Acerto pós-operatório: avaliação dos resultados da implantação de um protocolo multidisciplinar de cuidados peri-operatórios em cirurgia geral

PERIOPERATIVE CARE IN DIGESTIVE SURGERY: THE ERAS AND ACERTO PROTOCOLS - BRAZILIAN COLLEGE OF DIGESTIVE SURGERY POSITION PAPER

BACKGROUND

The concept introduced by protocols of enhanced recovery after surgery modifies perioperative traditional care in digestive surgery. The integration of these modern recommendations components during the perioperative period is of great importance to ensure fewer postoperative complications, reduced length of hospital stay, and decreased surgical costs.

AIMS

To emphasize the most important points of a multimodal perioperative care protocol.

METHODS

Careful analysis of each recommendation of both ERAS and ACERTO protocols, justifying their inclusion in the multimodal care recommended for digestive surgery patients.

RESULTS

Enhanced recovery programs (ERPs) such as ERAS and ACERTO protocols are a cornerstone in modern perioperative care. Nutritional therapy is fundamental in digestive surgery, and thus, both preoperative and postoperative nutrition care are key to ensuring fewer postoperative complications and reducing the length of hospital stay. The concept of prehabilitation is another key element in ERPs. The handling of crystalloid fluids in a perfect balance is vital. Fluid overload can delay the recovery of patients and increase postoperative complications. Abbreviation of preoperative fasting for two hours before anesthesia is now accepted by various guidelines of both surgical and anesthesiology societies. Combined with early postoperative refeeding, these prescriptions are not only safe but can also enhance the recovery of patients undergoing digestive procedures.

CONCLUSIONS

This position paper from the Brazilian College of Digestive Surgery strongly emphasizes that the implementation of ERPs in digestive surgery represents a paradigm shift in perioperative care, transcending traditional practices and embracing an intelligent approach to patient well-being.

COST-EFFECTIVENESS OF THE USE OF ACERTO PROTOCOL IN MAJOR DIGESTIVE SURGERY

Hospital costs in surgery constitute a burden for the health system in all over the world. Multimodal protocols such as the ACERTO project enhance postoperative recovery.

ACERTO Project - 15 years changing perioperative care in Brazil

The ACERTO project is a multimodal perioperative care protocol. Implemented in 2005, the project in the last 15 years has disseminated the idea of a modern perioperative care protocol, based on evidence and with interdisciplinary team work. Dozens of published studies, using the protocol, have shown benefits such as reduced hospital stay, postoperative complications and hospital costs. Disseminated in Brazil, the project is supported by the Brazilian College of Surgeons and the Brazilian Society of Parenteral and Enteral Nutrition, among others. This article compiles publications by the authors who belong to the CNPq research group "Acerto em Nutrição e Cirurgia", refers to the experience of other national authors in various surgical specialties, and finally outlines the evolution of the ACERTO project in the timeline.

Cost-effectiveness analysis of hernioplasties before and after the implementation of the ACERTO project

OBJECTIVE

to compare hospital costs and clinical outcomes in inguinal and incisional hernioplasty before and after implementation of the ACERTO project in a university hospital.

METHODS

retrospective study of 492 patients undergoing either inguinal hernioplasty (n=315) or incisional hernioplasty (n=177). The investigation involved two phases: between January 2002 and December 2005, encompassing cases admitted before the implementation of the ACERTO protocol (PRE-ACERTO period), and the other phase, with cases operated between January 2006 and December 2011, after the implementation of the protocol (ACERTO period). The main outcome variable was the comparison of the mean hospital costs between the two periods. As secondary endpoints, we analyzed the length of stay, the surgical site infection rate and mortality. We used the cost method suggested by Public Sector Cost Information System.

RESULTS

surgical site infection was higher (p = 0.039) in the first phase of the study for both inguinal hernia operations (2 (1.6%) versus 0 (0%) cases) and incisional hernioplasty (5 (7.6%) versus 3 (2.7%) cases). The length of stay decreased one day after the implementation of the ACERTO protocol (p=0.005). There was a reduction in costs per patient from R$ 4,328.58 per patient in the first phase to R$ 2,885.72 in the second phase (66.7% reduction).

CONCLUSION

there was a reduction in infectious morbidity, length of stay and hospital costs in hernioplasty after the implementation of the ACERTO protocol.

FACTORS RELATED TO THE REDUCTION OF THE RISK OF COMPLICATIONS IN COLORECTAL SURGERY WITHIN PERIOPERATIVE CARE RECOMMENDED BY THE ACERTO PROTOCOL

Background:

Perioperative care multimodal protocol significantly improve outcome in surgery.

Aim:

To investigate risk factors to various endpoints in patients submitted to elective colorectal operations under the ACERTO protocol.

Methods:

Cohort study analyzing through a logistic regression model able to assess independent risk factors for morbidity and mortality, patients submitted to elective open colon and/or rectum resection and primary anastomosis who were either exposed or non-exposed to demographic, clinical, and ACERTO interventions.

Results:

Two hundred thirty four patients were analyzed and submitted to 156 (66.7%) rectal and 78 (33.3%) colonic procedures. The length of hospital postoperative stay (LOS) ≥ 7 days was related to rectal surgery and high NNIS risk index; preoperative fasting ≤4 h (OR=0.250; CI95=0.114-0.551) and intravenous volume of crystalloid infused > 30ml/kg/day (OR=0.290; CI95=0.119-0.706). The risk of postoperative site infection (SSI) was approximately four times greater in malnourished; eight in rectal surgery and four in high NNIS index. The duration of preoperative fasting ≤4 h was a protective factor by reducing by 81.3% the risk of surgical site infection (SSI). An increased risk for anastomotic fistula was found in malnutrition, rectal surgery and high NNIS index. Conversely, preoperative fasting ≤4 h (OR=0.11; CI95=0.05-0.25; p<0.0001) decreased the risk of fistula. Factors associated with pneumonia-atelectasis were cancer and rectal surgery, while preoperative fasting ≤ 4 h (OR=0.10; CI95=0.04-0.24; p<0.0001) and intravenous crystalloid ≤ 30 ml/kg/day (OR=0.36; CI95=0.13-0.97, p=0.044) shown to decrease the risk. Mortality was lower with preoperative fasting ≤4 h and intravenous crystalloids infused ≤30 ml/kg/day.

