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1.
World J Surg Oncol ; 19(1): 8, 2021 Jan 11.
Artigo em Inglês | MEDLINE | ID: mdl-33430881

RESUMO

BACKGROUND: The long-term physiological consequences of SARS-CoV-2 (severe acute respiratory syndrome coronavirus) infection are not known. The ability of COVID-19 to cause chronic illness, sarcopenia, and physical deconditioning may be underestimated and go beyond the anticipated respiratory sequelae. Myalgia, lethargy, and anorexia are common symptoms even in mild to moderate cases and have the potential to exacerbate frailty. How this impacts on risk-stratification for patients requiring surgery for time-critical conditions, such as malignancy, requires further urgent investigation. MAIN BODY: The deleterious effect of sarcopenia and poor physical capacity are well recognised in cancer surgery. This review commentary highlights current evidence which suggests skeletal muscle as an under recognised cause of COVID-19-related functional deconditioning. The mechanisms behind this are via direct (viral induced myositis, nutritional decline, cytokine-mediated myopathy) and indirect mechanisms (social isolation, inactivity, and psychological consequences). CONCLUSION: Further mechanistic research is required to explore the processes behind the deconditioning effects of SARS-CoV-2 infection and how this impacts on treatment of malignant disease.


Assuntos
/complicações , Neoplasias/cirurgia , Desempenho Físico Funcional , Sarcopenia/etiologia , /fisiopatologia , Humanos , Mialgia/etiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos
2.
Anaesthesia ; 76 Suppl 1: 89-99, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33426666

RESUMO

Improvement in healthcare delivery depends on the ability to measure outcomes that can direct changes in the system. An overview of quality indicators within the field of regional anaesthesia is lacking. This systematic review aims to synthesise available quality indicators, as per the Donabedian framework, and provide a concise overview of evidence-based quality indicators within regional anaesthesia. A systematic literature search was conducted using the databases MEDLINE, Embase, CINAHL and Cochrane from 2003 to present, and a prespecified search of regional anaesthesia society websites and healthcare quality agencies. The quality indicators relevant to regional anaesthesia were subdivided into peri-operative structure, process and outcome indicators as per the Donabedian framework. The methodological quality of the indicators was determined as per the Oxford Centre for Evidence-Based Medicine's framework. Twenty manuscripts met our inclusion criteria and, in total, 68 unique quality indicators were identified. There were 4 (6%) structure, 12 (18%) process and 52 (76%) outcome indicators. Most of the indicators were related to the safety (57%) and effectiveness (19%) of regional anaesthesia and were general in nature (60%). In addition, most indicators (84%) were based on low levels of evidence. Our study is an important first step towards describing quality indicators for the provision of regional anaesthesia. Future research should focus on the development of structure and process quality indicators and improving the methodological quality and usability of these indicators.


Assuntos
Anestesia por Condução/normas , Indicadores de Qualidade em Assistência à Saúde , Procedimentos Cirúrgicos Operatórios/normas , Humanos , Melhoria de Qualidade , Procedimentos Cirúrgicos Operatórios/efeitos adversos
3.
J Surg Res ; 257: 221-226, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32858323

RESUMO

BACKGROUND: The Accreditation Council for Graduate Medical Education has defined six core competencies (CCs) that every successful physician should possess. However, the assessment of CC achievement among trainees is difficult. This project was designed to prospectively evaluate the impact of resident identification of CC as a component of morbidity review on error identification and standard of care (SOC) assessments. The platform was assessed for its reliability as a measure of resident critical analysis of complication causality across postgraduate year (PGY). MATERIALS AND METHODS: A total of 1945 general surgery cases with complications were assessed for error identification and SOC management between January 1, 2016, and December 31, 2018. CC identification was additionally assessed between January 1, 2019, and December 31, 2019, and included 708 general surgery cases. Data were evaluated for error assessments and overall SOC management. PGY4 and 5 residents were compared for number of cases and complications reviewed, severity, error causation, and CC relevance. RESULTS: Study groups were equivalent by Clavien-Dindo scores. Error identification significantly increased in all categories: diagnostic (P < 0.001), technical (P < 0.05), judgment (P < 0.001), system (P < 0.001), and communication (P < 0.001). Overall SOC assessments validated by a supervising surgical quality officer were unchanged. An increased exposure to cases with severe complications, error causation, and CC relevance was noted across PGY. CONCLUSIONS: The addition of CC assessment into morbidity review appears to improve the critical thinking of evaluating residents by increasing the identification of management errors. Used as an element of prospective self-assessment, teaching residents to identify CC principles in cases with complications may assist in learner progression toward clinical competence and critical thinking.


