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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">The incidence and prevalence rates of patients requiring renal replacement therapy &#40;RRT&#41; have increased by more than 100&#37; over the past 15 years&#44; from 61 and 392 per million population &#40;pmp&#41; in 1991 to 132 and 1&#44;009 pmp in 2007&#44; respectively&#46;<span class="elsevierStyleSup">1</span> The age group that recorded a greater percentage increase in the prevalence rate is that of patients over 75 years of age &#40;from 8&#46;5&#37; in 1992 to 40&#37; today&#41;&#46; In this group&#44; most patients are treated with haemodialysis &#40;94&#37; of incident patients&#41; while few change techniques throughout their life&#46; To summarise&#44; we are seeing an increase in the demand for arteriovenous fistulas &#40;AVF&#41; for haemodialysis from nephrology departments&#46; It is therefore more complicated for the departments of surgery to maintain adequate quality of care indicators&#46; This is a national problem and some nephrology departments have decided to deal with it&#46;<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">We believe that the majority of surgical procedures for the creation and repair of AVF for haemodialysis can be performed on an outpatient basis&#44; including emergency thrombosis repair&#46; In this sense&#44; we achieve a decrease in hospital stay&#44; in unnecessary catheter use and in the waiting list of surgeries that are favoured&#46;</p><p class="elsevierStylePara">Since its inauguration&#44; our hospital has a programme of ambulatory surgery&#44; which is integrated in the overall activity of the department of surgery&#46; In addition&#44; this programme is supported by a multidisciplinary team dedicated to the care of vascular access for haemodialysis&#44; which consists of nephrologists&#44; general surgeons&#44; interventional radiologists and nursing professionals&#46; The aim of this group was to standardise the procedures related to vascular access for haemodialysis &#40;both its creation and maintenance&#41;&#44; as well as monitoring the results through the application of quality of care indicators&#46;<span class="elsevierStyleSup">3-5</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIAL AND METHODS</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Scope</span></p><p class="elsevierStylePara">Our hospital serves the vascular access for haemodialysis in a healthcare district in the Community of Madrid of 550&#44;000 inhabitants&#46; In addition&#44; it frequently serves the units in the provinces of Avila and Segovia &#40;250&#44;000 inhabitants&#41;&#46; Finally&#44; the hospital also performs procedures in other healthcare districts&#44; where we work temporarily &#40;Leganes&#44; Alcala de Henares&#44; Badajoz and Guadalajara&#41;&#46; In our hospital&#44; medical records are computerised and there is a specific protocol for interventions related to AVF&#44; which the surgeon in charge fills in after the intervention&#46; The activity was carried out within the overall functioning of the department of general surgery without a major ambulatory surgery unit &#40;MASU&#41;&#46; The interventions were performed by 4 surgeons of the department&#44; who were interested in the subject but without working exclusively on it &#40;its activity is that of any general surgeon&#41; and without being on special duty&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Patients</span></p><p class="elsevierStylePara">The study patients were referred for their first AVF to our department following a visit of advanced chronic kidney disease &#40;ACKD&#41;&#44; as well as from dialysis units in the case of patients who started haemodialysis without previous vascular access&#46; All patients were older than 18 years&#44; since there is no child surgery or nephrology unit in our hospital&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Preoperative evaluation and selection</span><span class="elsevierStyleBold">&#160;</span><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">Almost all patients were put on the waiting list for ambulatory surgery&#44; except in the following situations&#58;</p><li>No family&#47;companions&#46;</li><li>Anticoagulation &#40;an attempt was made to perform an outpatient reversal&#44; but this was not always feasible&#41;&#46;</li><li>Patient refusal&#46;</li><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">AVF thrombosis was considered a complication that should be addressed urgently &#40;within 24 to 36 hours&#44; depending on the patient&#8217;s clinical status&#41; to avoid the unnecessary use of catheters&#46; The emergency procedures were performed at the centre and the operating theatres of the emergency department&#46;</p><p class="elsevierStylePara">The emergency interventions comprised patients admitted with a higher rate of the following&#58;</p><li>Treatment of infections&#46;</li><li>Social reasons at the time of the surgery&#46;</li><li>Need to coordinate the procedure with the nephrology department&#46;</li><li>Increased percentage of suboptimal results that required observation or imaging tests&#46;</li><p class="elsevierStylePara"><span class="elsevierStyleBold">Surgical procedure</span></p><p class="elsevierStylePara">Almost all of the interventions &#40;regardless of the type of AVF and its location&#41; were carried out under local anaesthesia&#46;</p><p class="elsevierStylePara">We used 1&#37; mepivacaine in cases requiring a small volume of anaesthetic &#40;autologous fistulas&#41;&#44; and 0&#46;25&#37; bupivacaine cases where the surgical field was wider &#40;prosthetic fistulas or complex repairs&#41;&#46; We performed another anaesthetic technique &#40;locoregional or general&#41; in the following cases&#58;</p><li>Surgery for severe infections&#46;</li><li>Lack of patient cooperation&#46;</li><li>Need for extensive dissection&#46;</li><p class="elsevierStylePara">Where necessary&#44; a 6 mm expanded polytetrafluoroethylene &#40;ePTFE&#41; &#40;PTFE standard wall&#47;stretch&#44; Gore-tex<span class="elsevierStyleSup">&#174;</span>&#41; was the prosthesis used&#46;</p><p class="elsevierStylePara">The autologous AVF thrombosis was treated with proximal re-anastomosis or repair with prosthetic bridge&#46; The prosthetic AVF thrombosis was treated by performing a thrombectomy with Fogarty catheter and bridge to a proximal vein&#44; proximal artery or partial replacement of ePTFE according to the cause detected&#46; Fistulography was performed&#44; as well as radiology treatment through angioplasty of the stenosis&#44; if it was present&#44; when the origin of the thrombosis was not detected during surgery &#40;thrombectomy without difficulty and smooth functioning of the AVF&#41;&#46;</p><p class="elsevierStylePara">The cases of steal syndrome were treated with banding or ligation of the AVF&#44; according to the severity of the symptoms and the possibility of rescuing the access&#46;</p><p class="elsevierStylePara">The prosthetic infections were treated with complete removal of the graft and arterial repair with a vein patch&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Surgical protocol</span><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">Following the intervention&#44; all interventions were recorded prospectively in a specific form with the following paragraphs&#58;</p><li>Demographics &#40;age&#44; gender&#44; referring hospital&#44; medical history number&#44; date of intervention&#41;&#46;</li><li>Nature of the intervention &#40;emergency or scheduled&#41;&#46;</li><li>Type of hospitalisation &#40;MASU or hospital admission&#41;&#46;</li><li>Diagnosis &#40;first access&#44; dysfunction&#44; etc&#46;&#41;&#46;</li><li>Current AVF type &#40;in repairs&#41;&#46;</li><p class="elsevierStylePara"><span class="elsevierStyleBold">Postoperative protocol</span><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">The patients are transferred from the operating room to the day hospital&#44; where they stayed for an average of two hours for observation&#46; The nursing staff checked the proper functioning of the access&#46; The patients were discharged if the constant values were normal and there were no complications&#46; They subsequently go to nursing and nephrology consultations to decide the start of the punctures&#46; Concerning autologous AVF&#44; the delay is at least 4 weeks&#46; The prosthetic AVFs are punctured in no less than 2 weeks if the patient needs them due to a malfunctioning catheter&#44; although the guidelines recommend delaying punctures up to 4 weeks &#40;we have not found complications secondary to a puncture at 2 weeks&#41;&#46;</p><p class="elsevierStylePara">In addition&#44; we prospectively filled in a form to know the percentage of unscheduled hospitalisations related to complications &#40;patients initially scheduled for ambulatory surgery&#41;&#44; the average postoperative hospital stay and the hospitalisation days in patients who required hospital stay&#44; so that they could be analysed as an indicator &#40;rate of hospitalisation and days of hospitalisation&#47;patient&#47;year&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Compliance</span></p><p class="elsevierStylePara">We reviewed all surgical protocols and forms on MASU created between 1998 and 2009 to discuss the types of intervention performed and their ambulatory implementation level&#46;</p><p class="elsevierStylePara">Nurses and nephrologists in charge of the unit performed the monitoring of AVF malfunctions and&#44; where necessary&#44; they requested a fistulography&#46;&#160;</p><p class="elsevierStylePara">Access thrombosis was considered a complication that should be addressed immediately within 24 hours to avoid the unnecessary use of catheters&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara">Since the opening of our hospital in 1998 until December 2009&#44; a total of 2&#44;410 interventions were performed in 1&#44;229 patients &#40;1&#46;96 interventions per patient&#41; for the creation or repair of AVF&#46;</p><p class="elsevierStylePara">This type of intervention represented 22&#37; &#40;13-36&#37;&#41; of the total activity of ambulatory surgery&#44; which belongs to the department of surgery&#44; during this decade&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Demographic characteristics</span></p><li>Age&#58; a mean of 68 years &#40;range&#58; 17-90&#41; with 40&#37; over 75 years&#46;</li><li>Gender&#58; 61&#37; male and 39&#37; female&#46;</li><li>Charlson comorbidity index mean&#58; 6&#46;</li><p class="elsevierStylePara">The most frequent surgery &#40;59&#37;&#41; was the creation of a new vascular access&#44; performing 88&#46;5&#37; with no hospitalisation&#46; Repairs &#40;41&#37; of the total interventions&#41; were performed as ambulatory surgeries in 73&#37; &#40;Table 1&#41;</p><p class="elsevierStylePara">Local anaesthesia was used in 98&#46;8&#37; of the interventions&#44; general anaesthesia in 0&#46;8&#37; and locoregional anaesthesia in 0&#46;3&#37;&#46;</p><p class="elsevierStylePara">The interventions were chosen in 74&#46;8&#37; of the cases&#46; The rest &#40;25&#46;2&#37;&#41; were performed urgently in the first 24 to 36 hours of the incident in 80&#37; of thromboses&#44; thus achieving the rescue of the AVF in 80&#37; of the cases&#46; The interventions were carried out by 3 surgeons from the department of general surgery&#46; With their on-duty days &#40;5 days per month per surgeon&#41;&#44; care was covered for 50&#37; of the days&#46;</p><p class="elsevierStylePara">A total of 1&#44;980 interventions were carried out without hospitalisation &#40;82&#37;&#41;&#46; Ambulatory surgery was 89&#37; when the surgery was scheduled&#46; Concerning emergency surgery&#44; ambulatory surgery accounted for 60&#37;&#46;</p><p class="elsevierStylePara">Unscheduled hospitalisations were 6&#37; &#40;the most frequent causes involved early malfunction of the access and haemorrhage&#41;&#46;</p><p class="elsevierStylePara">The mean postoperative hospital stay was 112 min&#44; while there were no postoperative deaths&#46;</p><p class="elsevierStylePara">The number of admissions in relation to AVF surgery &#40;excluding admissions related to catheters&#41; in our health district was 0&#46;09 per patient per year&#46; The average hospital stay in our hospital associated with surgery for arteriovenous AVFs for haemodialysis was 0&#46;2 days per patient per year&#46; These admissions constitute 12&#37; of all admissions of patients on haemodialysis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">Surgery departments are facing a major healthcare challenge generated by the increasing number of patients on haemodialysis&#46;<span class="elsevierStyleSup">1&#44;2</span> The maintenance of appropriate quality indicators gives rise to a high number of surgeries per year&#44; which leads to an increase in waiting lists and occupancy of hospital beds&#46; In our experience&#44; this constitutes the second most common disease operated with ambulatory surgery &#40;this is partly due to the performance of AVF surgery at other centres&#46;&#41; This is an important intervention for the outcome of patients on haemodialysis&#44; and it is a well-known factor which has a significant impact on the survival of patients on haemodialysis&#46;<span class="elsevierStyleSup">6&#44;7</span></p><p class="elsevierStylePara">Both the creation and repair of an AVF are technically complex surgeries&#44; which should be performed by trained surgeons&#46; However&#44; they are carried out in a surgical field that is limited in size and depth&#44; which allows for the use of local anaesthesia&#46; The technical results can be assessed immediately&#58; haemorrhage and early failure of the access can be treated in the same episode&#44; thus maintaining ambulatory surgery in some cases&#46; The patient hospitalisation does not modify the frequency of appearance of other late complications &#40;infection or steal syndrome&#41;&#46; For all these reasons&#44; with a few exceptions&#44; surgery related to AVFs can be performed without problems in ambulatory surgery&#46;<span class="elsevierStyleSup">9-16</span></p><p class="elsevierStylePara">Ambulatory surgery can be arranged at a hospital as an activity or as a separate unit&#46; Due to the characteristics of our hospital&#44; in our case it is organised as an activity within the department of general surgery&#44; since there is no unit of ambulatory surgery&#46;</p><p class="elsevierStylePara">Approximately 60&#37; of the interventions were carried out for the creation of an access and 40&#37; to treat malfunctions&#46; When a patient was operated to create a new vascular access&#44; the percentage was closer to 90&#37;&#44; including the placement of prosthetic parts&#46; The intervention with the smallest percentage is the treatment of infections of the vascular access with systemic impact &#40;2&#37; of interventions&#41;&#44; which in our experience require complex surgical procedures for the removal of the access and vascular repair&#46; In these cases&#44; 100&#37; of the patients were admitted&#44; while general or locoregional anaesthesia was mostly used&#46;</p><p class="elsevierStylePara">In surgical emergencies&#44; ambulatory surgery was more complex&#59; however&#44; we managed to perform it in approximately 60&#37; of the interventions&#46;</p><p class="elsevierStylePara">Some of the reasons for hospital admission &#40;emergency surgery&#44; social problems and suspected early malfunction&#41; could be avoided&#59; however&#44; this requires a greater allocation of resources for the continuous attention of the departments involved&#46;</p><p class="elsevierStylePara">We believe that one of the pillars of the high percentage of patients treated as outpatients is the use of local anaesthesia in the vast majority of interventions &#40;98&#46;8&#37;&#41;&#46; We found no adverse reactions related to the use of 1&#37; mepivacaine or 0&#46;25&#37; bupivacaine&#46; We have therefore avoided any possible admissions associated with anaesthesia complications&#46;</p><p class="elsevierStylePara">In this series&#44; the unscheduled hospitalisations &#40;6&#37;&#41; were mostly secondary to surgical complications &#40;haemorrhage and malfunction in 90&#37; of the cases&#41;&#46; Haemorrhagic complications were primarily self-limited hematomas&#44; and in very few cases required review surgery&#44; where patients were admitted for observation&#46; The other most common reason for admission was observation following the review of an access with early failure or malfunction &#40;in these cases&#44; the surgeon decided to admit the patient with empiric heparinisation for a few hours&#41;&#46; In most cases&#44; hospital admission was limited to a 24-hour observation&#46;</p><p class="elsevierStylePara">The results of our group regarding ambulatory percentages are comparable to those referred to in previous publications<span class="elsevierStyleSup">17-26</span> by reference groups&#46; However&#44; it should be noted that the activity was carried out under the overall functioning of the department of general surgery without a specific MASU unit by a number of surgeons interested in the subject but not working exclusively on this &#40;their activity is that of any general surgeon&#41; and without being on special duty&#46;</p><p class="elsevierStylePara">To conclude&#44; we believe this working protocol has a clear impact on the reduction of hospitalisations related to vascular access complications&#44; which in our experience is inferior to those mentioned in other publications&#44;<span class="elsevierStyleSup">27-29</span> concerning both the rate of hospitalisations as days of hospitalisation and the cause of admission compared with other diseases&#46; These results can be improved&#44; especially in cases of emergency surgery attempting to rescue the majority of the AVFs&#46; Nevertheless&#44; this requires the presence of a coordinator and special on-duty days for the members of the working group &#40;surgery&#44; nephrology&#44; interventional radiology and nursing in dialysis&#41;&#46;</p><p class="elsevierStylePara"><a href="10420&#95;108&#95;7533&#95;en&#95;w477710399410420&#95;tabla1&#95;en&#46;doc" class="elsevierStyleCrossRefs">10420&#95;108&#95;7533&#95;en&#95;w477710399410420&#95;tabla1&#95;en&#46;doc</a></p><p class="elsevierStylePara">Table 1&#46; Type of surgical interventions </p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introducci&#243;n&#58; </span>El aumento de pacientes que precisan tratamiento renal sustitutivo&#44; sobre todo en el grupo de pacientes sometidos a hemodi&#225;lisis&#44; supone un reto en incremento de actividad y de ocupaci&#243;n de recursos para los servicios de cirug&#237;a&#46; Las complicaciones relacionadas con los accesos vasculares son la causa fundamental de ingresos en muchas unidades de di&#225;lisis&#46; La cirug&#237;a sin ingreso puede disminuir la ocupaci&#243;n de camas hospitalarias&#44; reduce la lista de espera y las complicaciones relacionadas con un ingreso innecesario&#46;&#160;<span class="elsevierStyleBold">Material y m&#233;todos&#58; </span>Hemos realizado un estudio prospectivo de las intervenciones realizadas en el per&#237;odo 1998-2009 para la creaci&#243;n o la reparaci&#243;n de f&#237;stulas arteriovenosas &#40;FAV&#41; para hemodi&#225;lisis&#44; con el objetivo de conocer el nivel de ambulatorizaci&#243;n&#44; resultados&#44; complicaciones y su posible impacto en la tasa de ingresos de los pacientes en hemodi&#225;lisis&#46; La actividad fue realizada dentro del funcionamiento global del servicio de cirug&#237;a general sin unidad espec&#237;fica de cirug&#237;a mayor ambulatoria &#40;CMA&#41;&#46; Las intervenciones las realizaron varios cirujanos del servicio interesados en el tema&#44; pero sin dedicaci&#243;n exclusiva a &#233;ste &#40;su actividad es la de cualquier cirujano general&#41; y sin guardias espec&#237;ficas&#46; La cirug&#237;a ambulatoria se organiz&#243; dentro de la actividad ordinaria del servicio de cirug&#237;a general sin una unidad espec&#237;fica&#44; ni cirujanos especialmente dedicados a la misma&#46; <span class="elsevierStyleBold">Resultados&#58; </span>Desde la apertura de nuestro hospital en 1998 hasta diciembre de 2009 hemos realizado un total de 2&#46;413 intervenciones en 1&#46;229 pacientes &#40;primeros accesos y reparaciones de los mismos&#41;&#46; La cirug&#237;a programada supuso el 74&#44;8&#37; de las intervenciones&#59; el 25&#44;2&#37; restante fueron intervenciones urgentes&#46; El porcentaje global cirug&#237;a ambulatoria fue del 82&#37; &#40;89&#37; en cirug&#237;a programada y 60&#37; en cirug&#237;a urgente&#41;&#46; Se produjeron un 6&#37; de ingresos imprevistos&#46; No hubo mortalidad postoperatoria&#46; El n&#250;mero de ingresos fue de 0&#44;09 episodios por paciente a&#241;o con una estancia media de 0&#44;2 d&#237;as por paciente y a&#241;o&#46; <span class="elsevierStyleBold">Conclusiones&#58;</span> La mayor&#237;a de las intervenciones relacionadas con las FAV&#44; incluso la cirug&#237;a urgente&#44; se pueden realizar en r&#233;gimen ambulatorio dentro de la actividad habitual de un servicio de cirug&#237;a&#46; Se evitan as&#237; costes asociados con la ocupaci&#243;n de camas hospitalarias y se disminuyen las complicaciones relacionadas con el ingreso&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Introduction&#58;</span> The increase of prevalent haemodialysis patients is a challenge for surgery units&#46; Vascular access related complications are the main cause of hospital admissions in many dialysis units&#46; Outpatient surgery could decrease waiting lists&#44; cost and complications associated to vascular access&#46; <span class="elsevierStyleBold">Material and methods&#58;</span> We have performed a prospective study of the vascular access related surgery in a ten year period&#46; Outpatient surgery was included with the rest of the activity in a general surgery unit and was performed by not exclusive dedicated surgeons&#46; <span class="elsevierStyleBold">Results&#58;</span> Since 1998 to December 2009 we performed 2&#44;413 surgical interventions for creating and repairing arteriovenous fistula in 1&#44;229 patients&#44; including elective and emergency surgery &#40;74&#46;8&#37; and 25&#46;2&#37; respectively&#41;&#46; Outpatient procedures were performed in 82&#37; of cases &#40;89&#37; in elective and 60&#37; in emergency surgery&#41;&#46; There were unexpected admissions secondary to surgical complications in 6&#37; of patients&#46; There was no postoperative mortality&#46; The rate of admissions was 0&#46;09 events and 0&#46;2 days per patient&#47;year&#46; <span class="elsevierStyleBold">Conclusions&#58;</span> Outpatient surgery is possible in a high percentage of patients to perform or to repair an arteriovenous fistula&#44; including emergency surgery&#46; Vascular access surgery can be included in ordinary activity of a surgical unit&#46; Outpatient vascular access surgery decreases unnecessary hospital admissions&#44; reduces costs and nosocomial complications&#46;</span></p>"
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                  "referenciaCompleta" => "Sociedad Española de Nefrología. Diálisis y trasplante en España. Informe preliminar del Registro Español de Enfermos Renales (2007). XXXVIII Congreso Nacional de la Sociedad Española de Nefrología."
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                  "referenciaCompleta" => "García-Trío G, Alonso M, Saavedra J, Cigarrán S, Lamas JM. Gestión integral del acceso vascular por los nefrólogos. Resultados de tres años de trabajo. Nefrologia 2007;27:335-9.  <a href="http://www.ncbi.nlm.nih.gov/pubmed/17725453" target="_blank">[Pubmed]</a>"
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                  "referenciaCompleta" => "Jiménez-Almonacid P, Gruss E, Lorenzo S, Lasala M,Hernández MT, Portolés J, et al.\u{A0}Definición de procesos e indicadores para la gestión de accesos vasculares para hemodiálisis. Cir Esp 2007;81(5):257-63.  <a href="http://www.ncbi.nlm.nih.gov/pubmed/17498454" target="_blank">[Pubmed]</a>"
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                  "referenciaCompleta" => "López Revuelta K, Barril G, Caramelo C, Delgado R, García F, García J, et al.\u{A0}Grupo de gestión de calidad SEN: Álvarez Ude F, Angoso M, Aranaz J, Arenas MD, Lorenzo S, López Revuelta K. Developing a clinical performance measures system for hemodialysis, quality group, spanish society of nephrology. Nefrologia 2007;27(5):542-59. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18045030" target="_blank">[Pubmed]</a>"
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Ambulatory surgery of patients with arteriovenous fistulas for haemodialysis. Integrated activity in a department of general surgery
Cirugía sin ingreso de pacientes con fístulas arteriovenosas para hemodiálisis. Actividad integrada en un servicio de cirugía general
P.. Jiménez-Almonacida, M.. Lasalaa, J.A.. Ruedaa, E.. Grussb, P.. Hernándeza, M.. Pardoa, A.. Tatob, M.. Ramosa, M.. Jiméneza, L.. Vegaa, J.M.. Fernández-Cebriána, J.M.. Portolésb, A.. Quintánsa
a Unidad de Cirugía General y del Aparato Digestivo, Fundación Hospital Universitario Alcorcón, Alcorcón, Madrid,
b Unidad de Nefrología, Fundación Hospital Universitario Alcorcón, Alcorcón, Madrid,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">The incidence and prevalence rates of patients requiring renal replacement therapy &#40;RRT&#41; have increased by more than 100&#37; over the past 15 years&#44; from 61 and 392 per million population &#40;pmp&#41; in 1991 to 132 and 1&#44;009 pmp in 2007&#44; respectively&#46;<span class="elsevierStyleSup">1</span> The age group that recorded a greater percentage increase in the prevalence rate is that of patients over 75 years of age &#40;from 8&#46;5&#37; in 1992 to 40&#37; today&#41;&#46; In this group&#44; most patients are treated with haemodialysis &#40;94&#37; of incident patients&#41; while few change techniques throughout their life&#46; To summarise&#44; we are seeing an increase in the demand for arteriovenous fistulas &#40;AVF&#41; for haemodialysis from nephrology departments&#46; It is therefore more complicated for the departments of surgery to maintain adequate quality of care indicators&#46; This is a national problem and some nephrology departments have decided to deal with it&#46;<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">We believe that the majority of surgical procedures for the creation and repair of AVF for haemodialysis can be performed on an outpatient basis&#44; including emergency thrombosis repair&#46; In this sense&#44; we achieve a decrease in hospital stay&#44; in unnecessary catheter use and in the waiting list of surgeries that are favoured&#46;</p><p class="elsevierStylePara">Since its inauguration&#44; our hospital has a programme of ambulatory surgery&#44; which is integrated in the overall activity of the department of surgery&#46; In addition&#44; this programme is supported by a multidisciplinary team dedicated to the care of vascular access for haemodialysis&#44; which consists of nephrologists&#44; general surgeons&#44; interventional radiologists and nursing professionals&#46; The aim of this group was to standardise the procedures related to vascular access for haemodialysis &#40;both its creation and maintenance&#41;&#44; as well as monitoring the results through the application of quality of care indicators&#46;<span class="elsevierStyleSup">3-5</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIAL AND METHODS</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Scope</span></p><p class="elsevierStylePara">Our hospital serves the vascular access for haemodialysis in a healthcare district in the Community of Madrid of 550&#44;000 inhabitants&#46; In addition&#44; it frequently serves the units in the provinces of Avila and Segovia &#40;250&#44;000 inhabitants&#41;&#46; Finally&#44; the hospital also performs procedures in other healthcare districts&#44; where we work temporarily &#40;Leganes&#44; Alcala de Henares&#44; Badajoz and Guadalajara&#41;&#46; In our hospital&#44; medical records are computerised and there is a specific protocol for interventions related to AVF&#44; which the surgeon in charge fills in after the intervention&#46; The activity was carried out within the overall functioning of the department of general surgery without a major ambulatory surgery unit &#40;MASU&#41;&#46; The interventions were performed by 4 surgeons of the department&#44; who were interested in the subject but without working exclusively on it &#40;its activity is that of any general surgeon&#41; and without being on special duty&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Patients</span></p><p class="elsevierStylePara">The study patients were referred for their first AVF to our department following a visit of advanced chronic kidney disease &#40;ACKD&#41;&#44; as well as from dialysis units in the case of patients who started haemodialysis without previous vascular access&#46; All patients were older than 18 years&#44; since there is no child surgery or nephrology unit in our hospital&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Preoperative evaluation and selection</span><span class="elsevierStyleBold">&#160;</span><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">Almost all patients were put on the waiting list for ambulatory surgery&#44; except in the following situations&#58;</p><li>No family&#47;companions&#46;</li><li>Anticoagulation &#40;an attempt was made to perform an outpatient reversal&#44; but this was not always feasible&#41;&#46;</li><li>Patient refusal&#46;</li><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">AVF thrombosis was considered a complication that should be addressed urgently &#40;within 24 to 36 hours&#44; depending on the patient&#8217;s clinical status&#41; to avoid the unnecessary use of catheters&#46; The emergency procedures were performed at the centre and the operating theatres of the emergency department&#46;</p><p class="elsevierStylePara">The emergency interventions comprised patients admitted with a higher rate of the following&#58;</p><li>Treatment of infections&#46;</li><li>Social reasons at the time of the surgery&#46;</li><li>Need to coordinate the procedure with the nephrology department&#46;</li><li>Increased percentage of suboptimal results that required observation or imaging tests&#46;</li><p class="elsevierStylePara"><span class="elsevierStyleBold">Surgical procedure</span></p><p class="elsevierStylePara">Almost all of the interventions &#40;regardless of the type of AVF and its location&#41; were carried out under local anaesthesia&#46;</p><p class="elsevierStylePara">We used 1&#37; mepivacaine in cases requiring a small volume of anaesthetic &#40;autologous fistulas&#41;&#44; and 0&#46;25&#37; bupivacaine cases where the surgical field was wider &#40;prosthetic fistulas or complex repairs&#41;&#46; We performed another anaesthetic technique &#40;locoregional or general&#41; in the following cases&#58;</p><li>Surgery for severe infections&#46;</li><li>Lack of patient cooperation&#46;</li><li>Need for extensive dissection&#46;</li><p class="elsevierStylePara">Where necessary&#44; a 6 mm expanded polytetrafluoroethylene &#40;ePTFE&#41; &#40;PTFE standard wall&#47;stretch&#44; Gore-tex<span class="elsevierStyleSup">&#174;</span>&#41; was the prosthesis used&#46;</p><p class="elsevierStylePara">The autologous AVF thrombosis was treated with proximal re-anastomosis or repair with prosthetic bridge&#46; The prosthetic AVF thrombosis was treated by performing a thrombectomy with Fogarty catheter and bridge to a proximal vein&#44; proximal artery or partial replacement of ePTFE according to the cause detected&#46; Fistulography was performed&#44; as well as radiology treatment through angioplasty of the stenosis&#44; if it was present&#44; when the origin of the thrombosis was not detected during surgery &#40;thrombectomy without difficulty and smooth functioning of the AVF&#41;&#46;</p><p class="elsevierStylePara">The cases of steal syndrome were treated with banding or ligation of the AVF&#44; according to the severity of the symptoms and the possibility of rescuing the access&#46;</p><p class="elsevierStylePara">The prosthetic infections were treated with complete removal of the graft and arterial repair with a vein patch&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Surgical protocol</span><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">Following the intervention&#44; all interventions were recorded prospectively in a specific form with the following paragraphs&#58;</p><li>Demographics &#40;age&#44; gender&#44; referring hospital&#44; medical history number&#44; date of intervention&#41;&#46;</li><li>Nature of the intervention &#40;emergency or scheduled&#41;&#46;</li><li>Type of hospitalisation &#40;MASU or hospital admission&#41;&#46;</li><li>Diagnosis &#40;first access&#44; dysfunction&#44; etc&#46;&#41;&#46;</li><li>Current AVF type &#40;in repairs&#41;&#46;</li><p class="elsevierStylePara"><span class="elsevierStyleBold">Postoperative protocol</span><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">The patients are transferred from the operating room to the day hospital&#44; where they stayed for an average of two hours for observation&#46; The nursing staff checked the proper functioning of the access&#46; The patients were discharged if the constant values were normal and there were no complications&#46; They subsequently go to nursing and nephrology consultations to decide the start of the punctures&#46; Concerning autologous AVF&#44; the delay is at least 4 weeks&#46; The prosthetic AVFs are punctured in no less than 2 weeks if the patient needs them due to a malfunctioning catheter&#44; although the guidelines recommend delaying punctures up to 4 weeks &#40;we have not found complications secondary to a puncture at 2 weeks&#41;&#46;</p><p class="elsevierStylePara">In addition&#44; we prospectively filled in a form to know the percentage of unscheduled hospitalisations related to complications &#40;patients initially scheduled for ambulatory surgery&#41;&#44; the average postoperative hospital stay and the hospitalisation days in patients who required hospital stay&#44; so that they could be analysed as an indicator &#40;rate of hospitalisation and days of hospitalisation&#47;patient&#47;year&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Compliance</span></p><p class="elsevierStylePara">We reviewed all surgical protocols and forms on MASU created between 1998 and 2009 to discuss the types of intervention performed and their ambulatory implementation level&#46;</p><p class="elsevierStylePara">Nurses and nephrologists in charge of the unit performed the monitoring of AVF malfunctions and&#44; where necessary&#44; they requested a fistulography&#46;&#160;</p><p class="elsevierStylePara">Access thrombosis was considered a complication that should be addressed immediately within 24 hours to avoid the unnecessary use of catheters&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara">Since the opening of our hospital in 1998 until December 2009&#44; a total of 2&#44;410 interventions were performed in 1&#44;229 patients &#40;1&#46;96 interventions per patient&#41; for the creation or repair of AVF&#46;</p><p class="elsevierStylePara">This type of intervention represented 22&#37; &#40;13-36&#37;&#41; of the total activity of ambulatory surgery&#44; which belongs to the department of surgery&#44; during this decade&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Demographic characteristics</span></p><li>Age&#58; a mean of 68 years &#40;range&#58; 17-90&#41; with 40&#37; over 75 years&#46;</li><li>Gender&#58; 61&#37; male and 39&#37; female&#46;</li><li>Charlson comorbidity index mean&#58; 6&#46;</li><p class="elsevierStylePara">The most frequent surgery &#40;59&#37;&#41; was the creation of a new vascular access&#44; performing 88&#46;5&#37; with no hospitalisation&#46; Repairs &#40;41&#37; of the total interventions&#41; were performed as ambulatory surgeries in 73&#37; &#40;Table 1&#41;</p><p class="elsevierStylePara">Local anaesthesia was used in 98&#46;8&#37; of the interventions&#44; general anaesthesia in 0&#46;8&#37; and locoregional anaesthesia in 0&#46;3&#37;&#46;</p><p class="elsevierStylePara">The interventions were chosen in 74&#46;8&#37; of the cases&#46; The rest &#40;25&#46;2&#37;&#41; were performed urgently in the first 24 to 36 hours of the incident in 80&#37; of thromboses&#44; thus achieving the rescue of the AVF in 80&#37; of the cases&#46; The interventions were carried out by 3 surgeons from the department of general surgery&#46; With their on-duty days &#40;5 days per month per surgeon&#41;&#44; care was covered for 50&#37; of the days&#46;</p><p class="elsevierStylePara">A total of 1&#44;980 interventions were carried out without hospitalisation &#40;82&#37;&#41;&#46; Ambulatory surgery was 89&#37; when the surgery was scheduled&#46; Concerning emergency surgery&#44; ambulatory surgery accounted for 60&#37;&#46;</p><p class="elsevierStylePara">Unscheduled hospitalisations were 6&#37; &#40;the most frequent causes involved early malfunction of the access and haemorrhage&#41;&#46;</p><p class="elsevierStylePara">The mean postoperative hospital stay was 112 min&#44; while there were no postoperative deaths&#46;</p><p class="elsevierStylePara">The number of admissions in relation to AVF surgery &#40;excluding admissions related to catheters&#41; in our health district was 0&#46;09 per patient per year&#46; The average hospital stay in our hospital associated with surgery for arteriovenous AVFs for haemodialysis was 0&#46;2 days per patient per year&#46; These admissions constitute 12&#37; of all admissions of patients on haemodialysis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">Surgery departments are facing a major healthcare challenge generated by the increasing number of patients on haemodialysis&#46;<span class="elsevierStyleSup">1&#44;2</span> The maintenance of appropriate quality indicators gives rise to a high number of surgeries per year&#44; which leads to an increase in waiting lists and occupancy of hospital beds&#46; In our experience&#44; this constitutes the second most common disease operated with ambulatory surgery &#40;this is partly due to the performance of AVF surgery at other centres&#46;&#41; This is an important intervention for the outcome of patients on haemodialysis&#44; and it is a well-known factor which has a significant impact on the survival of patients on haemodialysis&#46;<span class="elsevierStyleSup">6&#44;7</span></p><p class="elsevierStylePara">Both the creation and repair of an AVF are technically complex surgeries&#44; which should be performed by trained surgeons&#46; However&#44; they are carried out in a surgical field that is limited in size and depth&#44; which allows for the use of local anaesthesia&#46; The technical results can be assessed immediately&#58; haemorrhage and early failure of the access can be treated in the same episode&#44; thus maintaining ambulatory surgery in some cases&#46; The patient hospitalisation does not modify the frequency of appearance of other late complications &#40;infection or steal syndrome&#41;&#46; For all these reasons&#44; with a few exceptions&#44; surgery related to AVFs can be performed without problems in ambulatory surgery&#46;<span class="elsevierStyleSup">9-16</span></p><p class="elsevierStylePara">Ambulatory surgery can be arranged at a hospital as an activity or as a separate unit&#46; Due to the characteristics of our hospital&#44; in our case it is organised as an activity within the department of general surgery&#44; since there is no unit of ambulatory surgery&#46;</p><p class="elsevierStylePara">Approximately 60&#37; of the interventions were carried out for the creation of an access and 40&#37; to treat malfunctions&#46; When a patient was operated to create a new vascular access&#44; the percentage was closer to 90&#37;&#44; including the placement of prosthetic parts&#46; The intervention with the smallest percentage is the treatment of infections of the vascular access with systemic impact &#40;2&#37; of interventions&#41;&#44; which in our experience require complex surgical procedures for the removal of the access and vascular repair&#46; In these cases&#44; 100&#37; of the patients were admitted&#44; while general or locoregional anaesthesia was mostly used&#46;</p><p class="elsevierStylePara">In surgical emergencies&#44; ambulatory surgery was more complex&#59; however&#44; we managed to perform it in approximately 60&#37; of the interventions&#46;</p><p class="elsevierStylePara">Some of the reasons for hospital admission &#40;emergency surgery&#44; social problems and suspected early malfunction&#41; could be avoided&#59; however&#44; this requires a greater allocation of resources for the continuous attention of the departments involved&#46;</p><p class="elsevierStylePara">We believe that one of the pillars of the high percentage of patients treated as outpatients is the use of local anaesthesia in the vast majority of interventions &#40;98&#46;8&#37;&#41;&#46; We found no adverse reactions related to the use of 1&#37; mepivacaine or 0&#46;25&#37; bupivacaine&#46; We have therefore avoided any possible admissions associated with anaesthesia complications&#46;</p><p class="elsevierStylePara">In this series&#44; the unscheduled hospitalisations &#40;6&#37;&#41; were mostly secondary to surgical complications &#40;haemorrhage and malfunction in 90&#37; of the cases&#41;&#46; Haemorrhagic complications were primarily self-limited hematomas&#44; and in very few cases required review surgery&#44; where patients were admitted for observation&#46; The other most common reason for admission was observation following the review of an access with early failure or malfunction &#40;in these cases&#44; the surgeon decided to admit the patient with empiric heparinisation for a few hours&#41;&#46; In most cases&#44; hospital admission was limited to a 24-hour observation&#46;</p><p class="elsevierStylePara">The results of our group regarding ambulatory percentages are comparable to those referred to in previous publications<span class="elsevierStyleSup">17-26</span> by reference groups&#46; However&#44; it should be noted that the activity was carried out under the overall functioning of the department of general surgery without a specific MASU unit by a number of surgeons interested in the subject but not working exclusively on this &#40;their activity is that of any general surgeon&#41; and without being on special duty&#46;</p><p class="elsevierStylePara">To conclude&#44; we believe this working protocol has a clear impact on the reduction of hospitalisations related to vascular access complications&#44; which in our experience is inferior to those mentioned in other publications&#44;<span class="elsevierStyleSup">27-29</span> concerning both the rate of hospitalisations as days of hospitalisation and the cause of admission compared with other diseases&#46; These results can be improved&#44; especially in cases of emergency surgery attempting to rescue the majority of the AVFs&#46; Nevertheless&#44; this requires the presence of a coordinator and special on-duty days for the members of the working group &#40;surgery&#44; nephrology&#44; interventional radiology and nursing in dialysis&#41;&#46;</p><p class="elsevierStylePara"><a href="10420&#95;108&#95;7533&#95;en&#95;w477710399410420&#95;tabla1&#95;en&#46;doc" class="elsevierStyleCrossRefs">10420&#95;108&#95;7533&#95;en&#95;w477710399410420&#95;tabla1&#95;en&#46;doc</a></p><p class="elsevierStylePara">Table 1&#46; Type of surgical interventions </p>"
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    "resumen" => array:2 [
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introducci&#243;n&#58; </span>El aumento de pacientes que precisan tratamiento renal sustitutivo&#44; sobre todo en el grupo de pacientes sometidos a hemodi&#225;lisis&#44; supone un reto en incremento de actividad y de ocupaci&#243;n de recursos para los servicios de cirug&#237;a&#46; Las complicaciones relacionadas con los accesos vasculares son la causa fundamental de ingresos en muchas unidades de di&#225;lisis&#46; La cirug&#237;a sin ingreso puede disminuir la ocupaci&#243;n de camas hospitalarias&#44; reduce la lista de espera y las complicaciones relacionadas con un ingreso innecesario&#46;&#160;<span class="elsevierStyleBold">Material y m&#233;todos&#58; </span>Hemos realizado un estudio prospectivo de las intervenciones realizadas en el per&#237;odo 1998-2009 para la creaci&#243;n o la reparaci&#243;n de f&#237;stulas arteriovenosas &#40;FAV&#41; para hemodi&#225;lisis&#44; con el objetivo de conocer el nivel de ambulatorizaci&#243;n&#44; resultados&#44; complicaciones y su posible impacto en la tasa de ingresos de los pacientes en hemodi&#225;lisis&#46; La actividad fue realizada dentro del funcionamiento global del servicio de cirug&#237;a general sin unidad espec&#237;fica de cirug&#237;a mayor ambulatoria &#40;CMA&#41;&#46; Las intervenciones las realizaron varios cirujanos del servicio interesados en el tema&#44; pero sin dedicaci&#243;n exclusiva a &#233;ste &#40;su actividad es la de cualquier cirujano general&#41; y sin guardias espec&#237;ficas&#46; La cirug&#237;a ambulatoria se organiz&#243; dentro de la actividad ordinaria del servicio de cirug&#237;a general sin una unidad espec&#237;fica&#44; ni cirujanos especialmente dedicados a la misma&#46; <span class="elsevierStyleBold">Resultados&#58; </span>Desde la apertura de nuestro hospital en 1998 hasta diciembre de 2009 hemos realizado un total de 2&#46;413 intervenciones en 1&#46;229 pacientes &#40;primeros accesos y reparaciones de los mismos&#41;&#46; La cirug&#237;a programada supuso el 74&#44;8&#37; de las intervenciones&#59; el 25&#44;2&#37; restante fueron intervenciones urgentes&#46; El porcentaje global cirug&#237;a ambulatoria fue del 82&#37; &#40;89&#37; en cirug&#237;a programada y 60&#37; en cirug&#237;a urgente&#41;&#46; Se produjeron un 6&#37; de ingresos imprevistos&#46; No hubo mortalidad postoperatoria&#46; El n&#250;mero de ingresos fue de 0&#44;09 episodios por paciente a&#241;o con una estancia media de 0&#44;2 d&#237;as por paciente y a&#241;o&#46; <span class="elsevierStyleBold">Conclusiones&#58;</span> La mayor&#237;a de las intervenciones relacionadas con las FAV&#44; incluso la cirug&#237;a urgente&#44; se pueden realizar en r&#233;gimen ambulatorio dentro de la actividad habitual de un servicio de cirug&#237;a&#46; Se evitan as&#237; costes asociados con la ocupaci&#243;n de camas hospitalarias y se disminuyen las complicaciones relacionadas con el ingreso&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Introduction&#58;</span> The increase of prevalent haemodialysis patients is a challenge for surgery units&#46; Vascular access related complications are the main cause of hospital admissions in many dialysis units&#46; Outpatient surgery could decrease waiting lists&#44; cost and complications associated to vascular access&#46; <span class="elsevierStyleBold">Material and methods&#58;</span> We have performed a prospective study of the vascular access related surgery in a ten year period&#46; Outpatient surgery was included with the rest of the activity in a general surgery unit and was performed by not exclusive dedicated surgeons&#46; <span class="elsevierStyleBold">Results&#58;</span> Since 1998 to December 2009 we performed 2&#44;413 surgical interventions for creating and repairing arteriovenous fistula in 1&#44;229 patients&#44; including elective and emergency surgery &#40;74&#46;8&#37; and 25&#46;2&#37; respectively&#41;&#46; Outpatient procedures were performed in 82&#37; of cases &#40;89&#37; in elective and 60&#37; in emergency surgery&#41;&#46; There were unexpected admissions secondary to surgical complications in 6&#37; of patients&#46; There was no postoperative mortality&#46; The rate of admissions was 0&#46;09 events and 0&#46;2 days per patient&#47;year&#46; <span class="elsevierStyleBold">Conclusions&#58;</span> Outpatient surgery is possible in a high percentage of patients to perform or to repair an arteriovenous fistula&#44; including emergency surgery&#46; Vascular access surgery can be included in ordinary activity of a surgical unit&#46; Outpatient vascular access surgery decreases unnecessary hospital admissions&#44; reduces costs and nosocomial complications&#46;</span></p>"
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                  "referenciaCompleta" => "Jiménez-Almonacid P, Gruss E, Lorenzo S, Lasala M,Hernández MT, Portolés J, et al.\u{A0}Definición de procesos e indicadores para la gestión de accesos vasculares para hemodiálisis. Cir Esp 2007;81(5):257-63.  <a href="http://www.ncbi.nlm.nih.gov/pubmed/17498454" target="_blank">[Pubmed]</a>"
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                  "referenciaCompleta" => "López Revuelta K, Barril G, Caramelo C, Delgado R, García F, García J, et al.\u{A0}Grupo de gestión de calidad SEN: Álvarez Ude F, Angoso M, Aranaz J, Arenas MD, Lorenzo S, López Revuelta K. Developing a clinical performance measures system for hemodialysis, quality group, spanish society of nephrology. Nefrologia 2007;27(5):542-59. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18045030" target="_blank">[Pubmed]</a>"
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                  "referenciaCompleta" => "Piera L, Cruz JM, Braga-Gresham JL, Eichleay MA, Pisoni RL, Port FK. Estimación, según el estudio DOPPS, de los años de vida de pacientes atribuibles a las prácticas de hemodiálisis modificables en España. Nefrologia 2007;27:496-504.  <a href="http://www.ncbi.nlm.nih.gov/pubmed/17944588" target="_blank">[Pubmed]</a>"
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              "identificador" => "bib15"
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            15 => array:3 [
              "identificador" => "bib16"
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