-2L: a combination of PEG and ascorbic acid 2L; and (3) group PiMg: sodium picosulfate and magnesium citrate 500 mL plus 2L of clear fluids. Tolerability was evaluated with a questionnaire and the quality of bowel preparation with the Boston Bowel Preparation Scale. RESULTS: A total of 292 participants were included: 98 in the PEG-ELS 4L control group, 96 in the AscPEG-2L study group and 98 in the PiMg study group. Low-volume treatments were better tolerated than the standard solution (AscPEG-2L 94.8% and PiMg 93.9% vs PEG-ELS 4L 75.5%; p < 0.0001). The effectiveness of AscPEG-2L was superior to that of PEG-ELS 4L and PiMg (p = 0.011 and p = 0.032, respectively). Patient acceptance was higher for single-dose than for split-dose administration but efficacy was higher with the split dose than with other doses. CONCLUSIONS: In early morning colonoscopies, ascPEG-2L appears to be the best option, especially when administered in a split-dose.

Entrenamiento clínico con fibrobroncoscopio en anestesia. Diseño y resultados del curso según encuesta de autoevaluación / Fibreoptic clinical training in anaesthesia. Course design and results based on a self-assessment survey

Objetivos. La intubación con fibrobroncoscopio es la técnica de elección para intubar a pacientes con vía aérea difícil prevista y no prevista, que se pueden ventilar correctamente. Nuestro objetivo fue determinar si un curso práctico e individualizado con esta técnica era capaz de proporcionar suficiente entrenamiento y autoconfianza para permitir que los anestesiólogos participantes practiquen rutinariamente la intubación con fibrobroncoscopio tras el curso. Material y métodos. En nuestro centro se realiza un curso práctico e individualizado de intubación con fibrobroncoscopio en pacientes con anestesia general, con sedación en ventilación espontánea y mediante dispositivos extraglóticos. Entre 2005 y 2009 realizamos una encuesta vía e-mail entre los participantes para autovalorar la adquisición de habilidades durante el curso y su grado de satisfacción. Resultados. La encuesta se remitió a 77 alumnos, 6 meses después de la realización del curso, con una respuesta del 61%. Todos los alumnos que respondieron se consideraron hábiles con el manejo del fibrobroncoscopio al acabar el curso y, el 97% lo utilizó en su práctica habitual en pacientes con vía aérea difícil. Conclusión. Estos resultados sugieren que la realización de cursos de intubación con fibrobroncoscopio que, además de la teoría y la práctica en maniquíes, incluya pacientes con anestesia general y en ventilación espontánea, tiene una alta tasa de éxito en cuanto a la adquisición de habilidades y autosuficiencia de los participantes(AU)

Background and objective. Fibreoptic intubation is the technique of choice for resolving complications related to a difficult airway. Our aim was to determine whether a clinical-practice-based, individualized course provides sufficient training and confidence to allow anaesthetists to routinely practice fibreoptic intubation. Methods. Our hospital developed a clinical-practice-based, individualized course on fibreoptic intubation in general anaesthesia that provided practice in sedated spontaneously breathing patients and insertion through supraglottic devices. From 2005 to 2009, we e-mailed participants for response to an anonymous online self-assessment survey. We asked participants about the training outcomes and their overall degree of satisfaction. Results. Seventy-seven participants were sent the questionnaire six months after the course and 61% responded. All respondents considered themselves skilled in handling the bronchoscope at the end of the course and 97% used it in their routine practice in patients with difficult airways. Conclusions. These results suggest a high success rate can be expected from individually tailored fibreoptic intubation courses that supplement theory and mannequin experience with clinical practice(AU)

[Fibreoptic clinical training in anaesthesia. Course design and results based on a self-assessment survey]. / Entrenamiento clínico con fibrobroncoscopio en anestesia. Diseño y resultados del curso según encuesta de autoevaluación.

BACKGROUND AND OBJECTIVE: Fibreoptic intubation is the technique of choice for resolving complications related to a difficult airway. Our aim was to determine whether a clinical-practice-based, individualized course provides sufficient training and confidence to allow anaesthetists to routinely practice fibreoptic intubation. METHODS: Our hospital developed a clinical-practice-based, individualized course on fibreoptic intubation in general anaesthesia that provided practice in sedated spontaneously breathing patients and insertion through supraglottic devices. From 2005 to 2009, we e-mailed participants for response to an anonymous online self-assessment survey. We asked participants about the training outcomes and their overall degree of satisfaction. RESULTS: Seventy-seven participants were sent the questionnaire six months after the course and 61% responded. All respondents considered themselves skilled in handling the bronchoscope at the end of the course and 97% used it in their routine practice in patients with difficult airways. CONCLUSIONS: These results suggest a high success rate can be expected from individually tailored fibreoptic intubation courses that supplement theory and mannequin experience with clinical practice.

[An established anesthesia team-care model: over 12000 cases in a digestive endoscopy unit]. / Consolidación de un modelo asistencial basado en un equipo de anestesia: experiencia en más de 12.000 casos en una Unidad de Endoscopia Digestiva.