Assuntos
Educação Baseada em Competências/métodos , Cirurgia Geral/educação , Complicações Pós-Operatórias/prevenção & controle , Autoavaliação , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Competência Clínica , Seguimentos , Humanos , Internato e Residência , Erros Médicos/efeitos adversos , Erros Médicos/prevenção & controle , Dano ao Paciente/prevenção & controle , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Avaliação de Programas e Projetos de Saúde , Estudos Prospectivos , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Cirurgiões/psicologia , Procedimentos Cirúrgicos Operatórios/educação
4.
J Surg Res ; 257: 278-284, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32866668

RESUMO

BACKGROUND: Emergency general surgery has higher adverse outcomes than elective surgery. Patients leaving the hospital against medical advice (AMA) have a greater risk for readmission and complications. We sought to identify clinical and demographic characteristics along with hospital factors associated with leaving AMA after EGS operations. METHODS: A retrospective review of the Nationwide Inpatient Sample was performed. All patients who underwent an EGS procedure accounting for >80% of the burden of EGS-related inpatient resources were identified. 4:1 propensity score analysis was conducted. Regression analyses determined predictive factors for leaving AMA. RESULTS: 546,856 patients were identified. 1085 (0.2%) patients who underwent EGS left AMA. They were more likely to be men (59% versus 42%), younger (median age 51 y, IQR [37.61] versus 54, IQR [38.69]), qualify for Medicaid (26% versus 13%) or be self-pay (17% versus 9%), and be within the lowest quartile median household income (40% versus 28%) (all P < 0.05). After applying 4:1 propensity score matching, individuals who were self-pay (OR 3.15, 95% CI 2.44-4.06) or insured through Medicare (OR 2.75, 95% CI 2.11-3.57) and Medicaid (OR 3.58, 95% CI 2.83-4.52) had increased odds of leaving AMA compared with privately insured patients. In addition, history of alcohol (OR 2.21, 95% CI 1.65-2.98), drug abuse (OR 4.54, 95% CI 3.23-6.38), and psychosis (OR 2.31, 95% CI 1.65-3.23) were associated with higher likelihood for leaving AMA. CONCLUSIONS: Patients undergoing EGS have a high risk of complications, and leaving AMA further increases this risk. Interventions to encourage safe discharge encompassing surgical, psychiatric, and socioeconomic factors are warranted to prevent a two-hit effect and compound postoperative risk.


Assuntos
Tratamento de Emergência/efeitos adversos , Cooperação do Paciente/estatística & dados numéricos , Alta do Paciente/normas , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adulto , Fatores Etários , Idoso , Feminino , Humanos , Renda/estatística & dados numéricos , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Cooperação do Paciente/psicologia , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Estados Unidos/epidemiologia
5.
Med Sci Monit ; 26: e928067, 2020 Dec 08.
Artigo em Inglês | MEDLINE | ID: mdl-33335087

RESUMO

BACKGROUND Our aim was to determine the optimum appendectomy technique in patients with morbid obesity by evaluating laparoscopic appendectomy (LA) and open appendectomy (OA) operations performed in these patients. MATERIAL AND METHODS The records of 2179 patients who underwent appendectomy for acute appendicitis between January 2010 and April 2019 were evaluated retrospectively. Patients were excluded for the following: age.


