Bicudo-Salomão Alberto, Salomão Rosana de Freitas, Cuerva Mariani Parra, Martins Michelle Santos, Dock-Nascimento Diana Borges, Aguilar-Nascimento José Eduardo de
Postgraduate Program in Health Sciences, Federal University of Mato Grosso, Cuiabá, MT, Brazil.
Arq Bras Cir Dig. 2019 Dec 20;32(4):e1477. doi: 10.1590/0102-672020190001e1477. eCollection 2019.
Perioperative care multimodal protocol significantly improve outcome in surgery.
To investigate risk factors to various endpoints in patients submitted to elective colorectal operations under the ACERTO protocol.
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.
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.
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.
围手术期护理多模式方案可显著改善手术结局。
探讨在ACERTO方案下接受择期结直肠手术患者出现各种终点事件的危险因素。
队列研究，通过逻辑回归模型分析，该模型能够评估发病率和死亡率的独立危险因素，研究对象为接受择期开放性结肠和/或直肠切除及一期吻合术的患者，这些患者暴露或未暴露于人口统计学、临床和ACERTO干预措施。
分析了234例患者，其中156例（66.7%）接受直肠手术，78例（33.3%）接受结肠手术。术后住院时间（LOS）≥7天与直肠手术和高NNIS风险指数有关；术前禁食≤4小时（OR = 0.250；95%CI = 0.114 - 0.551）以及输注的晶体液静脉量>30ml/kg/天（OR = 0.290；95%CI = 0.119 - 0.706）。营养不良患者术后手术部位感染（SSI）风险约高四倍；直肠手术患者高八倍，高NNIS指数患者高四倍。术前禁食≤4小时是一个保护因素，可将手术部位感染（SSI）风险降低81.3%。发现营养不良、直肠手术和高NNIS指数会增加吻合口瘘的风险。相反，术前禁食≤4小时（OR = 0.11；95%CI = 0.05 - 0.25；p<0.0001）可降低瘘的风险。与肺炎 - 肺不张相关的因素是癌症和直肠手术，而术前禁食≤4小时（OR = 0.10；95%CI = 0.04 - 0.24；p<0.0001）和晶体液静脉输注≤30ml/kg/天（OR = 0.36；95%CI = 0.13 - 0.97，p = 0.044）可降低风险。术前禁食≤4小时且晶体液静脉输注≤30ml/kg/天的患者死亡率较低。
本研究可以得出结论，直肠手术、高NNIS指数、术前禁食超过4小时以及术后48小时内静脉输液量大于30ml/kg/天是以下情况的独立危险因素：1）住院时间延长；2）与营养不良相关的手术部位感染和吻合口瘘；3）术后肺炎 - 肺不张；4）术后死亡率。
