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Editorial
The Dream of Surgery Without Complications: A Great Step, Much to Do
El sueño de la cirugía sin complicaciones: Un gran paso, mucho por hacer
Xavier Guirao
Servicio de Cirugía General y del Aparato Digestivo, Parc Taulí Hospital Universitari, Institut d’Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Surgical site infections &#40;SSI&#41; are one of the most relevant adverse effects associated with surgery&#46; The problem is global&#44; although it is more frequent in low-income countries&#44; where it seems that up to one-third of surgically treated patients present SSI&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> In countries with higher incomes&#44; SSI also has important healthcare&#44; economic and ethical repercussions&#46; Studies done in our setting demonstrate adjusted rates that range between 12&#37; and 23&#37; in colorectal surgery&#44; 2&#46;7&#37; and 11&#46;8&#37; in hip replacement and 1&#46;3&#8211;4&#37; in knee replacement&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The World Health Organization &#40;WHO&#41;&#44; which promotes actions to prevent the adverse effects of medical care &#40;<span class="elsevierStyleItalic">Clean care is safer care</span><a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a>&#41;&#44; has embarked on an ambitious project involving a large group of citizen representatives&#44; clinicians and methodologists from different countries and socio-economic levels&#44; who have worked for 4 years in the evaluation of the evidence of the main measures for preventing SSI&#46; The final document can be accessed freely for review in its entirety<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> or in a summarized version&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">5&#44;6</span></a> My intention is not to describe the excellent points of the document&#44; and there are many&#44; but to encourage reflection by uncovering the work that still remains to be done and by generating the inspiration to undertake the project of safe surgery&#46; Time and the opinion of healthcare recipients will judge and give credibility to these recommendations</p><p id="par0015" class="elsevierStylePara elsevierViewall">The first step was to decide the preventative measures to be studied and design the questions that should be answered&#46; The methodological sequence continued with the search for evidence&#44; selection of studies&#44; critical reading and extraction of the data of the main outcomes to be included in a program that would create the different meta-analyses &#40;REVman<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a>&#41;&#46; Finally&#44; the quality of the evidence was evaluated with the <span class="elsevierStyleItalic">Grading of Recommendation Assessment&#44; Development and Evaluation</span> &#40;GRADE&#41;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> approach&#44; which classifies the evidence as very low&#44; low&#44; moderate or high-quality&#44; based on which the group creating the guidelines has made a strong or weak recommendation&#44; or has refrained from recommending a certain measure&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A total of 25 generic measures have been analyzed&#44; generating 35 questions&#46; From the surgeon&#39;s point of view&#44; there is a prevalence of preoperative actions &#40;20&#41;&#44; followed by intra- &#40;8&#41; and postoperative &#40;5&#41; measures&#46; The members of the committee have made some kind of recommendation in 28 of the 35 evaluations carried out&#44; the most relevant of which we discuss below&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Three recommendations have to do with the reduction of the patients&#8217; skin flora&#46; The committee recommended cutaneous antisepsis by applying a solution of alcoholic chlorhexidine &#40;R&#58; strong&#47;C&#58; low-moderate&#41;&#46;<a class="elsevierStyleCrossRef" href="#fn0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The guidelines make special mention of the contraindications and the prevention of the rare but very important adverse effects&#44; mainly intraoperative fire&#46; Thus&#44; it is very important that the alcoholic antiseptic solution be applied appropriately&#44; avoiding soaking the adjacent surfaces and the hair of the patient&#46; The message is clear&#58; the application of an alcohol antiseptic must be precise in quantity and extension&#44; while the drying time &#40;no less than 3<span class="elsevierStyleHsp" style=""></span>min in hair-free skin areas&#41; is sacred&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">If the decision is made to remove the hair pre-operatively&#44; this should be done with electric clippers to avoid scratches and nicks&#46; There is not enough evidence to determine the ideal range of hair removal and surgery&#46; What is new is that the document recommends only removing hair when absolutely necessary &#40;R&#58; strong&#47;C&#58; moderate&#41;&#46; However&#44; this latter recommendation is based on indirect evidence &#40;clipped&#47;not clipped vs shaved&#41;&#46; In addition&#44; it is necessary to clarify