Assuntos
Apendicectomia , Apendicite , Laparoscopia , Obesidade Mórbida , Complicações Pós-Operatórias , Procedimentos Cirúrgicos Operatórios , Abdome/cirurgia , Adulto , Apendicectomia/efeitos adversos , Apendicectomia/métodos , Apendicite/complicações , Apendicite/cirurgia , Feminino , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Tempo de Internação/estatística & dados numéricos , Masculino , Obesidade Mórbida/complicações , Obesidade Mórbida/diagnóstico , Duração da Cirurgia , Avaliação de Processos e Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/métodos
6.
Anesthesiology ; 133(1): 96-108, 2020 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-33377920

RESUMO

BACKGROUND: Compared to other perioperative complications, failure to rescue (i.e., death after suffering a complication) is highest after perioperative myocardial infarction (a myocardial infarction that occurs intraoperatively or within 30 days after surgery). The purpose of this study was to identify patient and surgical risk factors for failure to rescue in patients who have had a perioperative myocardial infarction. METHODS: Individuals who experienced a perioperative myocardial infarction after noncardiac surgery between 2012 and 2016 were identified from the American College of Surgeons (Chicago, Illinois) National Surgical Quality Improvement Program database. Multivariable logistic regression was used to identify risk factors for failure to rescue. Subgroup and sensitivity analyses evaluated the robustness of primary findings. RESULTS: The authors identified 1,307,884 individuals who had intermediate to high-risk noncardiac surgery. A total of 8,923 (0.68%) individuals had a perioperative myocardial infarction, of which 1,726 (19.3%) experienced failure to rescue. Strongest associations (adjusted odds ratio greater than 1.5) were age 85 yr or older (2.52 [95% CI, 2.05 to 3.09] vs. age younger than 65 yr), underweight body mass index (1.53 [95% CI, 1.17 to 2.01] vs. normal body mass index), American Society of Anesthesiologists class IV (1.76 [95% CI, 1.33 to 2.31] vs. class I or II) and class V (3.48 [95% CI, 2.20 to 5.48] vs. class I or II), and presence of: ascites (1.81 [95% CI, 1.15 to 2.87]), disseminated cancer (1.54 [95% CI, 1.18 to 2.00]), systemic inflammatory response syndrome (1.55 [95% CI, 1.26 to 1.90]), sepsis (1.75 [95% CI, 1.39 to 2.20]), septic shock (1.79 [95% CI, 1.34 to 2.37]), and dyspnea at rest (1.94 [95% CI, 1.32 to 2.86]). Patients who had emergency surgery, high-risk procedures, and postoperative complications were at higher risk of failure to rescue. CONCLUSIONS: Routinely identified patient and surgical factors predict risk of failure to rescue after perioperative myocardial infarction.


Assuntos
Complicações Intraoperatórias/terapia , Infarto do Miocárdio/terapia , Complicações Pós-Operatórias/terapia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/mortalidade , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/mortalidade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Fatores de Risco , Falha de Tratamento
11.
Anesth Analg ; 131(5): 1607-1615, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33079885

RESUMO

BACKGROUND: Utilizing the intrinsic surgical risk (ISR) and the patient's chronic and acute conditions, this study aims to develop and validate a comprehensive predictive model of perioperative morbidity in children undergoing noncardiac surgery. METHODS: Following institutional review board (IRB) approval at a tertiary care children's hospital, data for all noncardiac surgical encounters for a derivation dataset from July 2017 to December 2018 including 16,724 cases and for a validation dataset from January 2019 to December 2019 including 9043 cases were collected retrospectively. The primary outcome was a composite morbidity score defined by unplanned transfer to an intensive care unit (ICU), acute respiratory failure requiring intubation, postoperative need for noninvasive or invasive positive pressure ventilation, or cardiac arrest. Internal model validation was performed using 1000 bootstrap resamples, and external validation was performed using the 2019 validation cohort. RESULTS: A total of 1519 surgical cases (9.1%) experienced the defined composite morbidity. Using multivariable logistic regression, the Risk Assessment of Morbidity in Pediatric Surgery (RAMPS) score was developed with very good predictive ability in the derivation cohort (area under the curve [AUC] = 0.805; 95% confidence interval [CI], 0.795-0.816), very good internal validity using 1000 bootstrap resamples (bias-corrected Nagelkerke R = 0.21 and Brier score = 0.07), and good external validity (AUC = 0.783; 95% CI, 0.770-0.797). The included variables are age <5 years, critically ill, chronic condition indicator (CCI) ≥3, significant CCI ≥2, and ISR quartile ≥3. The RAMPS score ranges from 0 to 10, with the risk of composite morbidity ranging from 1.8% to 42.7%. CONCLUSIONS: The RAMPS score provides the ability to identify a high-risk cohort of pediatric patients using a 5-component tool, and it demonstrated good internal and external validity and generalizability. It also provides an opportunity to improve perioperative planning with the intent of improving both individual-patient outcomes and the appropriate allocation of health care resources.


