Congenitally corrected transposition of the great arteries outcomes of different surgical techniques in a paediatric population: A single-centre report.

BACKGROUND: Congenitally corrected transposition of the great arteries is a complex pathology characterised by atrioventricular and ventriculo-arterial discordance. Optimal surgical approaches are still a matter of debate. OBJECTIVE: To evaluate the outcomes of different surgical treatments in a single centre. METHODS: Between 1998 and 2020, 89 patients were studied. The cohort was divided into three groups: physiologic, anatomic, and univentricular repair. RESULT: Physiologic correction (56.18%) was associated with significant tricuspid valve regurgitation progress (42%) and complete AV block (30%) compared to anatomic repair. Right ventricular systolic dysfunction was developed in 14%. Instead, anatomic correction (30.34%) (double switch 59% and Rastelli type 40.7%) presented moderate to severe aortic regurgitation (4%) and left ventricular systolic dysfunction (11%). Complete AV block was developed in 14.8%. Rate of reintervention was 34% for physiologic and 26% for anatomic. Univentricular palliation (13.8%) presented no complications or late mortality during the follow-up. The overall survival at 5 and 10 years, respectively, was 80% (95% CI 69, 87) and 75% (95% CI 62, 84). There was no statistically significant difference in mortality between the groups (p log-rank = 0.5752). CONCLUSION: Management of congenitally corrected transposition of the great arteries remains a challenge. In this cohort, outcomes after physiologic repair were satisfactory in spite of the progression of tricuspid regurgitation and the high incidence of AV block. Anatomic repair improved tricuspid regurgitation but increased the risk of aortic regurgitation and left ventricular systolic dysfunction. The Fontan group showed the lowest incidence of complications.

Asistencia con membrana de oxigenación extracorpórea en recuperación cardiovascular pediátrica: experiencia de un centro de Argentina / Extracorporeal membrane oxygenation in pediatric cardiovascular care: Experience of a center in Argentina

Objetivo: Describir resultados de membrana de oxigenación extracorpórea en pacientes con cirugía cardíaca y analizar los factores de riesgos de morbimortalidad. Métodos: Estudio retrospectivo, de pacientes cardíacos con asistencia circulatoria. Se registraron variables, diagnóstico, cirugía, puntaje Risk Adjustment for Congenital Heart Surgery (RACHS), momento de colocación, canulación, días de asistencia en internación, complicaciones, sobrevida y seguimiento. Se analizaron los riesgos edad, peso, RACHS, patología uni- o biventricular, momento de colocación, días de asistencia e internación, y complicaciones. Análisis estadístico descriptivo y de regresión logística para factores de riesgo. Resultados: En 5295 admisiones, 72 pacientes requirieron membrana de oxigenación extracorpórea (1,37 %). Edad mediana: 6,5 meses (rango intercuartilo -RIQ-: 20 días-2 años); peso: 5,5 kg (RIQ: 3,25-9,5); tiempo de bomba: 188 min (RIQ: 134-246,5); de clampeo: 92 min (65-117). La canulación fue en quirófano en 34 casos (47 %). La mediana de asistencia fue 3 días (RIQ: 2-5), y de internación, 20 (RIQ: 11-32). La sobrevida al alta fue 49 %; 8 pacientes fallecieron durante el seguimiento. La complicación más frecuente fue hemorragia ( 57 %). El peso <5 kg (p = 0,01) y vasopresores en asistencia (p = 0,012) tuvieron riesgo de mortalidad. La sobrevida a 10 años fue del 77 %, con 84 % en clase funcional 1-2 y el 37 % presentaba algún grado de retardo madurativo. Conclusiones: La complicación más frecuente fue la hemorragia; peso y vasopresores se asociaron con mortalidad.

