Erros de medicação num serviço de internamento hospitalar : estudo de prevalência

RESUMO - Os erros de medicação (EM) são uma das principais causas de eventos adversos, estimando-se serem as causas não relacionados com procedimentos cirúrgicos mais frequentes. Estes podem ser classificados por erros latentes ou erros ativos. Objetivos Definiram-se como principais objetivos deste estudo, determinar a prevalência de EM ativos num internamento hospitalar evitados e não evitados, nos momentos da prescrição escrita, transcrição, distribuição e administração, bem como a sua relação com algumas variáveis, como o Grupo farmacológico, Via de administração, Especialidade médica do prescritor e Área médica do médico responsável pelo episódio de internamento (MREI). Metodologia O estudo foi do tipo observacional descritivo de abordagem quantitativa, transversal com recrutamento prospetivo. Foi utilizado um instrumento de observação (check-list) para o registo de todos os EM e das variáveis em cada fase. Resultados Foram observadas 513 unidades amostrais com uma prevalência de 98,2% de EM, num total de 1655 erros dos quais 75% foram evitados. Nas variáveis Grupo farmacológico e Área médica do MREI não foram encontradas relações estatísticas relevantes. Obteve-se um OR=1,97 [1,18;3,27] para medicamentos orais quando comparados aos endovenosos nos erros de prescrição (EP) e um OR=7 [2,77;17,71] quando comparados com os endovenosos na transcrição dos Serviços Farmacêuticos (TSF). A anestesiologia apresentou um OR=0,41 [0,27;0,63] nos EP comparativamente às outras especialidades. Do total de EM observaram-se 30% de erros de prescrição (EP), 20% de erros na transcrição do internamento, 36% de erros na TSF, 2% de erros na distribuição e 12% de erros na administração. Os erros mais prevalentes foram a identificação do prescritor ilegível (16%) e a identificação do doente omissa na TSF (16%). Conclusão Apesar da elevada prevalência de EM observados, a maioria dos erros foram corrigidos e não chegaram ao doente. Tendo em conta os EM observados, a utilização de meios informáticos e o aumento da adesão dos enfermeiros ao procedimento de identificação dos doentes poderão permitir a redução do número de EM em cerca de 80%, reduzindo também a probabilidade de ocorrência de eventos adversos relacionados com os erros ativos na utilização de medicamentos.

Abordagem e maneio médico-cirúrgico de feridas abertas em cães e gatos : caracterização etiológica e estudo de padrões traumáticos

Dissertação de Mestrado Integrado em Medicina Veterinária

Does abdominoplasty with liposuction of the love handles yield a shorter scar? An analysis with abdominal 3D laser scanning.

The aim of this study was to evaluate the combination of abdominoplasty with liposuction of both flanks with regards to length of scar, complications, and patient's satisfaction. A retrospective analysis of 35 patients who underwent esthetic abdominoplasty at our institution between 2002 and 2004 was performed. Thirteen patients underwent abdominoplasty with liposuction of both flanks, 22 patients underwent conventional abdominoplasty. Liposuction of the flanks did not increase the rate of complications of the abdominoplasty procedures. We found a tendency toward shorter scars in patients who underwent abdominoplasty combined with liposuction of the flanks. Implementation of 3-dimensional laser surface scanning to objectify the postoperative outcomes, documented a comparable degree of flatness of the achieved body contouring in both procedures. 3-dimensional laser surface scanning can be a valuable tool to objectify assessment of postoperative results.

Minimal invasive surgery for coronoid fracture: technical note.

Operative treatment of coronoid fracture often requires a large dissection of soft tissue, resulting in elbow stiffness and functional limitation. The authors present a minimal invasive, safe technique, useful in the case of isolated coronoid fracture associated with elbow dislocation. This technique does not require soft tissue dissection and allows an early unlimited resumption of sports activities.

Impact of duration of chest tube drainage on pain after cardiac surgery.