Conclusion:

This study allows to conclude that rectal procedures, high NNIS index, preoperative fasting higher than 4 h and intravenous fluids greater than 30 ml/kg/day during the first 48 h after surgery are independent risk factors for: 1) prolonged LOS; 2) surgical site infection and anastomotic fistula associated with malnutrition; 3) postoperative pneumonia-atelectasis; and 4) postoperative mortality.

Nutritional status and evaluation of the perioperative fasting time among patients submitted to elective and emergency surgeries at a reference hospital

OBJECTIVE

to evaluate the clinical, surgical, and nutritional profile of surgical patients admitted to a reference hospital in Recife city, Pernambuco state, Brazil.

METHODS

a cross-sectional study carried out in the wards of the General Surgery Service of Hospital da Restauração Governador Paulo Guerra, from June to September 2018. We included adult and elderly patients (both genders) who were submitted to thoracoabdominal procedures and elective or emergency abdominal surgeries, and in which the assessment of nutritional status could be performed within 72 hours of hospital admission. Data on nutritional status and surgical procedures, as well as clinical and biochemical information, were collected.

RESULTS

we studied 140 patients with median age of 45 years. Among all, 59.3% were female and 23% malnourished, according to Subjective Global Assessment. The median preoperative fasting time was 15 hours for size I surgeries and 13.5 hours for size II ones. Longer postoperative hospital stay showed a strong correlation with the total length of hospital stay in both surgical sizes. Malnourished patients had a longer period of perioperative fasting and hospital stay when compared to well-nourished patients (p<0.001).

CONCLUSION

the perioperative fasting time for elective surgeries was longer than recommended by literature. Patients with longer fasting spent more time in hospital.

Impacto do estado nutricional e do tempo de jejum nas complicações gastrointestinais e no tempo de hospitalização em pacientes cirúrgicos

Introdução: O estado nutricional e o tempo de jejum pré e pós-cirúrgico impactam na morbimortalidade de pacientes submetidos a cirurgias eletivas. No Brasil, o tempo de jejum prolongado e a elevada prevalência de desnutrição são comuns nos hospitais terciários. Objetivo: Realizar levantamento do tempo de jejum médio praticado em hospital terciário e avaliar o impacto do jejum pré e pós-cirúrgico e do estado nutricional nas complicações gastrointestinais imediatas e no tempo de hospitalização em pacientes cirúrgicos. Material e métodos: Estudo prospectivo, realizado no Hospital Universitário Walter Cantídio, em Fortaleza. Foram avaliados 173 indivíduos submetidos a cirurgias eletivas de médio e grande porte entre agosto de 2016 a janeiro de 2017. Foram coletadas medidas antropométricas, hemograma e informações como tempo de jejum pré e pós-cirúrgico, permanência hospitalar e complicações gastrointestinais. As análises de correlação e associação foram realizadas no Software SPSS®, com nível de significância fixado em p< 0,05. Resultados: A maioria dos pacientes (71,1%) foi submetida à cirurgia de porte II (grande porte). Houve correlação negativa entre tempo de permanência hospitalar e índice de massa corporal [r= -0,223; p= 0,003], circunferência braquial [r= -0,335; p< 0,001], dobra cutânea tricipital [r= -0,320; p< 0,001], área muscular do braço corrigida [r= -0,253; p= 0,001], contagem total de linfócitos [r= -0,223; p= 0,008], hemoglobina [r= -0,243; p= 0,004] e relação linfócito/monócito [r= -0,308; p< 0,001]. Adicionalmente, houve correlação positiva entre tempo de permanência hospitalar com o tempo de jejum pós-cirúrgico [r= 0,456; p< 0,001]. Ausência de complicações gastrointestinais foi associada a valores de triagem (Nutritional Risk Screenin-2002) < 3 (p= 0,034) e entre menor tempo de jejum pós-cirúrgico (p= 0,033). Conclusão: Pacientes desnutridos, com maior risco nutricional e os que se submeteram a um tempo de jejum pós-cirúrgico elevado apresentaram maior tempo de permanência hospitalar e maior incidência de complicações gastrointestinais.

Efeitos da abreviação do jejum pré-operatório com solução de carboidrato e proteína em sintomas pós-operatórios de cirurgias ginecológicas: ensaio clínico randomizado controlado duplo-cego

RESUMO Objetivo: investigar os efeitos da abreviação do jejum pré-operatório, uma recomendação do protocolo de “Aceleração da Recuperação Total Pós-operatória” (ACERTO), em sintomas pós-operatórios de pacientes submetidas à cirurgias ginecológicas. Métodos: estudo controlado, randomizado, duplo-cego, de 80 cirurgias ginecológicas realizadas no período de janeiro a junho de 2016. As pacientes foram aleatoriamente alocadas em dois grupos: Grupo Controle, com 42 pacientes, e Grupo Suco, com 38, e que receberam, respectivamente, 200ml de solução inerte ou 200ml de líquido enriquecido com carboidrato e proteína quatro horas antes da cirurgia. Os sintomas pós-operatórios estudados foram sede, fome, dor, agitação, satisfação e bem-estar, em ambos os grupos. Para medir a intensidade dos sintomas foi utilizada a Escala Visual Analógica (EVA), associada à Escala Facial (EF) para dor, aplicadas dez horas após a cirurgia. Resultados: as pacientes do Grupo Suco apresentaram menos dor (3,51x1,59), sede (3,63x0,85), fome (3,86x2,09) e agitação (2,54x0,82) em relação ao Grupo Controle (P<0,05). As variáveis satisfação (6,89x8,68) e bem-estar (5,51x7,12) foram maiores (P<0,05) quando houve a ingestão do líquido contendo carboidrato e proteína (Grupo Suco) em relação à solução inerte (Grupo Controle). Conclusão: a abreviação do jejum pré-operatório com líquido contendo carboidrato e proteína antes de cirurgias ginecológicas reduz sede, fome, dor, agitação e favorece maior satisfação e bem-estar do que a ingestão de solução inerte.

