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ABSTRACT BACKGROUND: The concept introduced by protocols of enhanced recovery after surgery modifies perioperative traditional care in digestive surgery. The integration of these modern recommendations components during the perioperative period is of great importance to ensure fewer postoperative complications, reduced length of hospital stay, and decreased surgical costs. AIMS: To emphasize the most important points of a multimodal perioperative care protocol. METHODS: Careful analysis of each recommendation of both ERAS and ACERTO protocols, justifying their inclusion in the multimodal care recommended for digestive surgery patients. RESULTS: Enhanced recovery programs (ERPs) such as ERAS and ACERTO protocols are a cornerstone in modern perioperative care. Nutritional therapy is fundamental in digestive surgery, and thus, both preoperative and postoperative nutrition care are key to ensuring fewer postoperative complications and reducing the length of hospital stay. The concept of prehabilitation is another key element in ERPs. The handling of crystalloid fluids in a perfect balance is vital. Fluid overload can delay the recovery of patients and increase postoperative complications. Abbreviation of preoperative fasting for two hours before anesthesia is now accepted by various guidelines of both surgical and anesthesiology societies. Combined with early postoperative refeeding, these prescriptions are not only safe but can also enhance the recovery of patients undergoing digestive procedures. CONCLUSIONS: This position paper from the Brazilian College of Digestive Surgery strongly emphasizes that the implementation of ERPs in digestive surgery represents a paradigm shift in perioperative care, transcending traditional practices and embracing an intelligent approach to patient well-being.

RESUMO RACIONAL: O conceito introduzido pelos protocolos de recuperação após a cirurgia modifica os cuidados perioperatórios tradicionais em cirurgia digestiva. A integração desses componentes modernos de recomendações, durante o período perioperatório, é de grande importância para garantir menos complicações pós-operatórias, redução do tempo de internação hospitalar e diminuição dos custos cirúrgicos. OBJETIVOS: Enfatizar os pontos mais importantes de um protocolo multimodal de cuidados perioperatórios. MÉTODOS: Análise criteriosa de cada recomendação dos protocolos ERAS e ACERTO, justificando sua inclusão no atendimento multimodal recomendado para pacientes de cirurgia digestiva. RESULTADOS: Os programas de recuperação avançada (PRAs), tais como os protocolos ERAS e ACERTO, são a base dos cuidados perioperatórios modernos. A terapia nutricional é de grande importância na cirurgia digestiva e, portanto, tanto os cuidados nutricionais pré-operatórios, quanto pós-operatórios são fundamentais para garantir menos complicações pós-operatórias e reduzir o tempo de internação hospitalar. O conceito de pré-habilitação é outro elemento-chave nos PRAs. O manuseio de fluidos cristalóides em perfeito equilíbrio é vital. A sobrecarga de fluidos pode atrasar a recuperação dos pacientes e aumentar as complicações pós-operatórias. A abreviação do jejum pré-operatório para duas horas antes da anestesia é agora aceita por diversas diretrizes das sociedades cirúrgicas e de anestesiologia. Combinadas com a realimentação pós-operatória precoce, essas prescrições não são apenas seguras, mas também podem melhorar a recuperação de pacientes submetidos a procedimentos digestivos. CONCLUSÕES: Este posicionamento do Colégio Brasileiro de Cirurgia Digestiva enfatiza fortemente que a implementação de PRAs em cirurgia digestive, representa uma mudança de paradigma no cuidado perioperatório, transcendendo as práticas tradicionais e adotando uma abordagem inteligente para o bem-estar do paciente.

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Abstract Damage control resuscitation should be initiated as soon as possible after a trauma event to avoid metabolic decompensation and high mortality rates. The aim of this article is to assess the position of the Trauma and Emergency Surgery Group (CTE) from Cali, Colombia regarding prehospital care, and to present our experience in the implementation of the "Stop the Bleed" initiative within Latin America. Prehospital care is phase 0 of damage control resuscitation. Prehospital damage control must follow the guidelines proposed by the "Stop the Bleed" initiative. We identified that prehospital personnel have a better perception of hemostatic techniques such as tourniquet use than the hospital providers. The use of tourniquets is recommended as a measure to control bleeding. Fluid management should be initiated using low volume crystalloids, ideally 250 cc boluses, maintaining the principle of permissive hypotension with a systolic blood pressure range between 80- and 90-mm Hg. Hypothermia must be management using warmed blankets or the administration of intravenous fluids warmed prior to infusion. However, these prehospital measures should not delay the transfer time of a patient from the scene to the hospital. To conclude, prehospital damage control measures are the first steps in the control of bleeding and the initiation of hemostatic resuscitation in the traumatically injured patient. Early interventions without increasing the transfer time to a hospital are the keys to increase survival rate of severe trauma patients.