Assuntos
Medição de Risco/métodos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adolescente , Fatores Etários , Criança , Pré-Escolar , Cuidados Críticos/estatística & dados numéricos , Estado Terminal , Feminino , Parada Cardíaca/epidemiologia , Parada Cardíaca/terapia , Mortalidade Hospitalar , Humanos , Lactente , Masculino , Transferência de Pacientes/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Insuficiência Respiratória/epidemiologia , Insuficiência Respiratória/terapia , Estudos Retrospectivos , Centros de Atenção Terciária , Resultado do Tratamento
12.
Can J Surg ; 63(5): E431-E434, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33009897

RESUMO

SUMMARY: Hepato-pancreato-biliary (HPB) injuries can be extremely challenging to manage. This scoping review (8438 citations) offers a number of recommendations. If diagnosis and therapy are rapid, patients with major hepatic injuries who present in physiologic extremis have high survival rates despite prolonged hospital stays. Nonoperative management of major liver injuries, as diagnosed using computed tomography, is typically successful. Adjuncts (e.g., angioembolization, laparoscopic washouts, biliary stents) are essential in managing high-grade injuries. Injury to the extrahepatic biliary tree is rare. Cholecystectomy is indicated for all gallbladder trauma. Full-thickness common bile duct injuries require a hepaticojejunostomy, although damage control remains closed suction drainage. Injuries to the pancreatic head often involve concurrent trauma to regional vasculature. Damage control necessitates drainage after stopping hemorrhage. Injury to the left pancreas commonly requires a distal pancreatectomy. Outcomes for high-grade pancreatic and liver injuries are improved by involving an HPB team. Complications are multidisciplinary and should be managed without delay.


Assuntos
Traumatismos Abdominais/terapia , Sistema Biliar/lesões , Fígado/lesões , Pâncreas/lesões , Traumatismos Abdominais/complicações , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/mortalidade , Sistema Biliar/diagnóstico por imagem , Tratamento Conservador/efeitos adversos , Tratamento Conservador/métodos , Tratamento Conservador/normas , Tratamento Conservador/estatística & dados numéricos , Humanos , Fígado/diagnóstico por imagem , Pâncreas/diagnóstico por imagem , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Guias de Prática Clínica como Assunto , Índice de Gravidade de Doença , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/métodos , Procedimentos Cirúrgicos Operatórios/normas , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Fatores de Tempo , Tempo para o Tratamento/normas , Tomografia Computadorizada por Raios X , Resultado do Tratamento
13.
Can J Surg ; 63(5): E435-E441, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33009902

RESUMO

BACKGROUND: Most of the literature on emergency general surgery (EGS) has investigated appendiceal and biliary disease; however, EGS surgeons manage many other complex conditions. This study aimed to describe the operative burden of these conditions throughout Canada. METHODS: This multicentre retrospective cohort study evaluated EGS patients at 7 centres across Canada in 2014. Adult patients (aged ≥ 18 yr) undergoing nonelective operative interventions for nonbiliary, nonappendiceal diseases were included. Data collected included information on patients' demographic characteristics, diagnosis, procedure details, complications and hospital length of stay. Logistic regression was used to identify predictors of morbidity and mortality. RESULTS: A total of 2595 patients were included, with a median age of 60 years (interquartile range 46-73 yr). The most common principal diagnoses were small bowel obstruction (16%), hernia (15%), malignancy (11%) and perianal disease (9%). The most commonly performed procedures were bowel resection (30%), hernia repair (15%), adhesiolysis (11%) and débridement of skin and soft tissue infections (10%). A total of 47% of cases were completed overnight (between 5 pm and 8 am). The overall inhospital mortality rate was 8%. Thirty-three percent of patients had a complication, with independent predictors including increasing age (p = 0.001), increasing American Society of Anesthesiologists score (p = 0.02) and transfer from another centre (p = 0.001). CONCLUSION: This study characterizes the epidemiology of nonbiliary, nonappendiceal EGS operative interventions across Canada. Canadian surgeons are performing a large volume of EGS, and conditions treated by EGS services are associated with a substantial risk of morbidity and mortality. Results of this study will be used to guide future research efforts and set benchmarks for quality improvement.