Early physical therapy intervention in gynaecological surgery: "Case series"

PURPOSE

To implement a physical therapy intervention protocol targeting patients admitted for gynaecological surgery to the gynaecological ward of XXXX Hospital.

METHOD

A prospective, cross-sectional and observational study was conducted with women admitted to the gynaecology ward, from June 2014 through June 2015. The study was divided into three phases with data on admissions to the gynaecology ward. A total of 565 women were included, corresponding to phases I (197), II (178) and III (190). The physical therapy staff implemented an early ambulation protocol as well as a mobility assessment.

RESULTS

The physical therapy protocol was implemented, and the rate of adherence was 100%. All participants received preoperative instruction on the importance of early mobilisation. On postoperative day 1, the participants in phase I walked a mean of 77.4 m. Following implementation of the physical therapy protocol, the walked distance increased to 292.6 m in phase II, followed by a slight decrease to a mean of 233 m in phase III.

CONCLUSIONS

The physical therapy protocol could be implemented, and the patients' adherence was satisfactory. Early ambulation can be optimised, and the participants began ambulation starting at 13 h after surgery.

CHANGING PARADIGMS IN PREOPERATIVE FASTING: RESULTS OF A JOINT EFFORT IN PEDIATRIC SURGERY

Background:

Current researches associate long fasting periods to several adverse consequences. The fasting abbreviation to 2 h to clear liquids associated with the use of drinks containing carbohydrates attenuates endocrinometabolic response to surgical trauma, but often is observed children advised to not intake food from 00:00 h till the scheduled surgical time, regardless of what it is.

Aim:

To evaluate the safety of a protocol of preoperative fasting abbreviation with a beverage containing carbohydrates, and early postoperative feeding in children underwent elective small/mid-size surgical procedures during a national task-force on pediatric surgery.

Methods:

Thirty-six patients were prospectively included, and for several reasons five were excluded. All 31 who remained in the study received a nutritional supplement containing 150 ml of water plus 12.5% maltodextrin 2 h before the procedure. Data of the pre-operative fasting time, anesthetic complications and time of postoperative refeeding, were collected.

Results:

Twenty-three (74.2%) were males, the median age was 5 y, and the median weight was 20 kg. The median time of pre-operative fasting was 145 min and the time of post-operative refeeding was 135 min. There were no adverse effects on the anesthetic procedures or during surgery. Post-operatively, two children (6.5%) vomited.

Conclusion:

The abbreviation of pre-operative fasting to 2 h with beverage containing carbohydrate in pediatric surgery is safe. Early refeeding in elective small/mid-size procedures can be prescribed.

Racional:

Trabalhos atuais associam longos períodos de jejum com diversas consequências adversas. A abreviação do jejum de 2 h para líquidos claros associado ao uso de bebidas contendo carboidratos atenua resposta endocrinometabólica ao trauma, porém frequentemente as crianças são orientadas a não ingerir alimentos a partir das 00:00 h do dia anterior à operação, independente do horário do procedimento cirúrgico.

Objetivo:

Avaliar a segurança de um protocolo de abreviação do jejum pré-operatório, com o uso de bebida contendo carboidratos, e realimentação precoce.

Métodos:

Foram avaliados prospectivamente 36 crianças submetidas a procedimentos cirúrgicos eletivos de pequeno e médio porte. Cinco foram posteriormente excluídos do estudo. Todos os 31 remanescentes receberam suplemento nutricional com maltodextrina 12,5% em 150 ml de água aproximadamente 2 h antes do procedimento. Foram coletados dados do tempo de jejum pré-operatório, complicações anestésicas e tempo de realimentação.

Resultados:

Vinte e três (74,2%) eram do gênero masculino, com idade mediana de cinco anos e peso mediano de 20 kg. O tempo mediano de jejum pré-operatório foi de 145 min e o tempo mediano para realimentação foi de 135 min. Não houve eventos adversos durante a anestesia ou operação. No período pós-operatório, duas (6,5%) crianças vomitaram.

Conclusão:

A abreviação de jejum pré-operatório para 2 h com uso de bebida contendo carboidratos, em operações eletivas de crianças, é seguro e não está associado ao maior risco de broncoaspiração pulmonar. Realimentação precoce pode ser prescrita nos procedimentos cirúrgicos analisados.

ACERTO guidelines of perioperative nutritional interventions in elective general surgery

ABSTRACT Objective: to present recommendations based on the ACERTO Project (Acceleration of Total Post-Operative Recovery) and supported by evidence related to perioperative nutritional care in General Surgery elective procedures. Methods: review of relevant literature from 2006 to 2016, based on a search conducted in the main databases, with the purpose of answering guiding questions previously formulated by specialists, within each theme of this guideline. We preferably used randomized controlled trials, systematic reviews and meta-analyzes but also selected some cohort studies. We contextualized each recommendation-guiding question to determine the quality of the evidence and the strength of this recommendation (GRADE). This material was sent to authors using an open online questionnaire. After receiving the answers, we formalized the consensus for each recommendation of this guideline. Results: the level of evidence and the degree of recommendation for each item is presented in text form, followed by a summary of the evidence found. Conclusion: this guideline reflects the recommendations of the group of specialists of the Brazilian College of Surgeons, the Brazilian Society of Parenteral and Enteral Nutrition and the ACERTO Project for nutritional interventions in the perioperative period of Elective General Surgery. The prescription of these recommendations can accelerate the postoperative recovery of patients submitted to elective general surgery, with decrease in morbidity, length of stay and rehospitalization, and consequently, of costs.