OBJECTIVE: This study was designed to analyze the duration of chest tube drainage on pain intensity and distribution after cardiac surgery. METHODS: Two groups of 80 cardiac surgery adult patients, operated on in two different hospitals, by the same group of cardiac surgeons, and with similar postoperative strategies, were compared. However, in one hospital (long drainage group), a conservative policy was adopted with the removal the chest tubes by postoperative day (POD) 2 or 3, while in the second hospital (short drainage group), all the drains were usually removed on POD 1. RESULTS: There was a trend toward less pain in the short drainage group, with a statistically significant difference on POD 2 (P=0.047). There were less patients without pain on POD 3 in the long drainage group (P=0. 01). The areas corresponding to the tract of the pleural tube, namely the epigastric area, the left basis of the thorax, and the left shoulder were more often involved in the long drainage group. There were three pneumonias in each group and no patient required repeated drainage. CONCLUSIONS: A policy of early chest drain ablation limits pain sensation and simplifies nursing care, without increasing the need for repeated pleural puncture. Therefore, a policy of short drainage after cardiac surgery should be recommended.

Chirurgie

2007 was marked by a growing trend towards minimal invasive surgery and enhanced recovery, especially in visceral surgery. In comparison to the laparoscopic revolution in the eighties, Natural orifice transluminal endoscopic surgery (NOTES) must be watched on closely, and will probably have to be taken into account in a near future. Minimal invasive procedures in oesophageal cancer surgery have proved both efficient and oncologically safe. Implementation of Fast track protocols now permits a much faster patient's return to normal daily activity. In hepatobiliary and pancreatic surgery, multidisciplinary efforts have been done to better select patients, widen the indications and increase efficiency.

Atrial assist device, a new alternative to lifelong anticoagulation?

OBJECTIVE: Atrial fibrillation is a very common heart arrhythmia, associated with a five-fold increase in the risk of embolic strokes. Treatment strategies encompass palliative drugs or surgical procedures all of which can restore sinus rhythm. Unfortunately, atria often fail to recover their mechanical function and patients therefore require lifelong anticoagulation therapy. A motorless volume displacing device (Atripump) based on artificial muscle technology, positioned on the external surface of atrium could avoid the need of oral anticoagulation and its haemorrhagic complications. An animal study was conducted in order to assess the haemodynamic effects that such a pump could provide. METHODS: Atripump is a dome-shape siliconecoated nitinol actuator sewn on the external surface of the atrium. It is driven by a pacemaker-like control unit. Five non-anticoagulated sheep were selected for this experiment. The right atrium was surgically exposed, the device sutured and connected. Haemodynamic parameters and intracardiac ultrasound (ICUS) data were recorded in each animal and under three conditions; baseline; atrial fibrillation (AF); atripump assisted AF (aaAF). RESULTS: In two animals, after 20 min of AF, small thrombi appeared in the right atrial appendix and were washed out once the pump was turned on. Assistance also enhanced atrial ejection fraction. 31% baseline; 5% during AF; 20% under aaAF. Right atrial systolic surfaces (cm2) were; 5.2 +/- 0.3 baseline; 6.2 +/- 0.1 AF; 5.4 +/- 0.3 aaAF. CONCLUSION: This compact and reliable pump seems to restore the atrial "kick" and prevents embolic events. It could avoid long-term anticoagulation therapy and open new hopes in the care of end-stage heart failure.

Management of transitional-cell carcinoma of the renal pelvis and ureter.

Transitional-cell carcinoma of the renal pelvis or ureter is a relatively rare disease. Several risk factors are smoking, occupational carcinogens, analgesic abuse or Balkan nephropathy. The grade and stage of the disease have the most significant impact on the outcome. The treatment of renal pelvis and ureter tumours is open or laparoscopic surgery varying from conservative to more extensive surgical procedures, i.e. radical nephroureterectomy including removal of the contents of Gerota's fascia with ipsilateral ureter and a cuff of bladder at its distal extent. Most available data are from retrospective studies and surgery is the mainstay of treatment. Chemotherapy and/or radiation therapy are possible adjuvant or primary treatment for selected patients; however, prospective studies are needed to confirm their use.

