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CIRUGIA SEGURA
Jorge Rubio Elorza
Vocal académico SADEA
INTRODUCCIÓNINTRODUCCIÓN
• 234 millones cirugías/año
✔Muertes : 0,4-0,8% 1
millón
✔Complicaciones: 3 – 16%
7 millones dishabilidades
INTRODUCCIÓNINTRODUCCIÓN
• Estrategía OMS: CIRUGÍA SEGURA SALVA VIDAS
✔ Disminuir el número de MUERTES
QUIRÚRGICAS en el mundo
✔ Fortalecer las medidas de SEGURIDAD
✔ Implementar TÉCNICAS ANESTÉSICAS SEGURAS
✔ Evitar la INFECCIÓN QUIRÚRGICA
✔ Optimizar la COMUNICACIÓN en el equipo
quirúrgico
OBJETIVOS ESENCIALESOBJETIVOS ESENCIALES
• Realizar el Paciente y la cirugía CORRECTOS
• Prevenir los RIESGOS ANESTÉSICOS y evitar el
DOLOR
• Prevenir y manejar los RIESGOS DE VÍA AÉREA:
Difícil – Aspiración
• Reconocer y preparar el manejo de SANGRADO
MAYOR
• Evitar REACCIONES ALERGÍCAS y EFECTOS
FARMACOLÓGICOS ADVERSOS
OBJETIVOS ESENCIALESOBJETIVOS ESENCIALES• Minimizar riesgo de INFECCIÓN DE HERIDA
QUIRÚRGICA
• Prevenir la RETENCIÓN inadvertida de GASAS –
INSTRUMENTOS
• Identificar adecuadamente TODAS LAS MUESTRAS
DE PATOLOGÍA
• Comunicación adecuada para realizar una
CIRUGÍA SEGURA
• Establecer y difundir por las INSTITUCIONES y
EL SISTEMA DE SALUD INDICADORES DE
GESTIÓN
LISTA DE CHEQUEOLISTA DE CHEQUEO
LISTA DE CHEQUEOLISTA DE CHEQUEO
• CIRUGÍA SEGURA Prioritaria ESTRATEGIA – LIDERES y EQUIPO QUIRÚRGICO
✔ ADAPTABLE – NO REGULATORIO
✔ SIMPLE - BREVE
✔ FLUJO LABORAL NORMAL
✔ CREAR CULTURA PRACTICAS SEGURAS
RUTINARIAS
✔ SEGUIMIENTO – CUMPLIMIENTO – ADHERENCIA
minimizan RIESGOS COMUNES Y EVITABLES.
FASE DE ENTRADA
PRE-INDUCCIÓN ANESTÉSICA – SEGURIDAD DEL
PROCEDIMIENTO ANESTESIA - ENFERMERIA
✔ PACIENTE
Identificación – Sitio – Procedimiento -
Consentimiento
✔ SITIO
Marcación – No aplicable
✔ CHEQUEO DE ANESTESIA ABCDEes
Equipos – Medicaciones – Riesgos del paciente
FASE DE ENTRADA
✔ PULSO-OXÍMETRO
Disponibilidad – Visible – Alarmas audibles
✔ ALERGIAS
Alergeno reconocido – Confirmar o informar
✔ VÍA AÉREA
Difícil: Técnica – Equipo VAD disponible – 2º persona
Aspiración: RGE – estomago lleno
FASE DE ENTRADA
✔ SANGRADO
> 500 mls – Niños > 7 mls/kgr
Cirugía – Anestesiología
2 venas periféricas grandes
Líquidos – Sangre DISPONIBLES
• INDUCCIÓN ANESTÉSICA
FASE DE PAUSA
PRE-INCISIÓN QUIRÚRGICA – CONFIRMACIÓN
TODO EL EQUIPO QUIRÚRGICO
✔ INTEGRANTES
Identificación – Función – Capacidades
✔ PACIENTE Verbal
Nombre – Procedimiento – Sitio - Posición
✔ EVENTOS CRÍTICOS
Peligros críticos – Plan Quirúrgico
FASE DE PAUSAFASE DE PAUSA
✔ CIRUGIA
Pasos Modificados – Duración – SangradoSangrado severo – Lesiones – Morbilidad mayor
✔ ANESTESIA
Ptos sanguineos – Características - Comorbilidades
✔ ENFERMERIA
Esterilización OK – Problemas de equipo
FASE DE PAUSA
✔ PROFILAXIS ANTIBIÓTICA
< 60 minutos – Aplicación vs RedosificarProcedimientos NO aplicable
