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dif&#237;cil obter estimativas v&#225;lidas e compar&#225;veis da incid&#234;ncia de TEV por v&#225;rios motivos&#46; A sintomatologia e os sinais cl&#237;nicos n&#227;o s&#227;o espec&#237;ficos&#44; levando ao diagn&#243;stico de apenas cerca de 50&#37; dos casos&#44; e o valor preditivo dos testes de rastreio em doentes assintom&#225;ticos &#233; baixo<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">3</span></a>&#46; Estes fatores contribuem para a varia&#231;&#227;o de dados epidemiol&#243;gicos encontrada em diferentes estudos&#44; apesar de haver tamb&#233;m diferen&#231;as &#233;tnicas<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">No doente cir&#250;rgico o risco de TEV est&#225; aumentado e&#44; na aus&#234;ncia de tromboprofilaxia&#44; varia entre 15&#8208;60&#37;&#44; dependendo do tipo de cirurgia&#44; sendo mais elevado em cirurgia ortop&#233;dica <span class="elsevierStyleItalic">major</span><a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">4&#44;5</span></a><span class="elsevierStyleItalic">&#46;</span> Para esse risco contribuem&#44; tamb&#233;m&#44; fatores espec&#237;ficos do doente&#44; tipo de anestesia e dura&#231;&#227;o do procedimento e do internamento<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">4&#44;5</span></a>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">O estudo ENDORSE<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">6</span></a>&#44; que analisou o risco de TEV em 32 pa&#237;ses&#44; revelou que&#44; em Portugal&#44; dos 762 doentes cir&#250;rgicos avaliados&#44; 69&#37; estavam expostos a risco aumentado&#46; Apesar da import&#226;ncia do conhecimento de indicadores de resultado&#44; h&#225; poucos estudos epidemiol&#243;gicos sobre TEV no per&#237;odo p&#243;s&#8208;operat&#243;rio em Portugal&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Objetivos</span><p id="par0075" class="elsevierStylePara elsevierViewall">O estudo TRomboEmbolismo Venoso p&#243;s&#8208;Operat&#243;rio &#40;TREVO&#41; teve como objetivo prim&#225;rio estimar o risco de TEV p&#243;s&#8208;operat&#243;rio sintom&#225;tico&#44; global e por especialidade cir&#250;rgica num hospital terci&#225;rio&#46; Secundariamente&#44; foi analisada a gravidade e mortalidade dos casos de tromboembolismo&#44; incluindo caracter&#237;sticas dos doentes envolvidos e do tratamento a que foram submetidos&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">M&#233;todos</span><p id="par0080" class="elsevierStylePara elsevierViewall">O TREVO &#233; um estudo epidemiol&#243;gico retrospetivo&#44; na popula&#231;&#227;o adulta de doentes cir&#250;rgicos do Centro Hospitalar de S&#227;o Jo&#227;o&#44; que &#233; um hospital terci&#225;rio e universit&#225;rio&#46; O estudo foi aprovado pela Comiss&#227;o de &#201;tica para a Sa&#250;de da institui&#231;&#227;o&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Desenho do estudo</span><p id="par0085" class="elsevierStylePara elsevierViewall">Foram estudados os epis&#243;dios de internamento de doentes com idade igual ou superior a 18 anos&#44; submetidos a pelo menos uma interven&#231;&#227;o cir&#250;rgica&#44; programada ou urgente&#44; no per&#237;odo de um de janeiro de 2008 a 31 de dezembro de 2012&#44; registados em base de dados administrativa&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Identific&#225;mos casos de TEV&#44; a partir dos c&#243;digos da Classifica&#231;&#227;o Internacional de Doen&#231;as &#8211; 9&#46;&#170; revis&#227;o &#8211; Modifica&#231;&#227;o Cl&#237;nica &#40;CID9&#41; nos diagn&#243;sticos secund&#225;rios&#44; restritos aos primeiros 120 dias de internamento&#46; O crit&#233;rio de TEV utilizado foi o da <span class="elsevierStyleItalic">Joint</span> Commission <span class="elsevierStyleItalic">International</span><a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Os processos cl&#237;nicos