An Integrative Review of Postoperative Accelerated Recovery Protocols

We undertook an integrative literature review of articles pertaining to perioperative nursing care provided to patients using postoperative accelerated recovery protocols. To select the articles, we searched the MEDLINE, PubMed, Cumulative Index to Nursing and Allied Health Literature, and LiteraturaLatino-Americana e do Caribe em Ciências da Saúde databases. We identified 329 studies, 13 of which met our inclusion criteria and described perioperative nursing care activities. Nursing activities noted in these articles were hypothermia prevention and maintenance of normothermia, restriction of IV fluids, assessment of vital signs, management of symptoms and pain, support of early ambulation, care for tubes and drains, oral administration of carbohydrate-rich foods, assessment of ability to tolerate diet, and encouragement to resume activities of daily living. There was a lack of research on this topic by nursing professionals; additional research by nursing professionals is needed regarding nurses' roles in providing this care.

Perioperative care in bariatric surgery in the context of the ACERTO project: reality versus surgeons assumptions in a Cuiabá hospital

Objective:

to assess the level of knowledge among bariatric surgeons, about the recommendations of the ACERTO Project, correlating their assumptions on their perioperative prescriptions and the reality, according to the patients charts.

Method:

we conducted a prospective, longitudinal, observational study comparing the assumptions of bariatric surgeons obtained through responses on a specific questionnaire with the reality found in clinical data from the hospital records. We analyzed the following variables: preoperative fasting, early postoperative feeding, intravenous hydration, perioperative antibiotic prophylaxis, use of abdominal drains, type of analgesia, and prophylaxis of nausea and vomiting. We confronted the responses of seven surgeons with data from 200 records of patients undergoing gastroplasty for morbid obesity.

Results:

all interviewed surgeons knew the ACERTO Project. Five (72%) responded that they followed the protocol thoroughly. The median time of preoperative fasting found in the records was higher than the reported by the surgeons (p<0.05). Early postoperative feeding was prescribed for 96.5% of cases. The median volume of intravenous fluids prescribed in the first 24 hours was 4000ml, which was consistent with the interviews. There were no differences between the response in the questionnaire and the findings in the hospital records in relation to antibiotic prophylaxis, use of catheters and drains, analgesia and prophylaxis of nausea and vomiting.

Conclusion:

the ACERTO Project was well practiced among the surveyed surgeons. There was a good correlation between their assumptions and the reality in perioperative care of patients undergoing bariatric surgery. However, there was a significant difference in preoperative fasting time.

Enhanced muscle strength with carbohydrate supplement two hours before open cholecystectomy: a randomized, double-blind study

Objective: to investigate the effects of preoperative fasting abbreviation with oral supplementation with carbohydrate in the evolution of grip strength in patients undergoing cholecystectomy by laparotomy. Methods : we conducted a clinical, randomizeddouble blind study with adult female patients, aged 18-60 years. Patients were divided into two groups: Control Group, with fasting prescription 6-8h until the time of operation; and Intervention Group, which received prescription of fasting for solids 6-8h before surgery, but ingested an oral supplement containing 12.5% carbohydrate, six (400ml) and two (200ml) hours before theprocedure. The handgrip strength was measured in both hands in both groups, at patient's admission (6h before surgery), the immediate pre-operative time (1h before surgery) and 12-18h postoperatively. Results : we analyzed 27 patients, 14 in the intervention group and 13 in the control group. There was no mortality. The handgrip strength (mean [standard deviation]) was significantly higher in the intervention group in the three periods studied, in at least one hand: preoperatively in the dominant hand (27.8 [2.6] vs 24.1 [3.7] kg; p=0.04), in the immediate preoperative in both hands, and postoperatively in the non-dominant hand (28.5 [3.0] vs 21.3 [5.9] kg; p=0.01). Conclusion : the abbreviation of preoperative fasting to two hours with drink containing carbohydrate improves muscle function in the perioperative period.

Sleeve Gastrectomy With or Without a Multimodal Perioperative Care. A Randomized Pilot Study

BACKGROUND

Multimodal protocols may enhance postoperative recovery. The aim of this study was to evaluate the influence of a multimodal protocol in the clinical results, insulin resistance, and inflammatory response to trauma in morbidly obese patients undergoing sleeve gastrectomy.

METHODS

The population of the study consisted of morbidly obese patients, who were operated using sleeve gastrectomy, from Cuiaba, MT, Brazil, between April and October 2012. Twenty patients were divided into two groups whom received either traditional preoperative care or treatment following the Acerto (accelerating the total recovery of patients in the postoperative period) protocol. The study examined inflammatory response and insulin resistance by measuring levels of glucose, insulin, Homa-IR, reactive C protein, albumin, prealbumin, alpha 1 acid glycoprotein, interleukin 6, and glycosylated hemoglobin. In addition, the study investigated hydration levels, nausea and vomiting, hypertension, and length of hospital stay.

RESULTS

Patients who followed the Acerto protocol showed no postoperative hypertensive crises (p = 0.03), and 30 % less vomiting (p = 0.35), and showed significant reductions in length of hospital stay, on average of 3 days versus 2 days (p = 0.02). There were not significant statistical differences between the two groups with respect to inflammatory response and insulin resistance (p > 0.05).