✔ IMAGENES
Perioperatorias
Necesarias pero NO disponible
No aplicable
• INCISIÓN QUIRÚRGICA
FASE DE SALIDA
PRE-SALIDA DEL QX – INFORMAR AL PERSONAL DE LA
UCPA
✔ PROCEDIMIENTO REALIZADO
✔ CONTEO DE INSTRUMENTAL, GASAS Y AGUJAS
Curaciones – Basura – Herida - imagenes
✔ MUESTRA DE PATOLOGÍA
Paciente – Nombre – Descripción - Marcas
FASE DE SALIDA
✔ INSTRUMENTOS - EQUIPOS
✔ UCPA TODO EL EQUIPO QUIRÚRGICO
Plan de manejo – Eventos de riesgo específicos
en recuperación
• INFORMACIÓN APROPIADA A TODO EL EQUIPO
• HISTORIA CLÍNICA
• EVALUACIÓN DE CALIDAD DEL SERVICIO
London, UK EURO EMRO
WPRO I
SEARO
AFRO
PAHO I
Amman, JordanToronto, Canada
New Delhi, India
Manila, Philippines
Ifakara, Tanzania
WPRO II
Auckland, NZ
PAHO II
Seattle, USA
The Checklist was piloted in 8 cities…
VENTAJAS
• Adaptable a las necesidades específicas
• Implementación incremental?• Soportado por evidencia científica• Evaluado en diferentes condiciones• Asegura adherencia a prácticas
seguras• Mínimo consumo de recursos
POR QUE?POR QUE?
• SALVAVIDASSALVAVIDAS• Previene COMPLICACIONESCOMPLICACIONES• Disminuye COSTOSCOSTOS médicos por el
error• Participación institucional la red de
SOPORTESOPORTE internacional de LA LISTA DE LA LISTA DE CHEQUEOCHEQUEO
• Reconocimiento institucional como LIDERLIDER en SEGURIDAD DEL PACIENTESEGURIDAD DEL PACIENTE
BIBLIOGRAFIARealizar el Paciente y la cirugía CORRECTOS
• American Academy of Orthopaedic Surgery. "AAOS Advisory Statement on Wrong-Site Surgery." Retrieved 25 January, 2008, from http://www.aaos.org/about/papers/advistmt/1015.asp.
• American College of Surgeons (2002). "Statement on ensuring correct patient, correct site, and correct procedure surgery." Bulletin of the American College of Surgeons 87(12).
• Australian Commission on Safety and Quality in Healthcare. "Ensuring Correct Patient, Correct Site, Correct Procedure." Retrieved 23 August, 2007, from http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/content/former-pubs-archive-correct.
BIBLIOGRAFIARealizar el Paciente y la cirugía CORRECTOS
• Joint Commission. "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery." Retrieved 15 February, 2007, from http://www.jointcommission.org/PatientSafety/UniversalProtocol/.
• Kwaan, M. R., D. M. Studdert, et al. (2006). "Incidence, patterns, and prevention of wrong-site surgery." Arch Surg 141(4): 353-7; discussion 357-8.
• Joint Commission. "A follow-up review of wrong site surgery." Retrieved 3 May, 2007, from http://www.jointcommission.org/SentinelEvents/sentineleventalert/sea_24.htm
BIBLIOGRAFIAPrevenir los RIESGOS ANESTÉSICOS y evitar el DOLOR• Arbous, M. S., A. E. Meursing, et al. (2005). "Impact of
anesthesia management characteristics on severe morbidity and mortality." Anesthesiology 102: 257-68.