Objective: To describe the results of extracorporeal membrane oxygenation in patients undergoing heart surgery and analyze the risk factors for morbidity and mortality. Methods: Retrospective study conducted in cardiac patients under circulatory support. Outcome measures, diagnosis, surgery, Risk Adjustment for Congenital Heart Surgery (RACHS) score, implantation time, cannulation, length of support during stay, complications, survival, and follow-up were recorded. Risks were analyzed in relation to age, weight, RACHS score, single-ventricle or biventricular disease, implantation time, length of support and stay, and complications. Descriptive statistical and logistic regression analyses for risk factors were done. Results: Among 5295 hospitalizations, 72patients required extracorporeal membrane oxygenation (1.37 %). Median age: 6.5 months (interquartile range [IQR]: 20 days-2 years); weight: 5.5 kg (IQR: 3.25-9.5); pump time: 188 min (IQR: 134- 246.5); clamp time: 92 min (65-117). Cannulation was done in the operating room in 34 cases (47 %). The median length of support was 3 days (IQR: 2-5), and of stay, 20 days (IQR: 11-32). Survival at discharge was 49 %; 8 patients died during follow-up. The most common complication was bleeding (57 %). Weight<5 kg (p = 0.01) and vasopressor use during support (p = 0.012) were associated with a risk for mortality. The survival rate at 10 years was 77 %; 84% of patients corresponded to functional class 1-2, and 37% had some degree of developmental delay.

Extracorporeal membrane oxygenation in pediatric cardiovascular care: Experience of a center in Argentina. / Asistencia con membrana de oxigenación extracorpórea en recuperación cardiovascular pediátrica: experiencia de un centro de Argentina.

Objective: To describe the results of extracorporeal membrane oxygenation in patients undergoing heart surgery and analyze the risk factors for morbidity and mortality. Methods: Retrospective study conducted in cardiac patients under circulatory support. Outcome measures, diagnosis, surgery, Risk Adjustment for Congenital Heart Surgery (RACHS) score, implantation time, cannulation, length of support during stay, complications, survival, and follow-up were recorded. Risks were analyzed in relation to age, weight, RACHS score, single-ventricle or biventricular disease, implantation time, length of support and stay, and complications. Descriptive statistical and logistic regression analyses for risk factors were done. Results: Among 5295hospitalizations, 72 patients required extracorporeal membrane oxygenation (1.37 %). Median age: 6.5 months (interquartile range [IQR]: 20 days-2 years); weight: 5.5 kg (IQR: 3.25-9.5); pump time: 188 min (IQR: 134246.5); clamp time: 92 min (65-117). Cannulation was done in the operating room in 34 cases (47 %). The median length of support was 3 days (IQR: 2-5), and of stay, 20 days (IQR: 1132). Survival at discharge was 49 %; 8 patients died during follow-up. The most common complication was bleeding (57 %). Weight < 5 kg (p = 0.01) and vasopressor use during support (p = 0.012) were associated with a risk for mortality. The survival rate at 10 years was 77 %; 84 % of patients corresponded to functional class 1-2, and 37 % had some degree of developmental delay. Conclusions: The most common complication was bleeding; weight and vasopressor use were associated with mortality.

Objetivo: Describir resultados de membrana de oxigenación extracorpórea en pacientes con cirugía cardíaca y analizar los factores de riesgos de morbimortalidad. Métodos: Estudio retrospectivo, de pacientes cardíacos con asistencia circulatoria. Se registraron variables, diagnóstico, cirugía, puntaje Risk Adjustment for Congenital Heart Surgery (RACHS), momento de colocación, canulación, días de asistencia en internación, complicaciones, sobrevida y seguimiento. Se analizaron los riesgos edad, peso, RACHS, patología uni- o biventricular, momento de colocación, días de asistencia e internación, y complicaciones. Análisis estadístico descriptivo y de regresión logística para factores de riesgo. Resultados: En 5295 admisiones, 72 pacientes requirieron membrana de oxigenación extracorpórea (1,37 %). Edad mediana: 6,5 meses (rango intercuartilo -RIQ-: 20 días-2 años); peso: 5,5 kg (RIQ: 3,25-9,5); tiempo de bomba: 188 min (RIQ: 134-246,5); de clampeo: 92 min (65-117). La canulación fue en quirófano en 34 casos (47 %). La mediana de asistencia fue 3 días (RIQ: 2-5), y de internación, 20 (RIQ: 11-32). La sobrevida al alta fue 49 %; 8 pacientes fallecieron durante el seguimiento. La complicación más frecuente fue hemorragia ( 57 %). El peso <5 kg (p = 0,01) y vasopresores en asistencia (p = 0,012) tuvieron riesgo de mortalidad. La sobrevida a 10 años fue del 77 %, con 84 % en clase funcional 1-2 y el 37 % presentaba algún grado de retardo madurativo. Conclusiones: La complicación más frecuente fue la hemorragia; peso y vasopresores se asociaron con mortalidad.