CONCLUSION

This pilot study suggests that the prescription of the Acerto multimodal protocol for morbidly obese patients undergoing sleeve gastrectomy was safe, reduced the rate hypertensive complications, and the length of both ICU and hospital postoperative stay. However, there was no improvement in postoperative insulin resistance or inflammatory acute phase response.

FASTING IN ELECTIVE SURGICAL PATIENTS: COMPARISON AMONG THE TIME PRESCRIBED, PERFORMED AND RECOMMENDED ON PERIOPERATIVE CARE PROTOCOLS

BACKGROUND

Prolonged preoperative fasting may impair nutritional status of the patient and their recovery. In contrast, some studies show that fasting abbreviation can improve the response to trauma and decrease the length of hospital stay.

AIM

Investigate whether the prescribed perioperative fasting time and practiced by patients is in compliance with current multimodal protocols and identify the main factors associated.

METHODS

Cross-sectional study with 65 patients undergoing elective surgery of the digestive tract or abdominal wall. We investigated the fasting time in the perioperative period, hunger and thirst reports, physical status, diabetes diagnosis, type of surgery and anesthesia.

RESULTS

The patients were between 19 and 87 years, mostly female (73.8%). The most performed procedure was cholecystectomy (47.69%) and general anesthesia the most used (89.23%). The most common approach was to start fasting from midnight for liquids and solids, and most of the patients received grade II (64.6%) to the physical state. The real fasting average time was 16 h (9.5-41.58) was higher than prescribed (11 h, 6.58 -26.75). The patients submitted to surgery in the afternoon were in more fasting time than those who did in the morning (p<0.001). The intensity of hunger and thirst increased in postoperative fasting period (p=0.010 and 0.027). The average period of postoperative fasting was 18.25 h (3.33-91.83) and only 23.07% restarted feeding on the same day.

CONCLUSION

Patients were fasted for prolonged time, higher even than the prescribed time and intensity of the signs of discomfort such as hunger and thirst increased over time. To better recovery and the patient's well-being, it is necessary to establish a preoperative fasting abbreviation protocol.

Implementation of a perioperative management protocol for patients undergoing orthopedic surgery

OBJECTIVE: To evaluate the initial results after the implementation of perioperative protocol in patients over 60 years of age undergoing surgical treatment for femur fractures. METHODS: We conducted a prospective study of patients older than 60 years who were hospitalized with femur fracture. They were operated under spinal anesthesia and analgesia by lumbar plexus blockade. Data evaluation was performed before arrival in the operating room during surgery, in the post-anesthesia recovery room and in the ward the next morning of the operation. RESULTS: 105 patients underwent various types of surgical corrections of the femur. The hospital stay ranged from three to 86 days. Fasting ranged from 9h15min to 19h30mn. Hypotension occurred in 5.7%. The duration of motor blockade ranged from 1h45min to 5h30imn. Maltodextrin feeding ranged from 50min to 3h45min and the time spent in the post-anesthetic care unit ranged from 50 minutes to 4 hours. Onset of oral intake in the ward ranged from 4hto 8h15min. The duration of anesthesia ranged from 14 to 33 hours. No patient required a urinary catheter, nor was transferred to the ICU. All patients were able to be discharged on the first postoperative day. CONCLUSION: The use of a protocol to accelerate the postoperative period may reduce the fasting time, length of hospital stay and provide faster i discharge n elderly patients with femur fractures.

Ingestion of glutamine and maltodextrin two hours preoperatively improves insulin sensitivity after surgery: a randomized, double blind, controlled trial

OBJECTIVE

To investigate whether the abbreviation of preoperative fasting with a drink containing glutamine and dextrinomaltose improves organic response to surgical trauma.

METHODS

Thirty-six female patients adult (18-62 years) candidates for elective laparoscopic cholecystectomy were randomly divided into three groups: conventional fasting (fasting group), and two groups receiving two different diets, eight hours (400ml) and two hours before induction of anesthesia (200ml): carbohydrate (CHO) group (12.5% dextrinomaltose) and the glutamine (GLN) group (12.5% dextrinomaltose and 40 and 10g of glutamine, respectively). Blood samples were collected pre and postoperatively.

RESULTS

Twenty-eight patients completed the study. No pulmonary complication occurred. Gastric residual volume was similar between groups (p = 0.95). Postoperatively, all patients from the fasting group had abnormal glucose (> 110mg/dl), this abnormality being of 50% when compared to the CHO group (p = 0.14), and of 22.2% when compared to the GLN group (p = 0.01). All patients who had the fasting period shortened (CHO + GLN) had normal postoperative insulin, contrasting with 66.7% in the fasted group (p = 0.02). The abnormal sensitivity to insulin postoperatively rose from 32.1% to 46.4% of cases (p = 0.24), and it occurred in only 11.1% of patients in GLN group when compared to 55.5% in the fasting group (p = 0.02).

CONCLUSION

the abbreviation of preoperative fasting for two hours with dextrinomaltose and glutamine improves insulin sensitivity in patients undergoing elective laparoscopic cholecystectomy.