Comparing potentially avoidable hospitalization rates related to ambulatory care sensitive conditions in Switzerland: the need to refine the definition of health conditions and to adjust for population health status.

BACKGROUND: Regional rates of hospitalization for ambulatory care sensitive conditions (ACSC) are used to compare the availability and quality of ambulatory care but the risk adjustment for population health status is often minimal. The objectives of the study was to examine the impact of more extensive risk adjustment on regional comparisons and to investigate the relationship between various area-level factors and the properly adjusted rates. METHODS: Our study is an observational study based on routine data of 2 million anonymous insured in 26 Swiss cantons followed over one or two years. A binomial negative regression was modeled with increasingly detailed information on health status (age and gender only, inpatient diagnoses, outpatient conditions inferred from dispensed drugs and frequency of physician visits). Hospitalizations for ACSC were identified from principal diagnoses detecting 19 conditions, with an updated list of ICD-10 diagnostic codes. Co-morbidities and surgical procedures were used as exclusion criteria to improve the specificity of the detection of potentially avoidable hospitalizations. The impact of the adjustment approaches was measured by changes in the standardized ratios calculated with and without other data besides age and gender. RESULTS: 25% of cases identified by inpatient main diagnoses were removed by applying exclusion criteria. Cantonal ACSC hospitalizations rates varied from to 1.4 to 8.9 per 1,000 insured, per year. Morbidity inferred from diagnoses and drugs dramatically increased the predictive performance, the greatest effect found for conditions linked to an ACSC. More visits were associated with fewer PAH although very high users were at greater risk and subjects who had not consulted at negligible risk. By maximizing health status adjustment, two thirds of the cantons changed their adjusted ratio by more than 10 percent. Cantonal variations remained substantial but unexplained by supply or demand. CONCLUSION: Additional adjustment for health status is required when using ACSC to monitor ambulatory care. Drug-inferred morbidities are a promising approach.

Facteurs de risque de sévérité de la papillomatose respiratoire juvénile

La papillomatose respiratoire récurrente (PRR) juvénile est causée par les génotypes 6 et 11 du virus du papillome humain (VPH). Cette maladie est caractérisée par des verrues récurrentes généralement au larynx. La forme sévère peut avoir un impact dévastateur sur la santé et la qualité de vie de l’enfant atteint et de sa famille en raison des conséquences des multiples chirurgies nécessaires et du risque d'obstruction des voies respiratoires. Objectif: Examiner les facteurs de risque associés aux manifestations sévères de la PRR. Méthode: Étude rétrospective des 31 cas diagnostiqués entre janvier 1995 et décembre 2008. Les données démographiques, cliniques, génétiques et virologiques ont été évaluées. Des régressions logistiques furent effectuées afin d'évaluer le rôle des variables indépendantes sur la sévérité de la maladie. Résultats: Nos données suggèrent que les facteurs de risque de sévérité de la PRR seraient associés au genre féminin (Rapport de cotes (RC)=2.60, intervalles de confiance (IC) 95% : 0.44-15.44), au fait d’être premier-né (RC=3.51, IC 95% : 0.17-72.32), à un statut économique faible (RC=5.31, IC 95% : 0.17-164.19), à un jeune âge (RC=0.83, IC 95% : 0.68-1.01), à une charge virale élevée (RC=3.81, IC 95% : 0.23-63.16) et aux condylomes chez la mère pendant la grossesse (RC=12.05, IC 95% : 0.97-149.85). Conclusion: La sévérité de la PRR serait le résultat d'une combinaison de déterminants qui favoriseraient la croissance cellulaire particulièrement chez les jeunes enfants. Des mesures préventives et thérapeutiques visant à restreindre la contamination et la réplication du virus pourraient réduire le fardeau de la maladie.

Essays in partial identification and applications to treatment effects and policy evaluation.

