RESUMEN
Hemodynamic and depth of anesthesia (DOA) monitoring are used in many high-risk surgical patients without well-defined indications and objectives. We implemented monitoring guidelines to rationalize hemodynamic and anesthesia management during major cancer surgery. In early 2014, we developed guidelines with specific targets (Mean arterial pressure > 65 mmHg, stroke volume variation < 12%, cardiac index > 2.5 l min-1 m-2, central venous oxygen saturation > 70%, 40 < bispectral index < 60) for open abdominal cancer surgeries > 2 h. Pre-, intra-, and post-operative data were collected from our electronic medical record database and compared before (March-August 2013) and after (March-August 2014) guideline implementation. A total of 596 patients were studied, 313 before (Before group) and 283 after (After group) guideline implementation. The two groups were comparable for age, ASA score, physiological P-POSSUM score, and surgery duration, but the operative P-POSSUM score was higher in the after group (20 vs. 18, p = 0.009). The use of cardiac output, central venous oxygen saturation and DOA monitoring increased from 40 to 61%, 20 to 29%, and 60 to 88%, respectively (all p-values < 0.05). Intraoperative fluid volumes decreased (16.0 vs. 14.5 ml kg-1 h-1, p = 0.002), whereas the use of inotropes increased (6 vs. 11%, p = 0.022). Postoperative delirium (16 vs. 8%, p = 0.005), urinary tract infections (6 vs. 2%, p = 0.012) and median hospital length of stay (9.6 vs. 8.8 days, p = 0.032) decreased. In patients undergoing major open abdominal surgery for cancer, despite an increase in surgical risk, the implementation of guidelines with predefined targets for hemodynamic and DOA monitoring was associated with a significant improvement in postoperative outcome.
Asunto(s)
Neoplasias Abdominales/cirugía , Anestesia/métodos , Hemodinámica , Monitoreo Fisiológico/métodos , Neoplasias/cirugía , Abdomen/cirugía , Anciano , Presión Arterial , Gasto Cardíaco , Estudios Controlados Antes y Después , Femenino , Mortalidad Hospitalaria , Humanos , Periodo Intraoperatorio , Tiempo de Internación , Masculino , Persona de Mediana Edad , Periodo Perioperatorio , Complicaciones Posoperatorias , Periodo Posoperatorio , Estudios Retrospectivos , Riesgo , Volumen Sistólico , Volumen de Ventilación Pulmonar , Resultado del TratamientoRESUMEN
The International Standards for a Safe Practice of Anesthesia were developed on behalf of the World Federation of Societies of Anaesthesiologists (WFSA), a nonprofit organization representing anesthesiologists in 150 countries, and the World Health Organization (WHO). The recommendations have been approved by WHO and the membership of WFSA. These Standards are applicable to all anesthesia providers throughout the world. They are intended to provide guidance and assistance to anesthesia providers, their professional organizations, hospital and facility administrators, and governments for maintaining and improving the quality and safety of anesthesia care. The Standards cover professional aspects; facilities and equipment; medications and intravenous fluids; monitoring; and the conduct of anesthesia. HIGHLY RECOMMENDED standards, the functional equivalent of mandatory standards, include (amongst other things): the continuous presence of a trained and vigilant anesthesia provider; continuous monitoring of tissue oxygenation and perfusion by clinical observation and a pulse oximeter; intermittent monitoring of blood pressure; confirmation of correct placement of an endotracheal tube (if used) by auscultation and carbon dioxide detection; the use of the WHO Safe Surgery Checklist; and a system for transfer of care at the end of an anesthetic. The International Standards represent minimum standards and the goal should always be to practice to the highest possible standards, preferably exceeding the standards outlined in this document.