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Juárez-Soto, M. Pérez-García, M. Fuentes-Curtido, C. Guisado-Martin, M. Hernández-Garrido, M.A. Arrabal-Polo, M. de Paz-Suárez" "autores" => array:7 [ 0 => array:3 [ "nombre" => "Á." "apellidos" => "Juárez-Soto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Pérez-García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Fuentes-Curtido" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "C." "apellidos" => "Guisado-Martin" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "M." "apellidos" => "Hernández-Garrido" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:4 [ "nombre" => "M.A." "apellidos" => "Arrabal-Polo" "email" => array:1 [ 0 => "arrabalp@ono.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 6 => array:3 [ "nombre" => "M." "apellidos" => "de Paz-Suárez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Urología, Hospital del SAS de Jerez, Jerez de la Frontera, Cádiz, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital del SAS de Jerez, Jerez de la Frontera, Cádiz, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Complejo Hospitalario Universitario Granada, Instituto IBS Granada, Granada, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Código accidente vascular: un sistema de seguridad ante un sangrado masivo en la cirugía urológica laparoscópica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2365 "Ancho" => 3318 "Tamanyo" => 417026 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Algorithm for action in case of activation and implementation of the ‘stroke code’.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Patient safety</span><p id="par0005" class="elsevierStylePara elsevierViewall">The concept ‘patient safety’ is an old concept, but it was not until the early 70s, of the twentieth century, when the American College of Surgeons and the American Surgical Association found that 50% of non-severe complications, and 33% of deaths during surgery could be avoided.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–4</span></a> The concept ‘patient safety’ is intended to prevent or minimize the possible adverse outcomes of health care by developing action guidelines to help us make adequate, efficient and safe clinical decisions, thereby decreasing the variability in clinical practice. Different mechanisms seek to improve patient safety during surgery as the prevention of the surgical wound infection, thromboembolic prophylaxis, proper management of chronic medication, anesthetic management, in addition to a checklist of the patient.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient that will undergo surgery is exposed to certain risks since starting the pre-anesthesia consultation until the postoperative period, so it is essential to establish a series of stages and stratify the risk to implement protocols and measures to improve patient safety.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">From the multiple complications from surgery, one of the most severe for the patient is the massive bleeding from vascular injury, in which in many cases massive transfusion is required,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5,6</span></a> and it can even cause patient death. Therefore, we consider it necessary to implement a security protocol to improve and optimize the results when a severe or very severe stroke happens during surgery.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Our goal is to establish a standard operating procedure (SOP) to enable coordinated multidisciplinary action in the event of a stroke and which we will call ‘stroke code’.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Protocol development and initial results</span><p id="par0025" class="elsevierStylePara elsevierViewall">In this SOP, ‘stroke code’, all professionals, health and non-health, that integrate the surgical and support team are involved.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The SOP has 3 clearly differentiated stages, the pre-operative stage, consisting of the preparation of the operating room and pre-surgery actions, activation of the ‘stroke code’, which is the state of general alert that occurs when operating a patient at risk of massive bleeding and implementation of the ‘stroke code’, which is when in the code activation situation, massive bleeding occurs. These stages are detailed in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The preoperative stage includes all pre-surgery actions that will have an impact on the optimization of the results in safety, if massive bleeding occurs during surgery.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The stage ‘stroke code activation’ is the status of passive alert of the professionals involved in surgery, each assuming the appropriate role according to the SOP.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The stage ‘stroke code execution’ is the status of active alert that is generated when a stroke occurs de facto.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The day of surgery, SOP leadership is responsibility for the coordination of the code.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Its role is:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><p id="par0060" class="elsevierStylePara elsevierViewall">Presurgical stage<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">(1)</span><p id="par0065" class="elsevierStylePara elsevierViewall">Coordinating the entire surgical team and ensuring knowledge of the SOP ‘stroke code’.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">(2)</span><p id="par0070" class="elsevierStylePara elsevierViewall">Identifying the day of surgery, those support professionals who are not usually part of the surgical team, and explaining to them the SOP and their responsibility in it, and confirm that they understand.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">(3)</span><p id="par0075" class="elsevierStylePara elsevierViewall">Checking points 1 and 2 before the start of the surgery.</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0025"><p id="par0080" class="elsevierStylePara elsevierViewall">Code activation stage<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">(1)</span><p id="par0085" class="elsevierStylePara elsevierViewall">Checking all the elements of security, passive alert, and actions contained in the SOP.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">(2)</span><p id="par0090" class="elsevierStylePara elsevierViewall">Ensuring their compliance by professionals.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">(3)</span><p id="par0095" class="elsevierStylePara elsevierViewall">Deactivating the code, once past the risk of massive bleeding.