Assuntos
Tratamento de Emergência/estatística & dados numéricos , Cirurgia Geral/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Padrões de Prática Médica/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Idoso , Benchmarking , Canadá , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Feminino , Cirurgia Geral/organização & administração , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Padrões de Prática Médica/organização & administração , Melhoria de Qualidade , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Resultado do Tratamento
14.
J Glob Health ; 10(2): 020507, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33110590

RESUMO

Background: In a surgical setting, COVID-19 patients may trigger in-hospital outbreaks and have worse postoperative outcomes. Despite these risks, there have been no consistent statements on surgical guidelines regarding the perioperative screening or management of COVID-19 patients, and we do not have objective global data that describe the current conditions surrounding this issue. This study aimed to clarify the current global surgical practice including COVID-19 screening, preventive measures and in-hospital infection under the COVID-19 pandemic, and to clarify the international gaps on infection control policies among countries worldwide. Methods: During April 2-8, 2020, a cross-sectional online survey on surgical practice was distributed to surgeons worldwide through international surgical societies, social media and personal contacts. Main outcome and measures included preventive measures and screening policies of COVID-19 in surgical practice and centers' experiences of in-hospital COVID-19 infection. Data were analyzed by country's cumulative deaths number by April 8, 2020 (high risk, >5000; intermediate risk, 100-5000; low risk, <100). Results: A total of 936 centers in 71 countries responded to the survey (high risk, 330 centers; intermediate risk, 242 centers; low risk, 364 centers). In the majority (71.9%) of the centers, local guidelines recommended preoperative testing based on symptoms or suspicious radiologic findings. Universal testing for every surgical patient was recommended in only 18.4% of the centers. In-hospital COVID-19 infection was reported from 31.5% of the centers, with higher rates in higher risk countries (high risk, 53.6%; intermediate risk, 26.4%; low risk, 14.8%; P < 0.001). Of the 295 centers that experienced in-hospital COVID-19 infection, 122 (41.4%) failed to trace it and 58 (19.7%) reported the infection originating from asymptomatic patients/staff members. Higher risk countries adopted more preventive measures including universal testing, routine testing of hospital staff and use of dedicated personal protective equipment in operation theatres, but there were remarkable discrepancies across the countries. Conclusions: This large international survey captured the global surgical practice under the COVID-19 pandemic and highlighted the insufficient preoperative screening of COVID-19 in the current surgical practice. More intensive screening programs will be necessary particularly in severely affected countries/institutions. Study registration: Registered in ClinicalTrials.gov: NCT04344197.


Assuntos
Infecções por Coronavirus/prevenção & controle , Infecção Hospitalar/prevenção & controle , Controle de Infecções/estatística & dados numéricos , Programas de Rastreamento/estatística & dados numéricos , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Padrões de Prática Médica/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/normas , Betacoronavirus , Infecções por Coronavirus/transmissão , Infecção Hospitalar/virologia , Estudos Transversais , Hospitais/normas , Hospitais/estatística & dados numéricos , Humanos , Controle de Infecções/normas , Programas de Rastreamento/normas , Pneumonia Viral/transmissão , Políticas , Padrões de Prática Médica/normas , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Inquéritos e Questionários
15.
Int J Surg ; 82: 172-178, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32891829