Resumen La resucitación en el control de daños debe iniciarse lo más rápido posible después de presentado el evento traumático para evitar descompensación metabólica y aumento de la mortalidad. El objetivo de este artículo es sustentar nuestro enfoque respecto a la atención prehospitalaria y presentar nuestra experiencia en la implementación de la iniciativa "Stop the Bleed" en Latinoamérica. La atención prehospitalaria es la fase Cero de la resucitación del control de daños. Por medio de la implementación de la iniciativa "Stop the Bleed" se identificó que el personal prehospitalario tiene una mejor percepción sobre el uso de técnicas hemostáticas como el torniquete que el personal hospitalario. Se recomienda el uso de torniquetes como medida de control de sangrado en extremidades. El manejo de líquidos debe realizarse usando cristaloides a bajos volúmenes, con bolos de 250 mL para cumplir el principio de la hipotensión permisiva con un rango entre 80 y 90 mm Hg de presión arterial sistólica. Se deben realizar medidas para evitar la hipotermia como el uso de sábanas térmicas o paso de líquidos calientes. Estas medidas no deben retrasar en ningún momento el tiempo de traslado para recibir la atención hospitalaria. En conclusión, la atención prehospitalaria es el paso inicial para garantizar las primeras medidas de control de sangrado y de resucitación hemostática de los pacientes. Realizar intervenciones tempranas sin acortar el tiempo de traslado a la atención hospitalaria son las claves para aumentar la tasa de supervivencia.

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Abstract Hemorrhagic shock and its complications are a major cause of death among trauma patients. The management of hemorrhagic shock using a damage control resuscitation strategy has been shown to decrease mortality and improve patient outcomes. One of the components of damage control resuscitation is hemostatic resuscitation, which involves the replacement of lost blood volume with components such as packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets in a 1:1:1:1 ratio. However, this is a strategy that is not applicable in many parts of Latin America and other low-and-middle-income countries throughout the world, where there is a lack of well-equipped blood banks and an insufficient availability of blood products. To overcome these barriers, we propose the use of cold fresh whole blood for hemostatic resuscitation in exsanguinating patients. Over 6 years of experience in Ecuador has shown that resuscitation with cold fresh whole blood has similar outcomes and a similar safety profile compared to resuscitation with hemocomponents. Whole blood confers many advantages over component therapy including, but not limited to the transfusion of blood with a physiologic ratio of components, ease of transport and transfusion, less volume of anticoagulants and additives transfused to the patient, and exposure to fewer donors. Whole blood is a tool with reemerging potential that can be implemented in civilian trauma centers with optimal results and less technical demand.

Resumen El choque hemorrágico y sus complicaciones son la principal causa de muerte en los pacientes con trauma. La resucitación en control de daños ha demostrado una disminución en la mortalidad y mejoría en el manejo del paciente. La resucitación hemostática consiste en la recuperación del volumen con hemoderivados como glóbulos rojos, plasma, crioprecipitado y plaquetas, en proporciones de 1:1:1:1. Sin embargo, esta demanda de hemo componentes podría no aplicarse para toda Latinoamérica u otros países de medianos y bajos ingresos. Las principales barreras para la implementación de esta estrategia serían la escasa disponibilidad de bancos de sangre y de hemoderivados insuficientes para contar con un protocolo de transfusión masiva. Una propuesta para superar estas barreras es el uso de sangre total fresca fría para la resucitación hemostática de los pacientes exsanguinados. Ecuador ha sido pionero en la implementación de esta estrategia con una experiencia ya de seis años, en que han demostrado que la sangre total tiene ventajas sobre la terapia de hemo componentes incluyendo, pero no limitando, la trasfusión de sangre con una razón fisiológica de componentes, fácil transporte y transfusión, menor volumen de anticoagulantes y aditivos trasfundidos al paciente, y menor exposición a donantes. La sangre total es una herramienta con un potencial reemergente que puede ser implementado en centros de trauma civil con óptimos resultados y menor demanda técnica.