dos casos identificados foram revistos na edi&#231;&#227;o eletr&#243;nica e no arquivo em papel&#46; A informa&#231;&#227;o foi recolhida para um formul&#225;rio elaborado para o efeito&#44; e incluiu caracter&#237;sticas demogr&#225;ficas e patologia associada dos doentes envolvidos&#44; diagn&#243;sticos de admiss&#227;o e de alta&#59; caracter&#237;sticas do tratamento&#44; nomeadamente&#44; tipo de anestesia&#44; tipo de cirurgia&#44; procedimento de cateteriza&#231;&#227;o venosa central&#44; ocorr&#234;ncia de imobilidade p&#243;s&#8208;operat&#243;ria superior a dois dias&#44; prescri&#231;&#227;o de tromboprofilaxia p&#243;s&#8208;operat&#243;ria&#59; e estado vital &#224; sa&#237;da do internamento&#46; A vari&#225;vel gravidade dos eventos de TEV p&#243;s&#8208;operat&#243;rio foi analisada em quatro grupos&#58; EP fatal&#44; EP n&#227;o fatal&#44; TVP e outros TEV&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Foram exclu&#237;dos os casos de doentes cir&#250;rgicos internados n&#227;o operados&#44; aqueles com registo incompleto de dados e os casos com diagn&#243;stico secund&#225;rio de TEV n&#227;o confirmado&#46; Adicionalmente&#44; exclu&#237;ram&#8208;se os casos de TEV ocorridos antes da cirurgia&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">A sele&#231;&#227;o dos casos fundamentou&#8208;se no registo objetivo do diagn&#243;stico de TEV no processo cl&#237;nico&#44; suportado pela descri&#231;&#227;o de achados imagiol&#243;gicos&#46; A EP foi confirmada por tomografia computadorizada helicoidal&#44; angiografia de subtra&#231;&#227;o digital ou cintilografia de ventila&#231;&#227;o&#47;perfus&#227;o de alta probabilidade&#59; a TVP por ultrassonografia ou venografia&#59; e outros TEV por ultrassonografia&#44; venografia ou angiorresson&#226;ncia magn&#233;tica&#46; As imagens n&#227;o foram visualizadas pelos investigadores&#44; tendo estes validado as informa&#231;&#245;es registadas para compara&#231;&#227;o com a codifica&#231;&#227;o CID9&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Os epis&#243;dios inicialmente identificados foram revistos por um investigador diferente para confirma&#231;&#227;o da informa&#231;&#227;o recolhida&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">O <span class="elsevierStyleItalic">outcome</span> considerado foi o TEV sintom&#225;tico por ser pr&#225;tica instituicional orientar a imagiologia pela cl&#237;nica&#44; n&#227;o se fazendo rastreio do TEV&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Nos casos que cursaram com mais do que um evento de TEV&#44; foi considerado apenas o mais grave para efeitos estat&#237;sticos&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">An&#225;lise estat&#237;stica</span><p id="par0125" class="elsevierStylePara elsevierViewall">Foram elaboradas estat&#237;sticas descritivas dos dados&#44; recorrendo &#224; mediana e intervalo interquartis &#40;P<span class="elsevierStyleInf">25</span>&#8208;P<span class="elsevierStyleInf">75</span>&#41; para as vari&#225;veis quantitativas&#44; e propor&#231;&#245;es para as vari&#225;veis qualitativas&#46; As estimativas s&#227;o apresentadas com intervalos de confian&#231;a a 95&#37; &#40;IC95&#37;&#41;&#46; O risco de TEV e de EP entre subgrupos foi comparado pelo teste do quiquadrado&#46; Para avaliar a evolu&#231;&#227;o temporal do indicador de resultado TEV&#44; foi utilizado um teste para a tend&#234;ncia linear&#46; Os dados foram analisados no programa Stata vers&#227;o 11&#46;1 para <span class="elsevierStyleItalic">Windows</span> &#40;StataCorp LP&#44; College Station&#44; TX&#41; e o <span class="elsevierStyleItalic">Microsoft Excel</span> 2010 &#40;Microsoft Corp&#44; Redmond&#44; WA&#41;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Resultados</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Sele&#231;&#227;o de casos</span><p id="par0130" class="elsevierStylePara