Asistencia circulatoria mecánica en pediatría: Experiencia en el Hospital de Pediatría Dr. Juan P. Garrahan. Argentina / Mechanical circulatory support in pediatrics: Experience at the Hospital de Pediatría Dr. Juan P. Garrahan. Argentina

Introducción: La asistencia circulatoria mecánica permite aportar oxígeno a los tejidos en pacientes con enfermedades cardiacas y/o respiratorias reversibles refractarios a tratamientos convencionales. Objetivo: Mostrar los resultados iniciales de asistencia circulatoria mecánica en niños con cardiopatía en nuestra institución. Método: Estudio de cohorte descriptivo retrospectivo entre marzo de 2006 y marzo de 2012. Datos demográficos (edad, sexo, peso, diagnóstico cardiológico), de la cirugía (técnica, tiempo de bomba y de pinzamiento aórtico) y de la asistencia circulatoria mecánica (tipo, indicación, duración, complicaciones y evolución). Resultados: Fueron asistidos 33 pacientes (1.3% del total de cirugías), con oxigenación por membrana extracorpórea en 32 casos y un caso con dispositivo de asistencia ventricular. Mediana de edad 7.4 meses (un día-18 años) y peso 6 kg (2.3-75). Las malformaciones cardiacas que se asistieron con mayor frecuencia son las trasposiciones de grandes arterias asociadas a otras anomalías y las trasposiciones corregidas (inversión ventricular-doble discordancia). El motivo de ingreso más frecuente fue disfunción biventricular poscardiotomía. En 28 pacientes la asistencia circulatoria mecánica fue postoperatoria y en 4 preoperatoria. Un paciente presentó miocarditis. Mediana de asistencia 3 días (1-10). Complicaciones más frecuentes: infección el 21% y sangrado el 21%. Decanulación electiva en un 94% de los casos. Supervivencia con alta hospitalaria: 52%. Conclusiones: La asistencia circulatoria mecánica en nuestra institución es una herramienta segura con procedimiento estandarizado. Se utiliza en un reducido número de casos, con supervivencia similar a informes internacionales. Es un procedimiento complejo, plenamente justificado que permitió la recuperación en más de la mitad de los pacientes que de otro modo hubieran fallecido.

Introduction: Mechanical circulatory support provides oxygen to the tissues in patients with cardiac and/or respiratory reversible disease refractory to conventional treatments. Objective: The aim of this study is to show our initial results of mechanical circulatory support in children with heart disease. Method: Retrospective cohort between March 2006 and March 2012. Demographic data (age, sex, weight, cardiac diagnosis), surgery (technique, pump, aortic cross clamping time) and mechanical circulatory support (type of assistance, indication, duration, complications and outcome) were collected. Results: Thirty-three patients were supported (1.3% of all surgeries), extracorporeal membrane oxygenation 32 cases and one ventricular assist device. The median age 7.4 months (one day-18 years) and weight 6 kg (2.3-75). The most frequent cardiac malformations supported were the transpositions of the great arteries associated with other anomalies and the corrected transpositions (ventricular inversion or double discordance). The most common reason for admission was post-cardiotomy biventricular dysfunction. Twenty-eight patients were supported in the postoperative period, 4 in the preoperative period and in one with myocarditis. Median days of support were 3 days (1-10). The most common complications were infection (21%), bleeding (21%). Elective decannulation was achieved in 94% of cases. Hospital discharge survival: 52%. Conclusions: The mechanical circulatory support in our institution is a safe and standard procedure. We have been using it in a small number of cases with a similar survival to that reported internationally. This complex procedure is widely justified because it allows for the recovery of more than half of the patients who otherwise would have died.

[Mechanical circulatory support in pediatrics. Experience at the Dr. Juan P. Garrahan Pediatric Hospital. Argentina]. / Asistencia circulatoria mecánica en pediatría. Experiencia en el Hospital de Pediatría Dr. Juan P. Garrahan. Argentina.