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BACKGROUND AND OBJECTIVES: Modern crystalloid and colloid solutions are balanced solutions which are increasingly used in perioperative period. However, studies investigating their negative effect on whole blood coagulation are missing, and vivid debate is going on about which solution has the minimal coagulopathy effect. The aim of our study was to assess the effect of modern fluid solutions on whole blood coagulation using rotational thromboelastometry. METHODS: Blood samples were obtained from 30 patients during knee arthroscopy before and after administration of 500mL of crystalloid, Hydroxyethyl Starch and gelatin according to the randomization. Rotational thromboelastometry (Extem, Intem and Fibtem tests) was used to assess negative effect of fluid solutions on whole blood coagulation. RESULTS: In Extem test, the initiation phase of fibrin clot formation represented by CT parameter was not influenced by any fluid solution (p>0.05). The speed of clot formation represented by CFT and α angle was impaired by Hydroxyethyl Starch and gelatin but not by crystalloids (p<0.05). The strength of formatted coagulum represented by MCF parameter was impaired both in Extem and Fibtem test by HES and in Fibtem also by crystalloids (p<0.05). Intem test was not negatively influenced by any crystalloid or colloid solution in any parameter (p>0.05). CONCLUSION: Extem test appears to be sensitive to coagulopathy effect of modern colloids and crystalloids. Hydroxyethyl starch has the most obvious negative effect on clot formation followed by gelatin and finally by crystalloids. Intem test seems to be insensitive to adverse effect of modern colloids and crystalloids.

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Abstract Background and objectives Modern crystalloid and colloid solutions are balanced solutions which are increasingly used in perioperative period. However, studies investigating their negative effect on whole blood coagulation are missing, and vivid debate is going on about which solution has the minimal coagulopathy effect. The aim of our study was to assess the effect of modern fluid solutions on whole blood coagulation using rotational thromboelastometry. Methods Blood samples were obtained from 30 patients during knee arthroscopy before and after administration of 500 mL of crystalloid, Hydroxyethyl Starch and gelatin according to the randomization. Rotational thromboelastometry (Extem, Intem and Fibtem tests) was used to assess negative effect of fluid solutions on whole blood coagulation. Results In Extem test, the initiation phase of fibrin clot formation represented by CT parameter was not influenced by any fluid solution (p > 0.05). The speed of clot formation represented by CFT and α angle was impaired by Hydroxyethyl Starch and gelatin but not by crystalloids (p < 0.05). The strength of formatted coagulum represented by MCF parameter was impaired both in Extem and Fibtem test by HES and in Fibtem also by crystalloids (p < 0.05). Intem test was not negatively influenced by any crystalloid or colloid solution in any parameter (p > 0.05). Conclusion Extem test appears to be sensitive to coagulopathy effect of modern colloids and crystalloids. Hydroxyethyl starch has the most obvious negative effect on clot formation followed by gelatin and finally by crystalloids. Intem test seems to be insensitive to adverse effect of modern colloids and crystalloids.