• Cooper, J. B., R. S. Newbower, et al. (1978). "Preventable anesthesia mishaps: a study of human factors." Anesthesiology 49(6): 399-406.
• Eichhorn, J. H., J. B. Cooper, et al. (1986). "Standards for patient monitoring during anesthesia at Harvard Medical School." Jama 256(8): 1017-20.
• Gaba, D. M., K. J. Fish, et al. (1994). Crisis Management in Anesthesiology. New York, Churchill Livingston.
• Hodges, S. C., C. Mijumbi, et al. (2007). "Anaesthesia services in developing countries: defining the problems." Anaesthesia 62(1): 4-11.
BIBLIOGRAFIAPrevenir los RIESGOS ANESTÉSICOS y evitar el DOLOR• International Task Force on Anaesthesia Safety (1993).
"International standards for a safe practice of anaesthesia." European Journal of Anaesthesiology 10 (Suppl. 7): 12-15.
• Runciman, W. B. (1993). "Risk assessment in the formulation of anaesthesia safety standards." European Journal of Anaesthesiology - Supplement 7: 26-32.
• Runciman, W. B. (2005). "Iatrogenic harm and anaesthesia in Australia." Anaesthesia & Intensive Care 33(3): 297-300.
• World Federation of Societies of Anaesthesiologists (WFSA). (Endorsed by the General Assembly of the WFSA at the 14th World Congress of Anaesthesiologists on 7 March 2008). "2008 International Standards for Safe Practice of Anaesthesia." Retrieved 26 May 2008, from http://www.anaesthesiologists.org
BIBLIOGRAFIAPrevenir y manejar los RIESGOS DE VÍA AÉREA: Difícil–
Aspiración
• (1993). "Practice Guidelines for Management of the Difficult Airway. A Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway." Anesthesiology 78: 597-602.
• Cormack, R. S. and J. Lehane (1984). "Difficult tracheal intubation in obstetrics." Anaesthesia 39(11): 1105-11.
• Crosby, E. T., R. M. Cooper, et al. (1998). "The unanticipated difficult airway with recommendations for management." Can J Anaesth 45(8): 757-76.
• Mallampati, S., S. Gatt, et al. (1985). "A clinical sign to predict difficult tracheal intubation: a prospective study." Can Anaesth Soc J 32: 429-434.
BIBLIOGRAFIAPrevenir y manejar los RIESGOS DE VÍA AÉREA: Difícil–
Aspiración
• Murphy, M. and D. J. Doyle (2008). Airway evaluation. Management of the Difficult and Failed Airway. O. Hung and M. Murphy. New York, McGraw Hill: 3-15.
• Paix, A. D., J. A. Williamson, et al. (2005). "Crisis management during anaesthesia: difficult intubation." Qual Saf Health Care 14(3): e5.
• Samsoon, G. and J. Young (1987). "Difficult tracheal intubation: a retrospective study. ." Anaesthesia 42: 487-490.
• Shiga, T., Z. Wajima, et al. (2005). "Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance." Anesthesiology 103(2): 429-37.
BIBLIOGRAFIAReconocer y preparar el manejo de SANGRADO MAYOR• American College of Surgeons: Committee on Trauma
(1997). Advanced Trauma Life Support for Doctors. Chicago, ACS.
• Feliciano, D., K. Mattox, et al. (2008). Trauma. New York, McGraw Hill.
• Gaba, D. M., K. J. Fish, et al. (1994). Crisis Management in Anesthesiology. New York, Churchill Livingston.
• Rivers, E., B. Nguyen, et al. (2001). "Early goal-directed therapy in the treatment of severe sepsis and septic shock." N Engl J Med 345(19): 1368-77.
• Rotondo, M. F., C. W. Schwab, et al. (1993). "'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury." J Trauma 35(3): 375-82; discussion 382-3.
• Shires, T., D. Coln, et al. (1964). "Fluid Therapy in Hemorrhagic Shock." Arch Surg 88: 688-93.