elsevierViewall">A popula&#231;&#227;o estudada no TREVO incluiu 67<span class="elsevierStyleHsp" style=""></span>635 epis&#243;dios de internamento&#44; em que doentes adultos foram operados pelas especialidades de cirurgia cardiotor&#225;cica&#44; geral&#44; pl&#225;stica&#44; vascular&#44; neurocirurgia&#44; ortopedia&#44; otorrinolaringologia e urologia&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Dos 178 casos inicialmente identificados como TEV&#44; de acordo com os diagn&#243;sticos codificados pela CID9&#44; foram exclu&#237;dos 35 casos de doentes cir&#250;rgicos internados n&#227;o operados&#59; 16 casos por registo de dados incompleto&#44; nove por codifica&#231;&#227;o incongruente com a informa&#231;&#227;o cl&#237;nica e 28 por terem ocorrido antes da cirurgia &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figura 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Caracter&#237;sticas demogr&#225;ficas</span><p id="par0140" class="elsevierStylePara elsevierViewall">O risco global de TEV foi semelhante em doentes do sexo masculino ou feminino &#40;1&#44;35 <span class="elsevierStyleItalic">versus</span> 1&#44;31&#47;1000 epis&#243;dios&#44; respetivamente&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;96&#41;&#46; No entanto&#44; nos doentes com EP fatal o r&#225;cio feminino&#47;masculino foi de 63&#44;6&#37;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">A mediana de idades dos doentes com TEV foi de 59 anos &#40;P<span class="elsevierStyleInf">25</span>&#8208;P<span class="elsevierStyleInf">75</span>&#58; 46&#8208;70&#41;&#46; A diferen&#231;a da m&#233;dia das idades dos casos de TEV n&#227;o foi significativa comparativamente &#224; de toda a popula&#231;&#227;o estudada &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;191&#41;&#46; Os casos de EP fatal ocorreram na m&#233;dia das idades 63&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;6&#46; Os doentes com TVP pertenceram a um escal&#227;o et&#225;rio tendencialmente mais baixo &#40;m&#233;dia 54<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#44;3&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Risco por especialidade cir&#250;rgica</span><p id="par0150" class="elsevierStylePara elsevierViewall">Aos 90 casos de TEV sintom&#225;tico p&#243;s&#8208;operat&#243;rio confirmados correspondeu um risco de 1&#44;33&#47;1000 epis&#243;dios &#40;IC95&#37;&#44; 1&#44;1&#8208;1&#44;6&#47;1000&#41;&#46; No que respeita ao risco estimado por especialidade cir&#250;rgica&#44; a neurocirurgia foi a especialidade com maior risco &#40;4&#44;07&#47;1000&#41;&#44; seguida da urologia &#40;1&#44;55&#47;1000&#41; e cirurgia geral &#40;1&#44;42&#47;1000&#41;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#46; A especialidade com menor risco foi a cirurgia pl&#225;stica &#40;0&#44;47&#47;1000&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figura 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">Nos casos neurocir&#250;rgicos&#44; foi observada EP em cinco casos de cirurgia de remo&#231;&#227;o de les&#245;es neopl&#225;sicas &#40;dois neurinomas do ac&#250;stico&#44; astrocitoma&#44; adenoma da hip&#243;fise e meningioma&#41; e em outros cinco casos cir&#250;rgicos diversos &#40;duas drenagens de abcesso cerebral&#44; biopsia cerebral&#44; drenagem de hemorragia cerebral&#44; coloca&#231;&#227;o de um monitor de press&#227;o intracraniana&#41;&#46; Ocorreram TVP em tr&#234;s cirurgias de drenagem de hematoma subdural e numa drenagem de hemorragia intracerebral&#46; Um doente de Parkinson submetido a implanta&#231;&#227;o de neuroestimulador intracraniano teve outro tipo de TEV&#46; Nenhum dos casos com les&#245;es neopl&#225;sicas apresentou EP fatal&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Dos 14 doentes urol&#243;gicos&#44; quatro foram submetidos a transplante renal e em tr&#234;s destes ocorreu EP &#40;um outro TEV&#41;&#46; Um dos transplantados