Resumo Justificativa e objetivos Os cristaloides e coloides modernos são soluções balanceadas e cada vez mais utilizadas no período perioperatório. No entanto, não há estudos que avaliem seu efeito negativo na coagulação do sangue total e o intenso debate sobre a solução que cause um efeito mínimo na coagulopatia permanece. O objetivo de nosso estudo foi avaliar o efeito das soluções líquidas modernas na coagulação do sangue total com o uso da tromboelastometria rotacional. Métodos De acordo com a randomização, amostras de sangue foram colhidas de 30 pacientes durante a artroscopia de joelho, antes e após a administração de 500 mL de cristaloides, hidroxietilamido e gelatina. A tromboelastometria rotacional (testes Extem, Intem e Fibtem) foi utilizada para avaliar o efeito negativo das soluções líquidas na coagulação do sangue total. Resultados No teste Extem, a fase de iniciação da formação de coágulos de fibrina representada pelo parâmetro CT não foi influenciada por qualquer solução líquida (p > 0,05). A velocidade da formação de coágulos representada pelo CFT e pelo ângulo α foi prejudicada pelo hidroxietilamido e pela gelatina, mas não pelos cristaloides (p < 0,05). A força do coágulo formatado representado pelo parâmetro MCF foi prejudicada tanto no teste Extem quanto no teste Fibtem pelo HES e no teste Fibtem também pelos cristaloides (p < 0,05). O teste Intem não foi influenciado negativamente por nenhuma solução cristaloide ou coloide em nenhum parâmetro (p > 0,05). Conclusão O teste Extem parece ser sensível ao efeito de coagulopatia dos coloides e cristaloides modernos. O hidroxietilamido apresentou o efeito negativo mais óbvio na formação do coágulo, seguido pela gelatina e finalmente pelos cristaloides. O teste Intem parece ser insensível ao efeito adverso dos coloides e cristaloides modernos.

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Abstract Background and objectives: Hypothermia occurs in about 60% of patients under anesthesia and is generally not managed properly during short lasting surgical procedures. Hypothermia is associated with adverse clinical outcomes. The current study is designed to assess the effects of crystalloid warming on maternal and fetal outcomes in patients undergoing elective cesarean section with spinal anesthesia. Methods: In this prospective randomized controlled trial, sixty parturients scheduled for elective cesarean section with spinal anesthesia were randomly allocated to receive crystalloid at room temperature or warmed at 37 °C. Spinal anesthesia was performed at L3-L4 interspace with 10 mg of hyperbaric bupivacaine without adding opioids. Core temperature, shivering, and hemodynamic parameters were measured every minute until 10th minute and 5-min intervals until the end of operation. The primary outcome was maternal core temperature at the end of cesarean section. Results: There was no difference for baseline tympanic temperature measurements but the difference was significant at the end of the operation (p = 0.004). Core temperature was 36.8 ± 0.5 °C at baseline and decreased to 36.3 ± 0.5 °C for isothermic warmed crystalloid group and baseline tympanic core temperature was 36.9 ± 0.4 °C and decreased to 35.8 ± 0.7 °C for room temperature group at the end of the operation. Shivering was observed in 43.3% in the control group. Hemodynamic parameter changes and demographic data were not significant between groups. Conclusions: Isothermic warming crystalloid prevents the decrease in core temperature during cesarean section with spinal anesthesia in full-term parturients. Fetal Apgar scores at first and fifth minute are higher with isothermic warming.

Resumo Justificativa e objetivos: A hipotermia ocorre em cerca de 60% dos pacientes sob anestesia e geralmente não é tratada adequadamente durante procedimentos cirúrgicos de curta duração. A hipotermia está associada a desfechos clínicos adversos. O presente estudo teve como objetivo avaliar os efeitos do aquecimento de cristaloides nas condições maternas e fetais em pacientes submetidas à cesariana eletiva com raquianestesia. Métodos: Neste estudo prospectivo, randômico e controlado, 60 parturientes agendadas para cesárea eletiva com raquianestesia foram distribuídas aleatoriamente para receber cristaloides à temperatura ambiente ou aquecidos a 37 °C. A raquianestesia foi realizada no interespaço L3-L4 com 10 mg de bupivacaína hiperbárica sem adição de opioides. Temperatura central, tremores e parâmetros hemodinâmicos foram medidos a cada minuto até o décimo minuto e em intervalos de 5 min até o fim da operação. O desfecho primário foi a temperatura central materna ao final da cesárea. Resultados: Não houve diferença nas mensurações basais da temperatura timpânica, mas a diferença foi significativa no fim da operação (p = 0,004). A temperatura central foi de 36,8 ± 0,5 °C na fase basal e diminuiu para 36,3 ± 0,5 °C no grupo com aquecimento isotérmico de cristaloides e a temperatura basal timpânica foi de 36,9 ± 0,4 °C e diminuiu para 35,8 ± 0,7 °C no grupo sem aquecimento das soluções no fim da operação. Tremores foram observados em 43,3% no grupo controle. Alterações nos parâmetros hemodinâmicos e dados demográficos não foram significantes entre os grupos. Conclusões: O aquecimento isotérmico de cristaloides previne a redução da temperatura central durante a cesariana com raquianestesia em parturientes a termo. Os escores de Apgar para os fetos no primeiro e quinto minutos são maiores com o aquecimento isotérmico.