BIBLIOGRAFIAEvitar REACCIONES ALERGÍCAS y EFECTOS
FARMACOLÓGICOS ADVERSOS
• Baker, G. R., P. G. Norton, et al. (2004). "The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada." CMAJ Canadian Medical Association Journal 170(11): 1678-86.
• Bowdle, T. A. (2003). "Drug administration errors from the ASA Closed Claims Project." ASA Newsletter 67: 11-3.
• Jensen, L. S., A. F. Merry, et al. (2004). "Evidence-based strategies for preventing drug administration errors during anaesthesia." Anaesthesia 59(5): 493-504.
• Webster, C. S., A. F. Merry, et al. (2001). "The frequency and nature of drug administration error during anaesthesia." Anaesth Intensive Care 29(5): 494-500.
BIBLIOGRAFIAMinimizar riesgo de INFECCIÓN DE HERIDA
QUIRÚRGICA• Astagneau, P., C. Rioux, et al. (2001). "Morbidity and
mortality associated with surgical site infections: results from the 1997-1999 INCISO surveillance." J Hosp Infect 48(4): 267-74.
• Bratzler, D. W. and P. M. Houck (2004). "Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project." Clin Infect Dis 38(12): 1706
• Bratzler, D. W., P. M. Houck, et al. (2005). "Use of antimicrobial prophylaxis for major surgery: baseline results from the national surgical infection prevention project." Arch Surg 140(2): 174-82.-15.
BIBLIOGRAFIAMinimizar riesgo de INFECCIÓN DE HERIDA
QUIRÚRGICA
• Classen, D. C., R. S. Evans, et al. (1992). "The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection." N Engl J Med 326(5): 281-6.
• Dellinger, E. (1997). Surgical infections and choice of antibiotics. Textbook of surgery: the biological basis of modern surgical practice. D. Sabiston. Philadelphia, W.B. Saunders: 264-280.
• Dellinger, E. (1999). Nosocomial infection. American College of Surgeons. Care of the surgical patient. D. Wilmore, M. Brennan, A. Harken, J. Holcroft and J. Meakins. New York, Scientific American.
• Dellinger, E. P. (2007). "Prophylactic antibiotics: administration and timing before operation are more important than administration after operation." Clin Infect Dis 44(7): 928-30.
BIBLIOGRAFIA
Minimizar riesgo de INFECCIÓN DE HERIDA QUIRÚRGICA
• Dellinger, E. P., P. A. Gross, et al. (1994). "Quality standard for antimicrobial prophylaxis in surgical procedures. The Infectious Diseases Society of America." Infect Control Hosp Epidemiol 15(3): 182-8.
• Dellinger, E. P., S. M. Hausmann, et al. (2005). "Hospitals collaborate to decrease surgical site infections." Am J Surg 190(1): 9-15.
• Fry, D. (2003) Surgical site infection: Pathogenesis and prevention. Medscape Volume, DOI:
• Fry, D. E. (1995). Surgical Infections. Boston, Little, Brown and Company.
BIBLIOGRAFIAMinimizar riesgo de INFECCIÓN DE HERIDA
QUIRÚRGICA• Garibaldi, R. A., D. Skolnick, et al. (1988). "The impact of
preoperative skin disinfection on preventing intraoperative wound contamination." Infect Control Hosp Epidemiol 9(3): 109-13.
• Gaynes, R. P. (1998). Surveillance of nosocomial infections. Hospital Infections. J. V. Bennett and P. S. Brachman. Philadelphia, Lippincott-Raven Publishers: 65-84.
• Horan, T. C., D. H. Culver, et al. (1993). "Nosocomial infections in surgical patients in the United States, January 1986-June 1992. National Nosocomial Infections Surveillance (NNIS) System." Infection Control and Hospital Epidemiology 14(2): 73-80.
BIBLIOGRAFIAMinimizar riesgo de INFECCIÓN DE HERIDA
QUIRÚRGICA• Horan, T. C., R. P. Gaynes, et al. (1992). "CDC
definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections." Am J Infect Control 20: 271-274.