RESUMO

BACKGROUND: This study aimed to describe the epidemiologic and clinical characteristics of coronavirus disease 2019 (COVID-19) in surgical patients and medical staff. METHODS: A single-center case series of 1586 consecutive surgical patients was selected at our hospital from January 13 to March 12, 2020. The epidemiological and clinical characteristics of COVID-19 were analyzed and followed up to May 20, 2020. The transmission of COVID-19 between the surgical patients and medical staff was also recorded. RESULTS: Seventeen (1.07%) surgical patients were diagnosed with COVID-19, with a high incidence in the thoracic department (9.37%), and the median age was 58 years (IQR, 53-73). The median time from hospital admission to COVID-19 diagnosis was 9.0 days (7.0-12.0) and was 6.0 days (4.0-7.0) from the day of surgery to COVID-19 diagnosis. Eleven (64.70%) patients suffered from pulmonary infection before surgery. When COVID-19 was diagnosed, common symptoms were fever (82.35%) and cough (94.12%), and most (82.35%) neutrophil/lymphocyte ratios were high (>3.5). Chest computed tomography (CT) (82.35%) showed bilateral dense shadows. Surgical patients with COVID-19 stayed in the hospital for approximately 35.0 days (25.5-43.0), with a mortality rate of 11.76%. Sixteen medical staff were infected with COVID-19 in the early stage. CONCLUSIONS: In this series of 1586 surgical patients, the COVID-19 infection rate was 1.07%, with an especially high incidence among patients with thoracic diseases. Middle-aged and elderly patients with preoperative pulmonary infection were more susceptible to COVID-19 infection after surgery. Medical staff were infected with COVID-19 and should take protective measures to protect themselves.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/transmissão , Transmissão de Doença Infecciosa do Paciente para o Profissional , Pneumonia Viral/epidemiologia , Pneumonia Viral/transmissão , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adulto , Idoso , Infecções por Coronavirus/diagnóstico , Feminino , Febre , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/diagnóstico , Estudos Retrospectivos , Avaliação de Sintomas , Tomografia Computadorizada por Raios X , Adulto Jovem
16.
Anaesthesia ; 75(12): 1605-1613, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32955100

RESUMO

Despite the ongoing coronavirus disease 2019 (COVID-19) pandemic, elective paediatric surgery must continue safely through the first, second and subsequent waves of disease. This study presents outcome data from a children's hospital in north-west England, the region with the highest prevalence of COVID-19 in England. Children and young people undergoing elective surgery isolated within their household for 14 days, then presented for real-time reverse transcriptase polymerase chain reaction testing for severe acute respiratory syndrome coronavirus disease-2 (SARS-CoV-2) within 72 h of their procedure (or rapid testing within 24 h in high-risk cases), and completed a screening questionnaire on admission. Planned surgery resumed on 26 May 2020; in the four subsequent weeks, there were 197 patients for emergency and 501 for elective procedures. A total of 488 out of 501 (97.4%) elective admissions proceeded, representing a 2.6% COVID-19-related cancellation rate. There was no difference in the incidence of SARS-CoV-2 among children and young people who had or had not isolated for 14 days (p > 0.99). One out of 685 (0.1%) children who had surgery re-presented to the hospital with symptoms potentially consistent with SARS-CoV-2 within 14 days of surgery. Outcomes were similar to those in the same time period in 2019 for length of stay (p = 1.0); unplanned critical care admissions (p = 0.59); and 14-day hospital re-admission (p = 0.17). However, the current cohort were younger (p = 0.037); of increased complexity (p < 0.001) and underwent more complex surgery (p < 0.001). The combined use of household self-isolation, testing and screening questionnaires has allowed the re-initiation of elective paediatric surgery at high volume while maintaining pre-COVID-19 outcomes in children and young people undergoing surgery. This may provide a model for addressing the ongoing challenges posed by COVID-19, as well as future pandemics.


Assuntos
Infecções por Coronavirus/epidemiologia , Pneumonia Viral/epidemiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adolescente , Fatores Etários , Criança , Pré-Escolar , Estudos de Coortes , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Serviços Médicos de Emergência/estatística & dados numéricos , Feminino , Cirurgia Geral , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Lactente , Masculino , Pandemias , Segurança do Paciente , Pediatria , Prevalência , Quarentena , Resultado do Tratamento , Reino Unido/epidemiologia , Adulto Jovem
17.
JAMA ; 324(9): 848-858, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32870298