BACKGROUND AND OBJECTIVE: The growing demand for digestive and other endoscopic procedures outside the operating room, both in terms of type of endoscopy and number of patients, requires reorganization of the anesthesiology department's workload. We describe 2 years of our hospital digestive endoscopy unit's experience with a now well-established care model involving both anesthesiologists and nurse anesthetists. MATERIAL AND METHODS: After previously reviewing the medical records of outpatients and conducting a telephone interview about state of health, nurse anesthetists administered a combination of propofol and remifentanil through a target-controlled infusion system under an anesthesiologist's direct supervision. RESULTS: The ratio of anesthesiologists to nurses ranged from 1:2 to 1:3 according to the complexity of the examination procedure. Over 12000 endoscopies (simple to advanced) in a total of 11853 patients were performed under anesthesia during the study period. Airway management maneuvers were required by 4.9% of the patients; 0.18% required bag ventilation for respiratory depression, and 0.084% required bolus doses of a vasopressor to treat hypotension or atropine to treat bradycardia. The procedure had to be halted early in 9 patients (0.07%). No patient required orotracheal intubation and none died. Nor were any complications related to sedation recorded. CONCLUSION: The results suggest that this care model can safely accommodate a large caseload in anesthesia at an optimum level of quality.

Experiencia con el uso de la mascarilla laríngea Proseal en pacientes sometidos a cirugía de derivación ventrículo peritoneal / Experience with the Proseal laryngeal mask in ventriculoperitoneal shunting

Objetivo: Transmitir la experiencia con el uso de la mascarilla laríngea Proseal (MLP) en el manejo de la vía aérea de los pacientes sometidos a cirugía de derivación ventrículo peritoneal, en cuanto a su utilidad, eficacia y seguridad. Pacientes y métodos: Revisamos retrospectivamente las historias de todos los pacientes sometidos a derivación ventrículo peritoneal y ventilados con MLP entre enero del 2006 y octubre del 2009. Registramos las características demográficas de los pacientes, valoración de la vía aérea, tipo de anestesia, calidad de ventilación y complicaciones perioperatorias. Resultados: Se incluyeron 43 pacientes, 8 (18,6%) cumplían algún criterio de vía aérea difícil (VAD). La inserción de la MLP fue posible en todos los pacientes. La ventilación fue óptima en 39 pacientes (91%), manteniendo valores entre 35-40 mmHg de CO2 telespiratorio y presiones de vía aérea por debajo de 25 cmH2O durante todo el procedimiento. Tres pacientes (7%) presentaron fugas en la vía aérea al ser colocados en la posición quirúrgica cervical lateral forzada y precisaron intubación orotraqueal para iniciar la cirugía. El tiempo quirúrgico promedio fue de 53 minutos. La educción ocurrió sin incidentes en todos los casos. Conclusiones: La MLP es útil en el manejo de la vía aérea de los pacientes intervenidos de derivación ventriculoperitoneal, aunque debido a la posición forzada del cuello, puede ser necesario ajustar la colocación de la mascarilla, y en algunos casos la intubación orotraqueal. Como en otros usos avanzados se requiere experiencia en su uso y tener disponible el material de VAD(AU)

Objective: To describe the use, utility, safety, and effectiveness of the Proseal laryngeal mask for airway management in patients undergoing ventriculoperitoneal shunting. Patients and methods: We retrospectively reviewed the records of all patients in whom the Proseal laryngeal mask was used during ventriculoperitoneal shunting between January 2006 and October 2009. Patient demographic characteristics, airway assessments, type of anesthesia, quality of ventilation, and perioperative complications were recorded. Results: Of the 43 patients included, 8 (18.6%) had at least 1 difficult airway criterion. We were able to insert the Proseal laryngeal mask in all patients. Ventilation was optimal in 39 (91%) patients, with maintenance of end-expiratory carbon dioxide pressures between 35 and 40 mm Hg and airway pressures above 25 cm H2O throughout the procedures. Air leaks developed in 3 cases (7%) when the patient was placed in a lateralcervical position for surgery; these patients required orotracheal intubation before surgery could begin. Mean duration of surgery was 53 minutes. Awakening occurred without incident in all cases. Conclusions: The Proseal laryngeal mask is useful for airway management in patients undergoing ventriculoperitoneal shunting. Due to the forced position of the neck, however, it may be necessary to reposition the mask or even proceed to orotracheal intubation in some cases. As is the case for other advanced uses, experience with the device is necessary. Material for managing a difficult airway should be on hand(AU)

[Experience with the proseal laryngeal mask in ventriculoperitoneal shunting]. / Experiencia con el uso de la mascarilla laríngea Proseal en pacientes sometidos a cirugía de derivación ventrículo peritoneal.

OBJECTIVE: To describe the use, utility, safety, and effectiveness of the Proseal laryngeal mask for airway management in patients undergoing ventriculoperitonea shunting. PATIENTS AND METHODS: We retrospectively reviewed the records of all patients in whom the Proseal laryngeal mask was used during ventriculoperitoneal shunting between January 2006 and October 2009. Patient demographic characteristics, airway assessments, type of anesthesia, quality of ventilation, and perioperative complications were recorded. RESULTS: Of the 43 patients included, 8 (18.6%) had at least 1 difficult airway criterion. We were able to insert the Proseal laryngeal mask in all patients. Ventilation was optimal in 39 (91%) patients, with maintenance of end-expiratory carbon dioxide pressures between 35 and 40 mm Hg and airway pressures above 25 cm H2O throughout the procedures. Air leaks developed in 3 cases (7%) when the patient was placed in a lateral-cervical position for surgery; these patients required orotracheal intubation before surgery could begin. Mean duration of surgery was 53 minutes. Awakening occurred without incident in all cases. CONCLUSIONS: The Proseal laryngeal mask is useful for airway management in patients undergoing ventriculoperitoneal shunting. Due to the forced position of the neck, however, it may be necessary to reposition the mask or even proceed to orotracheal intubation in some cases. As is the case for other advanced uses, experience with the device is necessary. Material for managing a difficult airway should be on hand.

Complicación de la prescripción de ketamina fuera del área quirúrgica / No disponible

No disponible