Resultados clínicos antes e após a implantação do protocolo ACERTO

OBJETIVO: Comparar os resultados clínicos pós-operatórios de pacientes submetidos à cirurgia oncológica no Hospital de Câncer de Mato Grosso antes e após a implantação do protocolo ACERTO. MÉTODOS: Foram prospectivamente observados 271 pacientes durante dois períodos: o primeiro, entre abril e maio de 2010 (n=101) formado por pacientes submetidos a condutas convencionais (Fase 1) e o segundo, entre setembro a outubro de 2010 (n=171), formado por pacientes submetidos a um novo protocolo de condutas peri-operatórias estabelecidas pelo projeto ACERTO (Fase 2). As variáveis observadas foram: tempo de jejum pré-operatório, reintrodução da dieta no período pós-operatório, volume de hidratação e tempo de internação. RESULTADOS: Na comparação entre os dois períodos, na Fase 2 houve uma queda de aproximadamente 50% do tempo de jejum pré-operatório (14,7 [4-48] horas vs 7,2 [1-48] horas, p<0,001), houve redução de aproximadamente 35% do volume de fluidos intravenosos no pós-operatório imediato (p<0,001), de 47% no 1º PO (p<0,001) e de 28% no 2º PO (p=0,04), sendo a redução global de 23% (p<0,001). Não houve diferença no tempo de internação pós-operatória entre as duas fases (3,9 [0-51] vs. 3,2 [0-15] dias; p=0.52). Entretanto, nos pacientes cujo tempo de jejum pré-operatório foi de até 5 horas houve redução de um dia de internação (3.8 [0-51] vs 2.5 [0-15] dias, p=0,03). CONCLUSÃO: A adoção das medidas do projeto ACERTO é factível e segura em doentes oncológicos. Após a implantação do protocolo ACERTO reduziu-se o volume de fluidos intravenosos e quando o jejum pré-operatório foi reduzido o tempo de internação foi menor.

[Evaluation of changes made in the peri-operative care in patients submitted to elective abdominal surgery]

OBJECTIVE

To evaluate the results of the introduction of new measures to accelerate the postoperative recovery of patients undergoing elective abdominal surgery.

METHODS

We observed 162 patients and interviewed them on two distinct periods: the first between October to December 2009 (n = 81) comprised patients who underwent conventional perioperative monitoring (pre-intervention) and the second between March and May 2010 (n = 81), formed by a new group of patients, submitted to the new protocol of perioperative monitoring. Data collection in the two periods occurred without the knowledge of the professionals in the service. The variables were: indication for preoperative nutritional support, duration of fasting, post-operative volume of hydration, use of catheters and drains, length of stay and postoperative morbidity.

RESULTS

when comparing the two periods we observed a decrease of 2.5 hours in the time of preoperative fasting (p = 0.0002) in the post-intervention group. As for the reintroduction of oral diet, there was no difference between the two periods (p = 0.0007). When considering the patients without postoperative complications, there was a significantly decreased length of stay (p = 0.001325). There was a reduction of approximately 50% in antibiotic use in the post-intervention group (p = 0.00001).

CONCLUSION

The adoption of multidisciplinary perioperative measures is feasible within our reality, and although there was no statistically significant changes in the present study, it may improve morbidity and reduce length of stay in general surgery.

Avaliação de estratégias no manejo da sede na sala de recuperação pós-anestésica

OBJETIVO: Avaliar estratégias simples e seguras para mitigar a sede no pós-operatório imediato (POI). MÉTODOS: Estudo quantitativo, experimental, de corte transversal, com amostra de 90 pacientes. Aqueles que apresentaram sede foram divididos aleatoriamente em dois grupos, Água ou Gelo. RESULTADOS: 96 (75%) relataram sede. O jejum pré-operatório variou de 8 a 37 horas e não houve associação entre o tipo de anestesia, sangramento, tempo de jejum e sede. A intensidade média inicial de sede foi de 5,1 para o grupo Água e 6,1, ao grupo Gelo. Os métodos experimentados mostraram-se eficazes em aliviar a sede no POI. O grupo Gelo teve intensidade final de 1,51 contra os 2,33 de grupo Água. Dois (2,2%) pacientes apresentaram vômitos durante a pesquisa. CONCLUSÃO: A sede é um desconforto real e gera grande sofrimento ao paciente. Este estudo indicou estratégias viáveis e seguras no manejo da sede no POI.

Impact of the ACERTO project in the postoperative morbi-mortality in a university hospital

OBJECTIVE

To evaluate the postoperative outcomes of patients in the Department of General Surgery, University Hospital Julio Muller, before and after implementation of the ACERTO multimodal protocol.

METHODS

We conducted a retrospective study from 5974 patients' charts. We compared two periods: from January 2002 to December 2004 (before implementation of the ACERTO protocol: AA period, n = 1987) and January 2005 to December 2008 (after implementation of the protocol: DA period, n = 3987). The variables studied were length of hospital stay, blood transfusions, surgical site infections (SSI), postoperative complications and deaths.

RESULTS

There was a decrease in one day in length of stay between the AA and DA period (median [range]: 4 [0-137] vs 3. [0-126] days and mode: 3 vs. 2 days, p < 0.001). During AA there was a relationship of 2.53 packs of blood products transfused per patient against 0.77 in the DA period (p <0.001). A downward trend in the number of cases of SSI was noticeable over the years (A =-153.08; AA: 7.51% vs. DA: 3.36% (p <0.001, RR = 2.23, 95 % CI:1.73-2.89). There was also a decreasing trend in operative complications (A =- 51.41, AA: 7.9% vs. DA: 6.14%, p = 0.02, RR = 1.29, 95% CI:1.03-1.60), reoperation (A =- 57.10; AA: 2.65%. vs DA: 1.19%, p <0.001, RR = 2, 22, 95% CI: 1.43 to 3.44) and deaths (A =- 62.07, 2.81 vs. 1%, 73%, p <0.01, RR = 1.63, 95% CI: 1.15 to 2.31).

CONCLUSION

The introduction of the ACERTO protocol improved the surgical results, expressed as a shorter hospital stay, blood transfusion, and reduction in cases of surgical site infection, postoperative complications and deaths.

Clinical benefits after the implementation of a multimodal perioperative protocol in elderly patients

CONTEXT

Multimodal protocol of perioperative care may enhance recovery after surgery. Based on evidence these new routines of perioperative care changed conventional prescriptions in surgery.

OBJECTIVE

To evaluate the results of a multimodal protocol (ACERTO protocol) in elderly patients.