RESUMO

Importance: In patients who undergo mechanical ventilation during surgery, the ideal tidal volume is unclear. Objective: To determine whether low-tidal-volume ventilation compared with conventional ventilation during major surgery decreases postoperative pulmonary complications. Design, Setting, and Participants: Single-center, assessor-blinded, randomized clinical trial of 1236 patients older than 40 years undergoing major noncardiothoracic, nonintracranial surgery under general anesthesia lasting more than 2 hours in a tertiary hospital in Melbourne, Australia, from February 2015 to February 2019. The last date of follow-up was February 17, 2019. Interventions: Patients were randomized to receive a tidal volume of 6 mL/kg predicted body weight (n = 614; low tidal volume group) or a tidal volume of 10 mL/kg predicted body weight (n = 592; conventional tidal volume group). All patients received positive end-expiratory pressure (PEEP) at 5 cm H2O. Main Outcomes and Measures: The primary outcome was a composite of postoperative pulmonary complications within the first 7 postoperative days, including pneumonia, bronchospasm, atelectasis, pulmonary congestion, respiratory failure, pleural effusion, pneumothorax, or unplanned requirement for postoperative invasive or noninvasive ventilation. Secondary outcomes were postoperative pulmonary complications including development of pulmonary embolism, acute respiratory distress syndrome, systemic inflammatory response syndrome, sepsis, acute kidney injury, wound infection (superficial and deep), rate of intraoperative need for vasopressor, incidence of unplanned intensive care unit admission, rate of need for rapid response team call, intensive care unit length of stay, hospital length of stay, and in-hospital mortality. Results: Among 1236 patients who were randomized, 1206 (98.9%) completed the trial (mean age, 63.5 years; 494 [40.9%] women; 681 [56.4%] undergoing abdominal surgery). The primary outcome occurred in 231 of 608 patients (38%) in the low tidal volume group compared with 232 of 590 patients (39%) in the conventional tidal volume group (difference, -1.3% [95% CI, -6.8% to 4.2%]; risk ratio, 0.97 [95% CI, 0.84-1.11]; P = .64). There were no significant differences in any of the secondary outcomes. Conclusions and Relevance: Among adult patients undergoing major surgery, intraoperative ventilation with low tidal volume compared with conventional tidal volume, with PEEP applied equally between groups, did not significantly reduce pulmonary complications within the first 7 postoperative days. Trial Registration: ANZCTR Identifier: ACTRN12614000790640.


Assuntos
Pneumopatias/prevenção & controle , Respiração com Pressão Positiva/métodos , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Operatórios , Volume de Ventilação Pulmonar , Adulto , Feminino , Humanos , Incidência , Cuidados Intraoperatórios , Pneumopatias/epidemiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Período Pós-Operatório , Método Simples-Cego , Procedimentos Cirúrgicos Operatórios/efeitos adversos
18.
J Am Acad Orthop Surg ; 28(16): e716-e728, 2020 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-32769720

RESUMO

Improvements in cancer treatment have led to prolonged survival and increased rates of cure. An estimated 14 million cancer survivors live in the United States. The cornerstones of cancer treatment, including radiation, chemotherapy, and surgery, give rise to a host of chronic health conditions, some of which affect the musculoskeletal system. As survivorship continues to improve, orthopaedic surgeons across all subspecialties will be tasked with managing these complications of treatment. This article reviews orthopaedic health concerns secondary to cancer treatment that are likely to present to orthopaedic surgeons for evaluation, such as osteoporosis, osteonecrosis, secondary malignancies, radiation-associated fractures, exercise tolerance, and perioperative evaluation.


Assuntos
Antineoplásicos/efeitos adversos , Doenças Musculoesqueléticas/etiologia , Doenças Musculoesqueléticas/terapia , Neoplasias/terapia , Radioterapia/efeitos adversos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Sobreviventes de Câncer/estatística & dados numéricos , Fraturas Ósseas/diagnóstico , Fraturas Ósseas/etiologia , Fraturas Ósseas/prevenção & controle , Fraturas Ósseas/terapia , Humanos , Doenças Musculoesqueléticas/diagnóstico , Doenças Musculoesqueléticas/prevenção & controle , Neoplasias/complicações , Osteonecrose/diagnóstico , Osteonecrose/etiologia , Osteonecrose/prevenção & controle , Osteonecrose/terapia , Osteoporose/diagnóstico , Osteoporose/etiologia , Osteoporose/prevenção & controle , Osteoporose/terapia
19.
Medicine (Baltimore) ; 99(32): e20273, 2020 Aug 07.
Artigo em Inglês | MEDLINE | ID: mdl-32769860