Dans cette thèse, je me suis interessé à l’identification partielle des effets de traitements dans différents modèles de choix discrets avec traitements endogènes. Les modèles d’effets de traitement ont pour but de mesurer l’impact de certaines interventions sur certaines variables d’intérêt. Le type de traitement et la variable d’intérêt peuvent être défini de manière générale afin de pouvoir être appliqué à plusieurs différents contextes. Il y a plusieurs exemples de traitement en économie du travail, de la santé, de l’éducation, ou en organisation industrielle telle que les programmes de formation à l’emploi, les techniques médicales, l’investissement en recherche et développement, ou l’appartenance à un syndicat. La décision d’être traité ou pas n’est généralement pas aléatoire mais est basée sur des choix et des préférences individuelles. Dans un tel contexte, mesurer l’effet du traitement devient problématique car il faut tenir compte du biais de sélection. Plusieurs versions paramétriques de ces modèles ont été largement étudiées dans la littérature, cependant dans les modèles à variation discrète, la paramétrisation est une source importante d’identification. Dans un tel contexte, il est donc difficile de savoir si les résultats empiriques obtenus sont guidés par les données ou par la paramétrisation imposée au modèle. Etant donné, que les formes paramétriques proposées pour ces types de modèles n’ont généralement pas de fondement économique, je propose dans cette thèse de regarder la version nonparamétrique de ces modèles. Ceci permettra donc de proposer des politiques économiques plus robustes. La principale difficulté dans l’identification nonparamétrique de fonctions structurelles, est le fait que la structure suggérée ne permet pas d’identifier un unique processus générateur des données et ceci peut être du soit à la présence d’équilibres multiples ou soit à des contraintes sur les observables. Dans de telles situations, les méthodes d’identifications traditionnelles deviennent inapplicable d’où le récent développement de la littérature sur l’identification dans les modèles incomplets. Cette littérature porte une attention particuliere à l’identification de l’ensemble des fonctions structurelles d’intérêt qui sont compatibles avec la vraie distribution des données, cet ensemble est appelé : l’ensemble identifié. Par conséquent, dans le premier chapitre de la thèse, je caractérise l’ensemble identifié pour les effets de traitements dans le modèle triangulaire binaire. Dans le second chapitre, je considère le modèle de Roy discret. Je caractérise l’ensemble identifié pour les effets de traitements dans un modèle de choix de secteur lorsque la variable d’intérêt est discrète. Les hypothèses de sélection du secteur comprennent le choix de sélection simple, étendu et généralisé de Roy. Dans le dernier chapitre, je considère un modèle à variable dépendante binaire avec plusieurs dimensions d’hétérogéneité, tels que les jeux d’entrées ou de participation. je caractérise l’ensemble identifié pour les fonctions de profits des firmes dans un jeux avec deux firmes et à information complète. Dans tout les chapitres, l’ensemble identifié des fonctions d’intérêt sont écrites sous formes de bornes et assez simple pour être estimées à partir des méthodes d’inférence existantes.

Factores de riesgo para evento coronario asociado a cirugias no cardiacas en mayores de 65 años

Objetivo: Determinar si la presencia de hipertensión arterial severa, rangos de edad diferentes, sexo masculino, dislipidemia en tratamiento, obesidad o múltiples predictores clínicos de riesgo, se asocian a mayor probabilidad de desarrollar falla cardiaca aguda, infarto agudo de miocardio no fatal o muerte de origen cardiovascular, en pacientes mayores de 65 años llevados a un procedimiento quirúrgico no cardiaco. Materiales y Métodos. Se realizó un estudio de cohorte retrospectivo de los pacientes llevados a cirugías no cardiacas en la Fundación Cardioinfantil entre el 1ro de enero de 2003 y el 31 de diciembre de 2005. Por análisis bivariado, prueba T student y CHI2 se determino la significancia estadística, con posterior regresión logística. Resultados: De 1.600 eventos analizados, el 9,2% presentaron complicaciones cardiovasculares, de las cuales el 40,1% fueron mortales. El tabaquismo, hipertensión arterial severa y un mayor número de predictores clínicos de riesgo, se asocian con desenlaces mortales y no mortales, con un riesgo relativo de 5,3 (IC 95%, 3,7-7,69), 4,27 (IC 95%; 2,56-7,11) y hasta 18,86 (IC 95%; 9,59-37,1) respectivamente. La dislipidemia, sexo masculino y edad avanzada se asocian con eventos no mortales, con un RR de 3,1 (IC 95%; 1,97-4,87), 1,67 (95%; 1,06-2,62) y 2,49 (IC 95%; 1,03-6,05) respectivamente. Conclusiones: los factores de riesgo para enfermedad coronaria de la población general son también factores de riesgo para complicaciones cardiovasculares perioperatorias en cirugías no cardiacas.