METHODS

Non-randomized historical cohort study was performed at the surgical ward of a tertiary university hospital. One hundred seventeen patients aged 60 and older were submitted to elective abdominal operations under either conventional (n = 42; conventional group, January 2004-June 2005) or a fast-track perioperative protocol named ACERTO (n = 75; ACERTO group, July 2005-December 2007). Main endpoints were preoperative fasting time, postoperative day of re-feeding, volume of intravenous fluids, length of hospital stay and morbidity.

RESULTS

The implantation of the ACERTO protocol was followed by a decrease in both preoperative fasting (15 [8-20] vs 4 [2-20] hours, P<0.001) and postoperative day of refeeding (1st [1st-10th] vs 0 [0-5th] PO day; P<0.01), and intravenous fluids (10.7 [2.5-57.5] vs 2.5 [0.5-82] L, P<0.001). The changing of protocols reduced the mean length of hospital stay by 4 days (6[1-43] vs 2[1-97] days; P = 0.002) and surgical site infection rate by 85.7% (19%; 8/42 vs 2.7%; 2/75, P<0.001; relative risk = 1.20; 95% confidence interval = 1.03-1.39). Per-protocol analysis showed that hospital stay in major operations diminished only in patients who completed the protocol (P<0.01).

CONCLUSION

The implementation of multidisciplinary routines of the ACERTO protocol diminished both hospitalization and surgical site infection in elderly patients submitted to abdominal operations.

[Preoperative fasting of 8 hours or 2 hours: what does evidence reveal?]

Insulin resistance is a transitory phenomenon of the metabolic response to trauma. In uncomplicated operations it lasts for 2-4 weeks postoperatively, and is directly related to the magnitude of the injury. The fasting status caused by conventional fasting protocols aggravates this resistance and may induce hyperglycemia. Conventional preoperative fasting time may aggravate this resistance and increment the elevation of glycemia especially because it is frequently longer than the expected 6-8h and may reach 10-16 hs. Additionally, overnight fasting may cause variable degrees of dehydration depending on the extension of the fasting period. Recently, various societies of anesthesia and nutrition have changed their guidelines to propose a reduction of preoperative fasting to 2h with clear fluids containing carbohydrates. These new protocols (ACERTO, ERAS) are based on the safety of this routine as consistently demonstrated by various randomized trials and a meta-analysis.

Reducing preoperative fasting time: A trend based on evidence

Preoperative fasting is mandatory before anesthesia to reduce the risk of aspiration. However, the prescribed 6-8 h of fasting is usually prolonged to 12-16 h for various reasons. Prolonged fasting triggers a metabolic response that precipitates gluconeogenesis and increases the organic response to trauma. Various randomized trials and meta-analyses have consistently shown that is safe to reduce the preoperative fasting time with a carbohydrate-rich drink up to 2 h before surgery. Benefits related to this shorter preoperative fasting include the reduction of postoperative gastrointestinal discomfort and insulin resistance. New formulas containing amino acids such as glutamine and other peptides are being studied and are promising candidates to be used to reduce preoperative fasting time.

[Does abbreviation of preoperative fasting to two hours with carbohydrates increase the anesthetic risk?]

BACKGROUND AND OBJECTIVES

The objective of the present study was to evaluate the incidence of possible anesthetic complications related with the abbreviation of preoperative fasting to two hours with a solution of 12.5% dextrinomaltose within the ACERTO (from the Portuguese for Acceleration of Total Postoperative Recovery) project.

METHODS

All patients undergoing different types of digestive tract and abdominal wall surgeries within a new protocol of perioperative conducts, established by the ACERTO project, between August 2005 and December 2007 were evaluated. All patients received oral nutritional supplementation (12.5% dextrinomaltose) six and two hours before the procedure. Data were collected prospectively without the knowledge of the professionals in the department. The length of preoperative fasting and anesthetic complications related with the short fasting time (pulmonary aspiration) were recorded.

RESULTS

Three hundred and seventy five patients, 174 male (46.4%) and 201 female (53.6%), ages 18 to 90 years, were evaluated. The mean preoperative fasting time was four hours, ranging from two to 20 hours. Pulmonary aspiration was not observed during the procedures. The length of fasting was longer (p < 0.01) when combined anesthesia (blockade + general) was used.

CONCLUSIONS

Adopting the multidisciplinary preoperative measures of the ACERTO project was not associated with any preoperative fasting-associated complications. Dextrinomaltose is a useful and safe nutritional supplement for the patient.

Diferença entre volume de fluidos cristaloides intravenosos prescritos e infundidos em pacientes no pós-operatório precoce

OBJETIVO: O objetivo deste trabalho foi auditar a real quantidade de fluídos cristalóides infundidos por via intravenosa em pacientes submetidos a operações abdominais de grande porte num hospital universitário. MÉTODOS: Computou-se a carga hídrica total (CHT) de fluidos cristalóides intravenosos infundida diariamente do 1º ao 4º dia de PO em 31 pacientes submetidos à operações de grande porte. Comparou-se a CHT com a carga hídrica prescrita (CHP) pelo médico. A CHT foi definida como a somatória da CHP acrescida de diluentes e medicações intravenosas. O protocolo do serviço recomendava a hidratação venosa no peri-operatório entre 30 e 50 mL/Kg/dia em pacientes com prescrição de jejum oral. A comparação entre CHT e CHP foi realizada em todos os dias de pós-operatório pelo teste t pareado. Estabeleceu-se em 5% o nível de significância estatística. RESULTADOS: A CHT infundida do 1º ao 4ºdia de pós-operatório foi de 12,8 (6,4-17,5) L. Desse total, 9,5 litros (74,3%) corresponderam a CHP e 3,3 L (25,7%) a diluentes e medicações venosas. Em todos os dias de pós-operatório a CHT foi significativamente maior que a CHP (p<0.001). Até o 3º dia de PO os pacientes receberam uma CHT superior a 50 mL/kg/dia. CONCLUSÃO: Conclui-se que a prescrição médica não contém o real volume de fluidos cristalóides intravenosos infundido. O volume de diluentes e medicações intravenosas pode chegar a 25% da carga hídrica prescrita.