• Kurz, A., D. I. Sessler, et al. (1996). "Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group [see comments]." N Engl J Med 334(19): P 1209-15.
• Moro, M. L., F. Morsillo, et al. (2005). "Rates of surgical-site infection: an international comparison." Infect Control Hosp Epidemiol 26(5): 442-8.
BIBLIOGRAFIAMinimizar riesgo de INFECCIÓN DE HERIDA
QUIRÚRGICA• Rioux, C., B. Grandbastien, et al. (2007). "Impact of a six-
year control programme on surgical site infections in France: results of the INCISO surveillance." J Hosp Infect 66(3): 217-23.
• Smaill, F. and G. J. Hofmeyr (2002). "Antibiotic prophylaxis for cesarean section." Cochrane Database Syst Rev(3): CD000933. Stone, H. H., B. B. Haney, et al. (1979). "Prophylactic and preventive antibiotic therapy: timing, duration and economics." Ann Surg 189: 691-699.
• Sullivan, S. A., T. Smith, et al. (2007). "Administration of cefazolin prior to skin incision is superior to cefazolin at cord clamping in preventing postcesarean infectious morbidity: a randomized, controlled trial." Am J Obstet Gynecol 196(5): 455 e1-5.
BIBLIOGRAFIAMinimizar riesgo de INFECCIÓN DE HERIDA QUIRÚRGICA
• Van den Berghe, G., P. Wouters, et al. (2001). "Intensive insulin therapy in the critically ill patients.[see comment]." New England Journal of Medicine 345(19): 1359-67.
• Washington, J. A., 2nd, W. H. Dearing, et al. (1974). "Effect of preoperative antibiotic regimen on development of infection after intestinal surgery: Prospective, randomized, double-blind study." Ann Surg 180(4): 567-72.
• Wilson, A. P., T. Treasure, et al. (1986). "A scoring method (ASEPSIS) for postoperative wound infections for use in clinical trials of antibiotic prophylaxis." Lancet 1(8476): 311-3.
BIBLIOGRAFIAPrevenir la RETENCIÓN inadvertida de GASAS –
INSTRUMENTOS
• American College of Surgeons. "American College of Surgeons: Statement on the Prevention of Retained Foreign Bodies after Surgery." Retrieved 5 February, 2008, from http://www.facs.org/fellows_info/statements/st-51.html.
• Australian College of Operating Room Nurses and Association of peri-Operative Registered Nurses (2006). Counting of Accountable Items used during Surgery. Standards for Perioperative Nurses. ACORN: 1-12.
• Gawande, A. A., D. M. Studdert, et al. (2003). "Risk factors for retained instruments and sponges after surgery." N Engl J Med 348(3): 229-35.
BIBLIOGRAFIAIdentificar adecuadamente TODAS LAS MUESTRAS DE
PATOLOGÍA
• Howanitz, P. J. (2005). "Errors in laboratory medicine: practical lessons to improve patient safety." Arch.Pathol.Lab Med. 129(10): 1252-1261.
• Makary, M. A., J. Epstein, et al. (2007). "Surgical specimen identification errors: a new measure of quality in surgical care." Surgery 141(4): 450-455.
• Troxel, D. B. (2004). "Error in surgical pathology." Am.J.Surg.Pathol. 28(8): 1092-1095.
• Wagar, E. A., L. Tamashiro, et al. (2006). "Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors." Arch.Pathol.Lab Med. 130(11): 1662-1668.
BIBLIOGRAFIAComunicación adecuada para realizar una CIRUGÍA
SEGURA
• Greenberg, C. C., S. E. Regenbogen, et al. (2007). "Patterns of communication breakdowns resulting in injury to surgical patients." J Am Coll Surg 204(4): 533-40.
• Lingard, L., S. Espin, et al. (2005). "Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR." Qual.Saf Health Care 14(5): 340-346.
• Lingard, L., S. Espin, et al. (2004). "Communication failures in the operating room: an observational classification of recurrent types and effects." Qual.Saf Health Care 13(5): 330-334.