Experiencia del Instituto de Ortopedia Infantil Roosevelt en el manejo de pacientes con pseudoartrosis congenita de tibia

La pseudoartrosis congénita de la tibia es una enfermedad de muy baja incidencia, pero con gran morbilidad en el paciente afectado por la misma. Es un reto para el ortopedista infantil porque no existe un consenso sobre su etiología y tratamiento. La dificultad en el manejo, esta en obtener y mantener unión o consolidación y simultáneamente proveer una extremidad funcional. El Propósito de este estudio es describir los resultados en el manejo de esta patología en el Instituto de ortopedia Infantil Roosevelt. Metodologia : estudio descriptivo retrospectivo, que incluyo todos los pacientes afectados por esta enfermedad, entre 1980-2010, en una Institución especializada en ortopedia infantil de IV nivel. Resultados : en total se encontraron 26 pacientes, siendo la pierna derecha la más afectada por esta enfermedad. 24 pacientes lograron consolidación de la pseudoartrosis, después de varios procedimientos quirúrgicos, con una mediana de tiempo a la consolidación posterior a su último tratamiento de 10,1 meses. El tratamiento mas realizado fue el aloinjerto estructural y las principales complicaciones fueron la deformidad angular y la discrepancia de longitud. Discusion : esta es una patología de altísima complejidad, que requiere una aproximación multidisciplinaria y varios tratamientos en orden a lograr la consolidación de la tibia y con una alta frecuencia de complicaciones ortopédicas. Se requieren más estudios que aborden la problemática de estos pacientes.

El uso de sangre fresca total en cardiopatías congénitas complejas

Objetivos: Describir si el uso de sangre fresca total (SFT) intraoperatoria en pacientes llevados a procedimientos RACHS 3 y 4 en la Fundación Cardioinfantil, disminuye el sangrado postoperatorio y el volumen de transfusión de elementos sanguíneos, en comparación a aquellos en quienes no se usa SFT. Materiales y métodos: Se realizó un estudio de cohorte histórica, tomando una población menor de 1 año expuesta a la sangre fresca total y comparándola con una población de similares características, llevadas a procedimientos de riesgo similar no expuesta. Los análisis se realizaron mediante pruebas estándar para variables continuas y discretas. Un valor de p menor a 0.05 fue aceptado como signficativo. Resultados: 46 pacientes expuestos a SFT y se compararon con 50 pacientes no expuestos. La principal diferencia entre los grupos fue la edad, siendo mayor en el grupo de no expuestos (3.8 años vs 0.9; p<0.001). El volumen de sangrado postoperatorio fue similar, sin embargo los pacientes expuestos a SFT recibieron mayor volumen de transfusiones, sin ser una diferencia estadísticamente significativa (155cc vs 203cc, P=0.9). No hubo diferencia significativa en complicaciones o mortalidad. Conclusiones: En nuestro estudio no se encontró una disminución en el volumen de sangrado postoperatorio en los pacientes menores de 1 año, sometidos a cirugías catalogadas como RACHS 3 y 4, expuestos a SFT, sin embargo se necesitan estudios clínicos controlados que respondan definitivamente a la pregunta.