INTRODUCTION: Mechanical circulatory support provides oxygen to the tissues in patients with cardiac and/or respiratory reversible disease refractory to conventional treatments. OBJECTIVE: The aim of this study is to show our initial results of mechanical circulatory support in children with heart disease. METHOD: Retrospective cohort between March 2006 and March 2012. Demographic data (age, sex, weight, cardiac diagnosis), surgery (technique, pump, aortic cross clamping time) and mechanical circulatory support (type of assistance, indication, duration, complications and outcome) were collected. RESULTS: Thirty-three patients were supported (1.3% of all surgeries), extracorporeal membrane oxygenation 32 cases and one ventricular assist device. The median age 7.4 months (one day-18 years) and weight 6kg (2.3-75). The most frequent cardiac malformations supported were the transpositions of the great arteries associated with other anomalies and the corrected transpositions (ventricular inversion or double discordance). The most common reason for admission was post-cardiotomy biventricular dysfunction. Twenty-eight patients were supported in the postoperative period, 4 in the preoperative period and in one with myocarditis. Median days of support were 3 days (1-10). The most common complications were infection (21%), bleeding (21%). Elective decannulation was achieved in 94% of cases. Hospital discharge survival: 52%. CONCLUSIONS: The mechanical circulatory support in our institution is a safe and standard procedure. We have been using it in a small number of cases with a similar survival to that reported internationally. This complex procedure is widely justified because it allows for the recovery of more than half of the patients who otherwise would have died.

Glenn bidireccional: resultados y análisis de factores de riesgo en una experiencia de 5 años / Bidirectional Glenn: Outcomes and risk factor analysis in a 5 years' experience

Objetivo: La anastomosis de Glenn es un procedimiento paliativo en pacientes con ventrículo único. Si bien se asocia a baja morbimortalidad, el objetivo es exponer los resultados en cirugía de Glenn y analizar los factores de riesgo en nuestra población. Métodos: Estudio retrospectivo de pacientes con cirugía de Glenn entre 2005 y 2009. Se registraron variables demográficas, tipo de ventrículo único, cirugía previa, método de cirugía y evolución en postoperatorio. Se efectuó un análisis estadístico univariado y multivariado para identificar factores de riesgo de mortalidad y/o de internación prolongada (Stata 9.0). Resultados: Se operaron 101 pacientes, 87 con Glenn bidireccional y 14 con Glenn bilateral. Edad mediana 15 meses (2.5-108), peso 8.5 kg (4.2-27). El 74% tenían cirugía previa, en 54 se realizó algún procedimiento asociado al Glenn y en 4 se dejó una fuente adicional de flujo pulmonar. La mediana de internación fue de 8 días (2-97). El 35% presentó complicaciones postoperatorias. No encontramos asociación entre edad, peso o cirugías previas y mortalidad. Tampoco entre tiempo de bomba y <

Objective: Bidirectional Glenn shunt is a palliative surgical procedure in patients with single ventricle. Although morbimortality in this surgery is low, risk factors have been described. The purpose of this study is to report our outcomes in Glenn surgery, identifying mortality risk factors in our population. Methods: Retrospective study between 2005 and 2009. Age, weight, previous surgery, surgical procedure, and postoperative condition were analyzed. Results are reported as median and rank, or absolute values and percentage. Uni and multivariate analysis was made to identify risk factors of mortality and/or prolonged hospitalization (Stata 9.0). Results: One hundred and one patients were operated; 87 bidirectional Glenn and 14 bilateral Glenn. Median age 15 months (2.5-108), median weight 8.5 kg (4.2-27), and 74% of them with previous surgery. In 54 patients an associated procedure was performed simultaneously, only in 4 additional pulmonary blood flow was left. Median hospitalization was 8 days (2-97). Thirty-five percent of the patients presented complications. No association between age, weight, pulmonary hypertension, cardiopulmonary bypass, cross clamping, associated procedures or Glenn bilateral with mortality or morbidity was found. Overall mortality was 3.9%. Conclusion: Mortality was similar to other centers, but morbidity in this group of patients is high. No independent risk factors associated with morbidity or mortality were identified.

[Bidirectional Glenn: outcomes and risk factor analysis in a 5 years' experience]. / Glenn bidireccional: resultados y análisis de factores de riesgo en una experiencia de 5 años.

OBJECTIVE: Bidirectional Glenn shunt is a palliative surgical procedure in patients with single ventricle. Although morbimortality in this surgery is low, risk factors have been described. The purpose of this study is to report our outcomes in Glenn surgery, identifying mortality risk factors in our population. METHODS: Retrospective study between 2005 and 2009. Age, weight, previous surgery, surgical procedure, and postoperative condition were analyzed. Results are reported as median and rank, or absolute values and percentage. Uni and multivariate analysis was made to identify risk factors of mortality and/or prolonged hospitalization (Stata 9.0). RESULTS: One hundred and one patients were operated; 87 bidirectional Glenn and 14 bilateral Glenn. Median age 15 months (2.5-108), median weight 8.5 kg (4.2-27), and 74% of them with previous surgery. In 54 patients an associated procedure was performed simultaneously, only in 4 additional pulmonary blood flow was left. Median hospitalization was 8 days (2-97). Thirty-five percent of the patients presented complications. No association between age, weight, pulmonary hypertension, cardiopulmonary bypass, cross clamping, associated procedures or Glenn bilateral with mortality or morbidity was found. Overall mortality was 3.9%. CONCLUSION: Mortality was similar to other centers, but morbidity in this group of patients is high. No independent risk factors associated with morbidity or mortality were identified.