the interaction of this measure with the recommendation of the use of the alcoholic solutions&#44; given that the drying times of these solutions are longer in the presence of hair&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In patients who are carriers for nasal <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#44; decolonization is recommended with nasal topical mupirocin&#46; This recommendation is especially directed at patients who require orthopedic surgery with joint prostheses and candidates for cardiac surgery &#40;R&#58; strong&#47;C&#58; moderate&#41;&#46; Although the evidence concludes that the topical treatment of colonized patients improves the rates of postoperative staphylococcal infection&#44; it is unclear whether the measure within a complex and frequent care process &#40;sampling&#44; detection&#44; treatment and surgery&#41; is appropriately cost-effective&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The document also discusses hand hygiene in surgery&#46; The WHO<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> recommends surgical scrubbing either with a soapy solution of chlorhexidine&#47;povidone iodine or with an alcohol solution &#40;R&#58; strong&#47;C&#58; moderate&#41;&#46; As for the duration of hand scrubbing&#44; the document refers the reader to current guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> Thus&#44; using 4&#37; chlorhexidine soap&#44; the first washing &#40;not brushing&#41; is recommended for 4&#8211;5<span class="elsevierStyleHsp" style=""></span>min&#59; then 2<span class="elsevierStyleHsp" style=""></span>min are enough in the remaining surgeries&#44; either repeating the soapy solution or an alcoholic solution &#40;two 60<span class="elsevierStyleHsp" style=""></span>sec scrubs&#44; with complete drying at the end&#41;&#44; provided that&#44; in the interval between surgeries&#44; there has been no obvious contamination&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Among the measures aimed at reducing contamination of the surgical site by the endogenous flora of the patient&#44; the document supports the use of oral antibiotics and mechanical preparation of the colon&#46; Until results are published from studies comparing oral antibiotics with and without mechanical bowel preparation&#44; it is recommended to add oral antibiotics when the colon is prepared mechanically &#40;R&#58; weak&#47;C&#58; moderate&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Also worthy of mention are the recommendations aimed at optimizing patient homeostasis in general&#44; and the immune response in particular&#44; such as hyperoxygenation&#44; preservation of normothermia and perioperative normovolemia&#46; However&#44; the benefits of homeostatic optimization measures should be evaluated by taking into account a broader perspective of outcomes and also including the effects on other systems and organs&#46; The recommendation of perioperative hyperoxygenation &#40;R&#58; strong&#47;C&#58; moderate&#41; is a measure that will generate debate in different forums&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> There is a perception that the application of hyperoxygenation by anesthesia services will be far from universal since it is based on an effect in an unsolid subgroup&#46; The possible adverse effects and the limited pathophysiological evidence of the potential benefit of the increase in tissue oxygen when the hemoglobin saturation is 100&#37;&#44; together with other systematic reviews<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> with more prudent conclusions&#44; could be the cause of the lack of consolidation of this measure&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">On the opposite side of the spectrum is perioperative normothermia &#40;R&#58; weak&#47;C&#58; moderate&#41;&#46; Paradoxically&#44; the recommendation of preserving perioperative body temperature is weak&#44; which may seem insufficient given the fact that its application is generalized in anesthesiology services during major procedures&#46; The cause of this timid recommendation is&#44; perhaps&#44; that the group that created the guidelines did not consider that the number of patients and events from the 2 studies published were more than enough to give a more solid recommendation&#46; To my understanding&#44; this &#8220;disruptive&#8221; evidence does not require &#8211; nor should it wait for &#8211; more studies that corroborate the deleterious effects associated with perioperative hypothermia&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Perioperative normovolemia &#40;R&#58; weak&#47;C&#58; low&#41; extends to the concept of volume restriction protocols&#46; Individualized objectives are recommended to guide reanimation to avoid systemic and local hemodynamic deficit of the surgical site&#46; Persistent arterial hypotension can compromise the correct vascularization of intestinal anastomoses&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> and&#44; on the contrary&#44; an excessive extracellular volume can reduce the effectiveness of the antibiotic prophylaxis due to an increased distribution volume for the antibiotic&#44; while it may also worsen