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BACKGROUND AND OBJECTIVES: Hypothermia occurs in about 60% of patients under anesthesia and is generally not managed properly during short lasting surgical procedures. Hypothermia is associated with adverse clinical outcomes. The current study is designed to assess the effects of crystalloid warming on maternal and fetal outcomes in patients undergoing elective cesarean section with spinal anesthesia. METHODS: In this prospective randomized controlled trial, sixty parturients scheduled for elective cesarean section with spinal anesthesia were randomly allocated to receive crystalloid at room temperature or warmed at 37°C. Spinal anesthesia was performed at L3-L4 interspace with 10mg of hyperbaric bupivacaine without adding opioids. Core temperature, shivering, and hemodynamic parameters were measured every minute until 10th minute and 5-min intervals until the end of operation. The primary outcome was maternal core temperature at the end of cesarean section. RESULTS: There was no difference for baseline tympanic temperature measurements but the difference was significant at the end of the operation (p=0.004). Core temperature was 36.8±0.5°C at baseline and decreased to 36.3±0.5°C for isothermic warmed crystalloid group and baseline tympanic core temperature was 36.9±0.4°C and decreased to 35.8±0.7°C for room temperature group at the end of the operation. Shivering was observed in 43.3% in the control group. Hemodynamic parameter changes and demographic data were not significant between groups. CONCLUSIONS: Isothermic warming crystalloid prevents the decrease in core temperature during cesarean section with spinal anesthesia in full-term parturients. Fetal Apgar scores at first and fifth minute are higher with isothermic warming.

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Resumen OBJETIVO Evaluar cómo se atendieron las pacientes con hemorragia obstétrica, qué recursos se utilizaron y los costos directos relacionados con el tratamiento de pacientes con placenta previa, con o sin placenta acreta, en quienes se indicó Floseal® como parte de las medidas de control e inhibición de la hemorragia en comparación con quienes solo recibieron los cuidados convencionales. MATERIALES Y MÉTODOS Estudio retrospectivo, observacional y comparativo de los expedientes clínicos de pacientes adultas con más de 20 semanas de gestación y placenta previa tratadas entre septiembre y noviembre del 2012 en la Unidad Médica de Alta Especialidad 23 en Monterrey, México. Los resultados clínicos y costos se compararon con pruebas paramétricas y no paramétricas. RESULTADOS Se analizaron 29 expedientes (15: Floseal® coadyuvante, 14: solo con tratamiento convencional). El grupo tratado con Floseal® tuvo menos reintervenciones (0 vs 57.1%, p 0.0010), días de estancia hospitalaria [2(2-4) vs 6(4-11), p 0.0048] y cuidados intensivos (2.4 ± 1.5 vs 4.5 ± 2.1, p 0.0048). El costo promedio por remuestreo fue de 109,172.00 pesos mexicanos (IC95%: 80,153.10-139,073.71 pesos) para Floseal® vs 224,289.00 pesos mexicanos (IC95%: 181,881.48-269,061.23 pesos) para el tratamiento convencional a expensas de un número de piezas mayor de Tisseel®, crioprecipitados, cristaloides y retiro quirúrgico de compresas. CONCLUSIONES El uso coadyuvante de Floseal® se asoció con menor número de reintervenciones, días de estancia hospitalaria y atención en cuidados intensivos. Se registraron menores costos promedio y total asociados con la atención. Para corroborar estos resultados en población mexicana se requieren análisis de largo seguimiento y con muestras más grandes.