[Right postpneumonectomy syndrome: case report]. / Síndrome postneumonectomía derecha: informe de un caso.

Postpneumonectomy syndrome is a rare entity in children. We report a case secondary to pneumonectomy performed due to an intrathoracic tumor. A 4-year-old boy with a history of right pneumonectomy and progressive respiratory distress, with extrinsic airway obstruction due to displaced mediastinal structures. There were failure to intubate the airway with endoluminal devices and impossibility of withdrawing from mechanical ventilation. As mediastinal repositioning was not possible, an aortic bypass with a prosthetic tube graft was performed, with favorable outcome and hospital discharge.

Síndrome postneumonectomía derecha: informe de un caso / Right postpneumonectomy syndrome: Case report

El síndrome postneumonectomía es una entidad poco frecuente en pediatría. Comunicamos un caso secundario a una neumonectomía realizada por un tumor intratorácico. Niño de 4 años con antecedente de exéresis pulmonar derecha y dificultad respiratoria progresiva, con obstrucción extrínseca de la vía aérea por estructuras mediastínicas desplazadas. Hubo intentos frustros de tutorización con dispositivos endoluminales de la vía aérea, e imposibilidad de retiro de la asistencia ventilatoria mecánica. Ante la imposibilidad de reposicionamiento mediastinal, se realiza puente (bypass) aórtico con tubo protésico, con evolución favorable y egreso hospitalario.

Postpneumonectomy syndrome is a rare entity in children. We report a case secondary to pneumonectomy performed due to an intrathoracic tumor. A 4-year-old boy with a history of right pneumonectomy and progressive respiratory distress, with extrinsic airway obstruction due to displaced mediastinal structures. There were failure to intubate the airway with endoluminal devices and impossibility of withdrawing from mechanical ventilation. As mediastinal repositioning was not possible, an aortic bypass with a prosthetic tube graft was performed, with favorable outcome and hospital discharge.

Síndrome postneumonectomía derecha: informe de un caso / Right postpneumonectomy syndrome: Case report

El síndrome postneumonectomía es una entidad poco frecuente en pediatría. Comunicamos un caso secundario a una neumonectomía realizada por un tumor intratorácico. Niño de 4 años con antecedente de exéresis pulmonar derecha y dificultad respiratoria progresiva, con obstrucción extrínseca de la vía aérea por estructuras mediastínicas desplazadas. Hubo intentos frustros de tutorización con dispositivos endoluminales de la vía aérea, e imposibilidad de retiro de la asistencia ventilatoria mecánica. Ante la imposibilidad de reposicionamiento mediastinal, se realiza puente (bypass) aórtico con tubo protésico, con evolución favorable y egreso hospitalario.(AU)

Postpneumonectomy syndrome is a rare entity in children. We report a case secondary to pneumonectomy performed due to an intrathoracic tumor. A 4-year-old boy with a history of right pneumonectomy and progressive respiratory distress, with extrinsic airway obstruction due to displaced mediastinal structures. There were failure to intubate the airway with endoluminal devices and impossibility of withdrawing from mechanical ventilation. As mediastinal repositioning was not possible, an aortic bypass with a prosthetic tube graft was performed, with favorable outcome and hospital discharge.(AU)

Cirugía de Rastelli: impacto adverso de la comunicación interventricular no relacionada con los grandes vasos en los resultados quirúrgicos / The Rastelli Procedure: Adverse Impact in Surgical Outcomes of a Ventricular Septal Defect Noncommitted to the Great Arteries