the cardiorespiratory response of the patient&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Perhaps it is surprising that&#44; in the WHO recommendations&#44; measures related to antibiotic prophylaxis are not given preference&#46; While waiting for a more extensive review to be published&#44; the document reinforces the classic concepts of performing prophylaxis before surgery and not prolonging it beyond 24<span class="elsevierStyleHsp" style=""></span>hours &#40;R&#58; strong&#47;C&#58; moderate&#41;&#46; As an added detail&#44; the evidence analyzed allows for the administration time to be &#8220;relaxed&#8221; &#40;generally accepted between 30 and 60<span class="elsevierStyleHsp" style=""></span>min&#41; up to 2<span class="elsevierStyleHsp" style=""></span>h before the initial incision &#40;R&#58; strong&#47;C&#58; moderate&#41;&#46; This latter point can generate a discussion&#44; given that the evidence analyzed that supports this extension of pre-incisional administration time distances itself from the basic precepts of antibiotic prophylaxis &#40;high concentrations of antibiotics at the time of incision contamination&#41; and is a generic recommendation for any type of surgery &#40;with different contamination times&#41; and antibiotic &#40;regardless of their half-life&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Other measures with weak recommendations deserve to be commented&#46; The guidelines are in favor of the application of perioperative glucose control&#44; the use of plastic surgical wound protectors&#44; triclosan-impregnated sutures&#44; negative-pressure therapy in high-risk wounds&#44; perioperative enteral nutrition and the irrigation of the surgical wound with a povidone-iodine solution&#46; Meanwhile&#44; they are against the application of wound dressings with antiseptics&#44; the laminar flow of operating rooms&#44; suspension of immunosuppressants before surgery&#44; irrigation of the surgical wound with antibiotics&#44; prolongation of antibiotic prophylaxis until the withdrawal of drain tubes and the use of skin sealants and plastic adhesives &#40;Steri-Drape&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Due to the limited evidence found&#44; the committee did not comment on 6 &#40;17&#37;&#41; of the measures evaluated&#44; including the use of sterile gloves &#40;use and replacement of the double glove&#41; and irrigation with saline solution of the surgical wound&#44; among others&#46; It seems logical to recommend the substitution of the external glove in procedures with the risk or confirmation of perforation or contamination&#46; It is true that the available evidence is limited and low quality&#44; but it is unlikely that general surgeons will stop irrigating and cleaning dirty wounds with saline solution if they decide to carry out a primary closure&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">As in all consensus documents&#44; there are intrinsic limitations that we would like to mention&#46; First&#44; although the method used for the analysis and gradation of the evidence reduces the possibility of bias in the recommendations&#44; it does not exclude it&#46; Thus&#44; there are several stages of the study in which the subjective opinion of experts may &#8220;contaminate&#8221; the analysis&#46; Given these threats&#44; the best &#8220;vaccine&#8221; is a complete declaration and management of conflicts of interest&#46; In addition&#44; when elaborating the recommendations&#44; the presence of all parties involved in the prevention measures is important&#46; The opinion of first-line specialists who decide on the relevant aspects of some of the prevention measures analyzed can facilitate the decision of the panel on certain recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a> However&#44; these and other difficulties that panelists face should be adequately addressed through a structured approach to the development of the guidelines that ensures maximum transparency in terms of the selection and analysis of the evidence&#44; as well as in the reasoning behind decision-making&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Second&#44; the application of these measures will undoubtedly help improve the rates of postoperative infectious complications&#44; although simple adhesion does not substitute correct decision-making criteria or the application of the optimal surgical technique&#46; The best &#8220;package&#8221; will not improve the rate of surgical infection of heroic surgical procedures that exceed patient resistance&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">And third&#44; the quantity and quality of the application of measures in medical centers and healthcare institutions will undoubtedly lead to difficulties in making the necessary changes&#44; especially given the involvement of users in the processes and the hierarchical decision-making system&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a> In any event&#44; it seems reasonable to start from less and progress toward more&#44; identify departments to use as a reference while combining pedagogy with enthusiasm&#46;</p></span>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos