Revista médica de Chile
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Revista médica de Chile · Nov 2017
[Clinical guidelines using the GRADE system (Grading of Recommendations Assessment, Development and Evaluation)].
The Ministry of Health of Chile, aiming to improve the quality of clinical practice guidelines, gradually incorporated the GRADE system (Grading of Recommendations, Assessment, Development and Evaluation) to develop evidence based recommendations. This system summarizes and evaluates the certainty of the available evidence. It moves from evidence to decision in a systematic and transparent manner, based on four main dimensions: balance between benefits and harms, certainty of evidence, patient's values and preferences and use of resources. ⋯ Conditional recommendations, however, indicate that there is a close balance between favorable and unfavorable consequences of the intervention, there is uncertainty in the magnitude of benefits or adverse effects, there is uncertainty or variability in values and preferences of individuals or costs are not justified. These recommendations apply to many patients, but not all of them: ideally they should be discussed with each person. To achieve a better implementation of the recommendations made with GRADE methodology, health professionals should know the meaning of strong and conditional recommendations and they should be able to critically assess of them.
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The trauma involved in any surgical procedure, even if elective, causes a metabolic stress response characterized by postoperative insulin resistance (PIR). PIR is considered a surgical stress marker and is associated with increased morbidity and postoperative length of stay. PIR worsens when the patient is operated in a state of prolonged preoperative fasting or when postoperative feeding is delayed. ⋯ The nutritional perioperative interventions in the ERAS protocols, focus on avoiding prolonged preoperative fasting by oral carbohydrate loading up to two hours before surgery, accompanied by early postoperative feeding through the digestive tube. These nutritional perioperative interventions are safe and effective to reduce complications and postoperative stay, even in patients with well controlled type 2 diabetes. Nevertheless, their implementation and compliance are rather low, therefore, we must continue to make efforts in order to change perioperative nutritional management of our patients to achieve the best possible postoperative recovery.
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Revista médica de Chile · Nov 2017
Review[Perioperative care of older patients with hip fractures].
The number of osteoporotic fractures is increasing along with population aging. Most patients with these type of fractures are older than 65 years, with multiple chronic conditions and different degrees of disability. Hip fracture is the most relevant osteoporotic fracture due to its frequency, costs, severity and complications. ⋯ We herein review the management of this fracture. Orthogeriatric joint management should be incorporated in fragility fracture treatment. We contribute with general recommendations for the perioperative management, which can be homologated for the management of older patients with other type of fragility fractures.
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Medical graduates face different postgraduate training options, but their priority is to obtain a primary medical specialty, defined as a specialty that does not derive from other. There are different specialty training programs in Chile, which can be dependent or independent of the Ministry of Health. ⋯ However a centralized information service that groups and synthetize these programs is lacking, hampering graduate choice decisions. This article aims to review all specialization program modalities, providing a general vision of the institutional structure and implications that govern the specialization process in Chile.