Introducción La evolución de los pacientes operados con técnica de Rastelli revela que se trata de un procedimiento quirúrgico complejo no exento de morbilidad y mortalidad a mediano y a largo plazos. Las complicaciones serían, aparentemente, más frecuentes cuando la comunicación interventricular (CIV) es anatómicamente remota o no relacionada con la aorta. Objetivo Evaluar el impacto de la localización anatómica de la CIV en la cirugía de Rastelli. Material y métodos Se incluyeron 47 pacientes con una media (X) de seguimiento posquirúrgico de 6 años (15 meses-14 años). Los pacientes se subdividieron en: grupo I, CIV relacionada con la aorta (n = 29) y grupo II, CIV remota o no relacionada (n = 18). Resultados En el posquirúrgico inmediato, las reoperaciones (p = 0,05) fueron más frecuentes en el grupo II, en el cual se observó también una tendencia a mayor frecuencia de arritmias (p = 0,06). Luego de una X = 3 años (1 día-13 años) posquirúrgicos se realizaron 27 reoperaciones en 22 pacientes. Se cerró CIV residual en 11 pacientes a una X = 1 mes. En 8 de ellos, la CIV era remota (p =0,007). Desarrollaron estenosis subaórtica que requirieron cirugía 6 pacientes a una X = 5 años. Se reemplazó el conducto ventrículo derecho-arteria pulmonar en 12 pacientes a una X = 5 años. La mortalidad en el período posquirúrgico inmediato fue del 6% (3 pacientes). La mortalidad global fue del 17,2% (n = 8); 7 pacientes tenían CIV no relacionada (p = 0,003). Conclusiones La CIV remota en la cirugía de Rastelli se asocia con: 1) mayor mortalidad, 2) mayor frecuencia de reoperaciones en el posquirúrgico inmediato y 3) tendencia a mayor frecuencia de arritmias en el posquirúrgico inmediato.

Background The Rastelli procedure is complex surgical procedure with marked morbidity and mortality in the medium and long-term follow-up. These adverse outcomes seem to be more frequent when the ventricular septal defect (VSD) is anatomically remote or noncommitted to the aorta. Objective To evaluate the impact of the anatomical location of the VSD on the outcomes of the Rastelli procedure. Material and Methods A total of 47 patients were included with a mean follow-up of 6 years after surgery (15 months-14 years). Patients were divided into two groups: group I (committed VSD, n=29) and group II (remote or noncommitted VSD, n=18). Results During the immediate postoperative period, reoperations and arrhythmias were more frequent in group II (p=0.05 and p=0.06, respectively). After a mean follow-up of 3 years (1 day-13 years) following surgery, 22 patients underwent 27 reoperations. A residual VSD was closed in 11 patients at a mean of 1 month, 8 of which were remote VSD (p=0.007). Six patients developed subaortic stenosis requiring surgery at a mean of 5 years. The right ventricleto-pulmonary artery conduit was replaced in 12 patients at a mean of 5 years. Immediate postoperative mortality was 6% (3 patients). Global mortality was 17.2% (n=8); 7 patients had noncommitted VSD (p=0.003). Conclusions Remote VSD in patients undergoing the Rastelli procedure is associated with: 1) increased mortality, 2) greater incidence of reoperations in the immediate postoperative period, and, 3) a trend towards greater incidence of arrhythmias in the immediate postoperative period.

Programa de capacitaión en el manejo de accidentes de trabajo, dirigido al personal de salud del Hospital Santa Elena de Huanuni / Program of capacitaión in the handling of industrial accidents, directed to the personnel of health of the Hospital Santa Elena of Huanuni

La actividad minera presenta una gran variedad de situaciones que involucran riesgos que en cualquier momento puede derivar en un accidente de trabajo produciendo lesiones de diferente intensidad causando transtornos funcionales u orgánicos que causen a lo posterior incapacidades o incluso la muerte. En Huanuni uno de las importantes ciudades del departamento de Oruro con una población cuya actividad es eminentemente minera, necesita de un Hospital cuyo personal esté capacitado para solucionar adecuadamente cualquier accidente de trabajo que se presente en sus asegurados y mucho mas por la frecuencia y la severidad con que se presentan estos accidentes. Consideramos que una capacitación a todo el personal del Hospital Santa Elena beneficiará enormemente a todos los trabajadores asegurados a este Hospitla con una atención adecuada y oportuna disminuyendo de esta manera las discapacidades y el pronto retorno del trabajador a su fuente de trabajo; nuestro proyecto se circunscribe precisamente a este hecho: que la inadecuada atención en casos de accidentes de trabajo pueden ser superada con la capacitación del personal de este Hospitla.