BIBLIOGRAFIAComunicación adecuada para realizar una
CIRUGÍA SEGURA
• Makary, M. A., C. G. Holzmueller, et al. (2006). "Operating room debriefings." Jt.Comm J.Qual.Patient.Saf 32(7): 407-10, 357.
• Makary, M. A., A. Mukherjee, et al. (2007). "Operating room briefings and wrong-site surgery." J.Am.Coll.Surg. 204(2): 236-243.
• Makary, M. A., J. B. Sexton, et al. (2006). "Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder." J.Am.Coll.Surg. 202(5): 746-752.
BIBLIOGRAFIAComunicación adecuada para realizar una
CIRUGÍA SEGURA
• Pronovost, P., D. Needham, et al. (2006). "An
intervention to decrease catheter-related
bloodstream infections in the ICU." N Engl J Med
355(26): 2725-32.• Reason, J. (1992). Human Error. Cambridge, Mass,
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human factors." Qual.Health Care 4(2): 80-89.• Reason, J. (2000). "Human error: models and
management." Bmj 320(7237): 768-70.
BIBLIOGRAFIAComunicación adecuada para realizar una
CIRUGÍA SEGURA
• Sexton, J. B., M. A. Makary, et al. (2006). "Teamwork
in the operating room: frontline perspectives among
hospitals and operating room personnel."
Anesthesiology 105(5): 877-884.
• Sexton, J. B., E. J. Thomas, et al. (2000). "Error,
stress, and teamwork in medicine and aviation: cross
sectional surveys." BMJ 320(7237): 745-749.
BIBLIOGRAFIAComunicación adecuada para realizar una
CIRUGÍA SEGURA
• Reason, J. (2002). "Combating omission errors
through task analysis and good reminders." Qual Saf
Health Care 11(1): 40-4.
• Thomas, E. J., J. B. Sexton, et al. (2003). "Discrepant
attitudes about teamwork among critical care nurses
and physicians." Crit Care Med. 31(3): 956-959.
BIBLIOGRAFIAEstablecer y difundir por las INSTITUCIONES y EL
SISTEMA DE SALUD INDICADORES DE GESTIÓN • Berwick, D. M. (1989). "Continuous improvement as
an ideal in health care." N Engl J Med 320(1): 53-6.• Berwick, D. M. (2003). "Disseminating innovations in
health care." Jama 289(15): 1969-75.• Berwick, D. M. (2008). "The science of improvement."
Jama 299(10): 1182-4.• Berwick, D. M., D. R. Calkins, et al. (2006). "The
100,000 lives campaign: setting a goal and a deadline for improving health care quality." Jama 295(3): 324-7.
• Burke, J. P. (2003). "Infection control - a problem for patient safety." N Engl J Med 348(7): 651-6.
BIBLIOGRAFIAEstablecer y difundir por las INSTITUCIONES y EL
SISTEMA DE SALUD INDICADORES DE GESTIÓN
• Donabedian, A. (1966). "Evaluating the Quality of Medical Care." Milbank Memorial Fund Quarterly 44:: 166—203.
• Donabedian, A. (1988). "The quality of care: how can it be assessed?" JAMA 260(12): 1743-1748.
• Gawande, A. A., M. R. Kwaan, et al. (2007). "An Apgar
score for surgery." J Am Coll Surg 204(2): 201-8.
• Health Metrics Network (2006). Framework and
standards for the development of country health
information systems, World Health Organisation.
BIBLIOGRAFIAEstablecer y difundir por las INSTITUCIONES y EL
SISTEMA DE SALUD INDICADORES DE GESTIÓN
• Regenbogen, S. E., R. T. Lancaster, et al. (2008). "Does the Surgical Apgar Score measure intraoperative performance?" Ann Surg (in press).
• Ronsmans, C. and W. J. Graham (2006). "Maternal mortality: who, when, where, and why." Lancet 368(9542): 1189-200.
• Weiser, T., S. Regenbogen, et al. "An estimation of
the global volume of surgery." (submitted).