RESUMO

As surgeries are performed around the clock, the time of surgery might have an impact on outcomes. Our aim is to investigate the impact of daytime and nighttime shifts on surgeons and their performance. We believe that such studies are important to enhance the quality of surgeries and their outcomes and help understand the effects of time of the day on surgeons and the surgeries they perform.A retrospective cohort study was conducted using the database from the King Abdulaziz Medical City trauma center. We selected 330 cases of patients between 2015 and 2018, who underwent a trauma intervention surgery within 24 hours after admission. Patients were aged 15 years and above who underwent 1 or more of the following trauma interventions: neurosurgery, general surgery, plastic surgery, vascular surgery, orthopedics, ophthalmology, and/or otolaryngology. We divided the work hours into 3 shifts: 8 AM to 3:59 PM, 4 PM to 11:59 PM, and midnight to 7:59 AM.Participants' mean age was 31.4 (standard deviation ±â€Š13) years. Most surgeries occurred on weekdays (68.4%). Complications were one and a half times more on weekends, with 5 complicated cases on weekends (1.55%) and 3 (0.9%) on weekdays. Half of all surgeries were performed in the morning (152 cases, 53.15%); 73 surgeries (25.5%) were performed in the evening and 61 (21.3%) were performed late at night. Surgeries performed during late-night shifts were marginally better. Complications occurred in 4 out of 152 morning surgeries (2.6%), 2 out of 73 evening surgeries (2.7%), and only 1 out of 61 late-night surgeries (1.6%). The earlier comparison scored a P-value of >.99, suggesting that patients in morning and evening surgeries were twice more likely to experience complications than late-night surgeries.This study may support previous research that there is little difference in outcomes between daytime and nighttime surgeries. The popular belief that rested physicians are better physicians requires further assessment and research.


Assuntos
Complicações Pós-Operatórias/epidemiologia , Qualidade da Assistência à Saúde , Jornada de Trabalho em Turnos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Centros de Traumatologia , Adulto , Feminino , Humanos , Masculino , Duração da Cirurgia , Estudos Retrospectivos , Arábia Saudita , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Fatores de Tempo , Tempo para o Tratamento , Adulto Jovem
20.
Int J Surg ; 81: 47-54, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32738546

RESUMO

Globally, a staggering 310 million major surgeries are performed each year; around 40 to 50 million in USA and 20 million in Europe. It is estimated that 1-4% of these patients will die, up to 15% will have serious postoperative morbidity, and 5-15% will be readmitted within 30 days. An annual global mortality of around 8 million patients places major surgery comparable with the leading causes of death from cardiovascular disease and stroke, cancer and injury. If surgical complications were classified as a pandemic, like HIV/AIDS or coronavirus (COVID-19), developed countries would work together and devise an immediate action plan and allocate resources to address it. Seeking to reduce preventable deaths and post-surgical complications would save billions of dollars in healthcare costs. Part of the global problem resides in differences in institutional practice patterns in high- and low-income countries, and part from a lack of effective perioperative drug therapies to protect the patient from surgical stress. We briefly review the history of surgical stress and provide a path forward from a systems-based approach. Key to progress is recognizing that the anesthetized brain is still physiologically 'awake' and responsive to the sterile stressors of surgery. New intravenous drug therapies are urgently required after anesthesia and before the first incision to prevent the brain from switching to sympathetic overdrive and activating secondary injury progression such as hyperinflammation, coagulopathy, immune activation and metabolic dysfunction. A systems-based approach targeting central nervous system-mitochondrial coupling may help drive research to improve outcomes following major surgery in civilian and military medicine.


Assuntos
Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Operatórios/mortalidade , Saúde Global , Glicocálix/fisiologia , Humanos , Sistema Hipotálamo-Hipofisário/fisiologia , Mitocôndrias/fisiologia , Sistema Hipófise-Suprarrenal/fisiologia , Complicações Pós-Operatórias/prevenção & controle , Estresse Fisiológico , Procedimentos Cirúrgicos Operatórios/efeitos adversos
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