Abordagem multimodal em cirurgia colorretal sem preparo mecânico de cólon

OBJETIVO: Avaliar os resultados pós-operatórios de um protocolo multimodal de cuidados peri-operatórios sem preparo mecânico de cólon (protocolo ACERTO) em pacientes submetidos a operações colorretais. METODOS: Foram avaliados prospectivamente 53 pacientes (37M e 16F; 57 [18-82] anos) submetidos à diversas operações colorretais com pelo menos uma anastomose divididos em dois grupos. O primeiro grupo (n=25) foi operado entre Janeiro de 2004 e Julho de 2005 com protocolo convencional incluindo preparo mecânico de cólon. O segundo grupo (n=28) foi operado entre agosto de 2005 e junho de 2008, após a implantação do protocolo ACERTO e sem preparo de cólon. Comparou-se estatisticamente a incidência de complicações, a duração da hospitalização e a mortalidade em ambos os grupos. RESULTADOS: Dois (3,8%) pacientes faleceram no pós-operatório, um em cada grupo. Pacientes do grupo ACERTO tiveram jejum pré-operatório abreviado, receberam menos fluido intravenoso e re-alimentaram mais cedo que o grupo convencional (p<0.05). Não houve diferença na morbidade pós-operatória (36% vs. 28,6%; p=0,56) com incidência de fístula anastomótica semelhante (12 vs. 10,7%; p=1,00). O número de complicações por paciente foi menor no grupo ACERTO (p=0.01). O tempo de internação do grupo ACERTO, operado sem preparo de cólon foi abreviado em 4,5 dias (12 [4-43] dias vs 7,5 [3-47] dias, p = 0,04). CONCLUSÃO: As rotinas do protocolo ACERTO são seguras e melhoram resultados em cirurgia colorretal por diminuir gravidade de complicações e o tempo de internação.

Volume de fluído intravenoso e alta hospitalar precoce em colecistectomia aberta

OBJETIVO: Investigar se a adoção de um protocolo de restrição hídrica intravenosa em colecistectomia aberta diminui a permanência hospitalar. MÉTODO: Estudo prospectivo envolvendo pacientes submetidas a colecistectomia aberta após a adoção de um protocolo multimodal (projeto ACERTO). Pacientes com intercorrencias intra- ou pós-operatórias foram excluídas. Todas as pacientes receberam uma solução de carboidratos 2h antes da operação. Foram coletadas as seguintes variáveis: peso, altura, estado nutricional, volume total de fluidos intravenosos (VTFI) e volume prescrito em ml/kg de peso por dia. RESULTADOS: 64 pacientes (11 M e 53 F; idade mediana = 43 [18-65] anos) completaram o estudo. A re-alimentação pós-operatória ocorreu no mesmo dia da operação (62,5%) ou no dia seguinte (37,5%). Não foram registradas complicações infecciosas ou óbitos. O tempo mediano de internação pós-operatória foi de 1 (1-4) dia. Observou-se correlação entre o VTFI (r=0,44; p<0.001) e volume de fluídos / kg peso /dia (r=-0,29; p=0,03) e o tempo de internação pós-operatória. Alta no 1º PO foi possível em 73,3% dos casos quando a prescrição foi de até 20mL/Kg/dia e em 41,2% quando o volume prescrito foi maior (p<0.001; Odds Ratio=3,92; IC95% 1,36-11,32). CONCLUSÃO: A restrição de fluidos intravenosos em colecistectomia aberta determina alta mais precoce.

Ingestão pré-operatória de carboidratos diminui a ocorrência de sintomas gastrointestinais pós-operatórios em pacientes submetidos à colecistectomia

RACIONAL: Estudos recentes mostram que a abreviação do jejum pré-operatório, ao contrário do jejum de 6-8 h apresenta vários benefícios. Pacientes que recebem carboidratos apresentam menos fome e menos ansiedade do que os que permaneceram em jejum noturno. A ingestão pré-operatória de carboidratos por via oral no dia da operação diminui a resposta orgânica ao trauma. OBJETIVO: Avaliar o efeito da ingestão de bebida com carboidratos 6 e 2 horas antes da operação na ocorrência de sintomas gastrointestinais pós-operatórios em pacientes colecistectomizadas. MÉTODOS: Estudo prospectivo e randomizado com 54 pacientes do sexo feminino (42[19-69] anos) candidatas à colecistectomia eletiva foram randomizadas para receber uma bebida contendo 12.5% de carboidratos, 6 (400 mL) e 2 horas (200 mL) antes da operação (grupo carboidrato n = 28) ou jejum de 6-8 horas (grupo convencional n= 26). As variáveis investigadas foram a ocorrência de vômitos, náuseas, distensão abdominal, eliminação de flatos e fezes, e o tempo de internação no pós-operatório. RESULTADOS: A ocorrência de distensão abdominal (42.3% vs 17.8%; P = 0,04), vômitos (53.8% vs 21.4%; P = 0,01) a associação de dois ou mais sintomas gastrointestinais (73.1% vs 39.3%; P = 0,01) e o tempo de internação pós-operatória (2 [1-3] vs 1 [1-3] dias; P = 0,04) foram significativamente menores no grupo carboidrato. CONCLUSÃO: A ingestão carboidratos no pré-operatório diminui a ocorrência de manifestações gastrointestinais pós-operatórias e o tempo de internação em colecistectomia.