Abstract OBJECTIVE To evaluate the clinical outcomes and direct costs related to treatment of placenta previa with Floseal® hemostatic matrix as part of the treatment of obstetric hemorrhage in comparison with conventional management only. METHODS Clinical records of patients with hemorrhagic hemorrhage, with more than 20 weeks of pregnancy and placenta previa were reviewed, all patients were adults and treated within September and November of 2012 in the "Unidad Médica de Alta Especialidad 23" of the Mexican Institute of Social Security, Monterrey, México. Costs where estimated using the Diario Oficial de la Federación 2013) and a resampling was performed. Clinical and costs outcomes where compared with parametric and non-parametric tests. RESULTS 29 clinical records (15: Adjuvant Floseal®, 14: conventional treatment only). Floseal® group resulted in less re-interventions (0% vs 57.1%, p 0.0010), days of hospital stay [2(2-4) vs 6(4-11), p 0.0048] and days in the intensive care unit (2.4 ± 1.5 vs 4.5 ± 2.1, p 0.0048). Average cost by resampling was $109,172.00 [CI95% (80,153.10-139,073.71 mexican pesos)] for Floseal® vs 224,289.00 mexican pesos [IC95% (181,881.48-269,061.23)] for conventional treatment at the expense greater number of pieces of Tisseel®, cryoprecipitate, crystalloids and surgical removal of compresses. CONCLUSIONS The adjuvant use of Floseal® was associated with fewer re-interventions, days of hospital stay and intensive care. Lower average and total costs associated with treatment were also estimated. Future long-term analyzes and larger sample sizes are necessary to corroborate these results in the Mexican population.

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Sepse, definida pela Síndrome da Resposta Inflamatória Sistêmica (SRIS) secundária a um agente infeccioso, é uma afecção comum em cães e gatos e está relacionada a altos índices de morbidade e mortalidade nestas espécies. Sua patogenia é complexa e multifatorial, mas a instabilidade hemodinâmica tem sido apontada como fator relevante para o alto índice de óbito nos pacientes, pois gera hipóxia e subsequente disfunção de múltiplos órgãos. O tratamento é baseado na terapia guiada por metas e tem como objetivo restaurar o equilíbrio circulatório pela infusão de grandes quantidades de fluido, sendo que a escolha da fluidoterapia adequada é ainda muito controversa. Assim, esta revisão descreve a fisiopatogenia da sepse e compara resultados do uso de coloides e cristaloides apresentados nos periódicos consultados.(AU)

Defined by the Systemic Inflammatory Response Syndrome (SIRS), which is secondary to an infectious agent, sepsis is a common affection in dogs and cats, being related to high morbidity and mortality rates in these species. The pathogenesis is multifactorial and complex. Hemodynamic instability is being identified as a key factor for the high mortality rate, since it causes hypoxia and subsequent multiple organ dysfunction. The treatment consists of goal-oriented therapy and the primary objective is to restore the circulatory balance through the infusion of large amounts of fluid. However, choosing the adequate fluid therapy is still very controversial. Thus, the objective of this review is to describe the pathophysiology of sepsis and to compare the results of the use of the colloids and crystalloids presented in the scientific articles analyzed.(AU)

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Sepse, definida pela Síndrome da Resposta Inflamatória Sistêmica (SRIS) secundária a um agente infeccioso, é uma afecção comum em cães e gatos e está relacionada a altos índices de morbidade e mortalidade nestas espécies. Sua patogenia é complexa e multifatorial, mas a instabilidade hemodinâmica tem sido apontada como fator relevante para o alto índice de óbito nos pacientes, pois gera hipóxia e subsequente disfunção de múltiplos órgãos. O tratamento é baseado na terapia guiada por metas e tem como objetivo restaurar o equilíbrio circulatório pela infusão de grandes quantidades de fluido, sendo que a escolha da fluidoterapia adequada é ainda muito controversa. Assim, esta revisão descreve a fisiopatogenia da sepse e compara resultados do uso de coloides e cristaloides apresentados nos periódicos consultados.

Defined by the Systemic Inflammatory Response Syndrome (SIRS), which is secondary to an infectious agent, sepsis is a common affection in dogs and cats, being related to high morbidity and mortality rates in these species. The pathogenesis is multifactorial and complex. Hemodynamic instability is being identified as a key factor for the high mortality rate, since it causes hypoxia and subsequent multiple organ dysfunction. The treatment consists of goal-oriented therapy and the primary objective is to restore the circulatory balance through the infusion of large amounts of fluid. However, choosing the adequate fluid therapy is still very controversial. Thus, the objective of this review is to describe the pathophysiology of sepsis and to compare the results of the use of the colloids and crystalloids presented in the scientific articles analyzed.

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