</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0045"><p id="par0100" class="elsevierStylePara elsevierViewall">Stage of code execution<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">(1)</span><p id="par0105" class="elsevierStylePara elsevierViewall">Coordinating the implementation by the professionals who make up the surgical team of each and every one of the planned actions, if massive bleeding occurs.</p></li></ul></p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">After having finished the surgery and deactivated the ‘stroke code’, the Security Committee of the Clinical Management Unit of Urology is summoned, where the operation of surgical systems established and the establishment of areas for improvement if necessary are evaluated by professionals.</p><p id="par0115" class="elsevierStylePara elsevierViewall">In the Urology Department of the Hospital de Jerez, we activated the SOP ‘stroke code’ in high-risk cases of massive bleeding, such as surgery of large renal masses with vascular infiltration, surgery of retroperitoneal masses adjacent to the great vessels, surgery of xanthogranulomatous pyelonephritis, etc.</p><p id="par0120" class="elsevierStylePara elsevierViewall">We did not apply it to simple nephrectomies, partial nephrectomies, radical prostatectomies, or cystectomies, unless they have some characteristic that makes a massive bleeding likely.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Since the implementation of the SOP ‘stroke code’ in 2011, until January 2016, we applied it to 32 patients. The SOP has been modified on 3 occasions (currently in force its 4th edition), incorporating in each of them the improvements to address the weaknesses identified during the activation and/or execution of the ‘stroke code’.</p><p id="par0130" class="elsevierStylePara elsevierViewall">The main weaknesses, which caused SOP modifications, were:<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">1.</span><p id="par0135" class="elsevierStylePara elsevierViewall">Interprofessional communication problems.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">2.</span><p id="par0140" class="elsevierStylePara elsevierViewall">Lack of awareness of some professionals of the urology team, with attitudes that caused deconcentration of the surgical team at risk (during an extension of surgery, requesting shift change and leaving operating room unattended).</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">3.</span><p id="par0145" class="elsevierStylePara elsevierViewall">Lack of awareness of some professionals outside the operating room of urology who, due to ignoring the importance of the SOP, came into the operating room for reasons not related to it, causing deconcentration of the team in difficult moments of the surgery.</p></li></ul></p><p id="par0150" class="elsevierStylePara elsevierViewall">The ‘stroke code’ has been executed on 3 occasions due to massive bleeding (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), the surgical team acting with order, calm, and security.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">All vascular accidents that occurred since the introduction of the SOP have been resolved laparoscopically, which was rare before implantation thereof, which we always opted to convert to open surgery.</p><p id="par0160" class="elsevierStylePara elsevierViewall">The ‘stroke code’ is a powerful tool to transform the chaos and uncertainty in a critical situation, in order, calm of the team, and safety for the patient and for professionals.</p><p id="par0165" class="elsevierStylePara elsevierViewall">When all team members know how to act each individually and have the certainty that the rest know what to do, calm and good governance flood the operating room. Professionals know that there may be a surgical accident, but that with the SOP ‘stroke code’, they are prepared to act with the greatest possible safety for the patient. A stroke during surgery may have a fatal outcome, but with the ‘stroke code’ tool, it will not be because of unsafe acts by professionals, or due to lack of foresight or the organization.</p><p id="par0170" class="elsevierStylePara elsevierViewall">This SOP has limitations as it is a project of the Department of Urology at the Hospital de Jerez, but we consider it a powerful tool that provides security to patients undergoing high-risk interventions of massive bleeding and professionals of urology.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Patient safety" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Protocol development and initial results" ] 2 => array:2 [ "identificador" => "xack253802" "titulo" => "Acknowledgements" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Juárez-Soto Á, Pérez-García M, Fuentes-Curtido M, Guisado-Martin C, Hernández-Garrido M, Arrabal-Polo MA, et al. Código accidente vascular: un sistema de seguridad ante un sangrado masivo en la cirugía urológica laparoscópica. Actas Urol Esp. 2016;40:597–600.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2486 "Ancho" => 3287 "Tamanyo" => 737244 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Algorithm in which all actions to be performed in the preoperative phase of the ‘stroke code’ are described.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2365 "Ancho" => 3318 "Tamanyo" => 417026 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Algorithm for action in case of activation and implementation of the ‘stroke code’.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cause of code execution \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Resolution \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Interaortocaval adenopathies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Avulsion of the remaining renal artery in patient with prior nephrectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Laparoscopic suturing of the arterial injury \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Large right renal mass (lymphoma) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vena cava injury \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Laparoscopic suturing of the venous injury \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Large hilar adenopathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Renal artery injury \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Laparoscopic suturing of the arterial injury \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1260318.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Causes of execution of the ‘stroke code’ in the operating room due to massive bleeding.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Bachiller Burgos J. 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