apresentou EP&#44; TVP e outro TEV&#46; Este e outro transplantado&#44; ambos homens&#44; faleceram&#46; A EP complicou ainda uma resse&#231;&#227;o transuretral da pr&#243;stata&#44; uma ureteroscopia com biopsia e uma nefroureterectomia&#46; Os restantes epis&#243;dios urol&#243;gicos foram TVP&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Dos 90 casos de TEV identificados&#44; 11 &#40;12&#44;2&#37;&#41; decorreram sob anestesia do neuroeixo&#44; das quais tr&#234;s combinadas com anestesia geral e duas combinadas do neuroeixo &#40;bloqueio subaracnoideu e epidural&#41;&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Os casos de TEV distribu&#237;ram&#8208;se por estado f&#237;sico da <span class="elsevierStyleItalic">American Society of Anesthesiology</span> &#40;ASA&#41;&#44; segundo o descrito&#58; ASA <span class="elsevierStyleSmallCaps">III</span> &#40;55&#44;1&#37;&#41;&#44; ASA <span class="elsevierStyleSmallCaps">II</span> &#40;21&#44;4&#37;&#41; e ASA <span class="elsevierStyleSmallCaps">IV</span> &#40;13&#44;5&#37;&#41;&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">O risco global decresceu ao longo dos anos no per&#237;odo de estudo&#44; de 1&#44;95&#47;1000 em 2008 at&#233; 1&#44;01&#47;1000 em 2012 &#40;p<span class="elsevierStyleInf">tend&#234;ncia linear</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;036&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figura 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Gravidade dos eventos</span><p id="par0180" class="elsevierStylePara elsevierViewall">No total dos casos&#44; identificaram&#8208;se 50 casos de EP&#44; correspondendo a um risco de 0&#44;75&#47;1000 epis&#243;dios &#40;IC95&#37; 0&#44;56&#8208;0&#44;99&#47;1000&#41;&#44; mais elevado na neurocirurgia &#40;2&#44;39&#47;1000&#41;&#44; seguida da ortopedia &#40;0&#44;91&#47;1000&#41; e urologia &#40;0&#44;89&#47;1000&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figura 2</a>&#41;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Houve 11 EP fatais &#40;mortalidade 22&#44;0&#37;&#41;&#44; a que esteve associada uma maior percentagem de doentes com doen&#231;a maligna ou com insufici&#234;ncia renal &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a>&#41;&#46; Mais de metade destes doentes tinham sido submetidos a cateteriza&#231;&#227;o venosa central na subcl&#225;via direita e&#44; se inclu&#237;da a cateteriza&#231;&#227;o da jugular interna&#44; 72&#44;7&#37; dos doentes tinham cateter central &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">A imobilidade superior a dois dias esteve associada a um maior n&#250;mero de eventos graves &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41;&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Pelo menos 37&#44;7&#37; dos doentes com eventos estavam sob dose profil&#225;tica de anticoagulante injet&#225;vel no p&#243;s&#8208;operat&#243;rio &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41;&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Houve 19 doentes com TEV que faleceram e as poss&#237;veis causas associadas est&#227;o explicitadas na <a class="elsevierStyleCrossRef" href="#tbl0020">Tabela 4</a>&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0205" class="elsevierStylePara elsevierViewall">A mortalidade do total dos epis&#243;dios de TEV foi de 21&#44;1&#37; &#40;IC95&#37;&#44; 13&#44;6&#8208;30&#44;4&#41;&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discuss&#227;o</span><p id="par0210" class="elsevierStylePara elsevierViewall">No TREVO englobaram&#8208;se doentes de cirurgia programada e urgente de oito especialidades&#46; Estimou&#8208;se um risco de TEV de 1&#44;33&#47;1000 epis&#243;dios&#44; correspondente ao <span class="elsevierStyleItalic">outcome</span> intra&#8208;hospitalar&#46; Comparativamente ao risco atribu&#237;do &#224; popula&#231;&#227;o cir&#250;rgica portuguesa no estudo ENDORSE &#40;69&#37;&#41;&#44; este valor &#233; extremamente baixo&#46; O ENDORSE considera n&#227;o o <span class="elsevierStyleItalic">outcome</span>&#44; mas a avalia&#231;&#227;o dos fatores de risco e somente em doentes agudos&#44; de cirurgia geral&#44; uroginecologia e ortotraumatologia<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">6&#44;10</span></a>&#44; constituindo estes um grupo de maior risco de TEV&#46; Bilimoria et al&#46; relatam um risco de 5&#44;35&#47;1000 num estudo multic&#234;ntrico&#44; fundamentado em <span class="elsevierStyleItalic">outcomes</span>&#44; que inclui ortopedia&#44; neurocirurgia&#44; cirurgia cardiotor&#225;cica&#44; urologia e cirurgia geral<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">8</span></a>&#46; Neste estudo&#44; baseado na popula&#231;&#227;o norte&#8208;americana&#44; os autores chamam a aten&#231;&#227;o para o facto de o n&#237;vel de vigil&#226;ncia cl&#237;nica constituir um importante vi&#233;s nos resultados encontrados&#44; tanto maior quanto mais interventivos sejam os protocolos locais no pedido de exames imagiol&#243;gicos&#46; Se&#44; por um lado&#44; alguns eventos t&#234;m sintomatologia fruste&#44; podendo n&#227;o ser valorizados em locais em que a imagiologia &#40;<span class="elsevierStyleItalic">standard</span> diagn&#243;stico&#41; &#233; orientada pela cl&#237;nica&#44; por outro&#44; em alguns centros&#44; como nos de traumatologia&#44; a imagiologia &#233; feita por rotina<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">8</span></a>&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">O risco de TEV observado neste estudo incorpora o efeito da tromboprofilaxia&#44; que reduz a incid&#234;ncia de TEV de 50&#8208;75&#37;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a>&#44; refletindo os processos institucionais&#46; Al&#233;m disso&#44; o TEV sintom&#225;tico&#44; que foi o <span class="elsevierStyleItalic">outcome</span> considerado&#44; representa cerca de 50&#37; de todos os eventos de TEV<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">3</span></a>&#46; Ainda assim&#44; o TREVO mostra valores mais baixos do que outros encontrados na literatura&#44; o que pode&#44; por um lado&#44; relacionar&#8208;se com rejei&#231;&#227;o de casos por inconformidade no processo cl&#237;nico ou menor sensibilidade no diagn&#243;stico&#47;registo&#46; Neste &#250;ltimo caso&#44; poder&#225; justificar&#8208;se a elevada mortalidade por os eventos fatais obrigarem a um registo mais conforme&#44; tanto mais que a literatura descreve uma incid&#234;ncia de EP inferior a outros TEV&#44; o que n&#227;o foi constatado neste estudo&#44; levantando a hip&#243;tese de subdiagn&#243;stico de outros TEV&#44; que n&#227;o EP&#44; proporcionalmente&#46; Por outro lado&#44; este menor risco pode refletir tromboprofilaxia mais adequada&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">No TREVO&#44; a especialidade com maior risco de TEV foi a neurocirurgia&#46; A especialidade descrita na literatura como exposta a maior risco<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">4&#44;10&#44;12&#44;13</span></a> &#233; a ortopedia&#46; Tzu&#8208;Frei Wang et al&#46;&#44; num estudo retrospetivo de 94 casos de TEV intra&#8208;hospitalar&#44; identificaram a cirurgia intracraniana como fator preditivo de TEV&#44; com um <span class="elsevierStyleItalic">odds ratio</span> singularmente elevado de 16&#44;1<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a>&#46; Num estudo anterior&#44; Hamilton et al&#46; observaram que metade dos doentes neurocir&#250;rgicos&#44; quando triados imagiologicamente&#44; apresentavam TEV detet&#225;vel&#44; enquanto s&#243; 5&#37; desenvolviam TEV sintom&#225;tico<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a>&#46; Um fator de risco conhecido de TEV que pode estar associado &#233; o facto da cirurgia intracraniana envolver cateteriza&#231;&#227;o venosa central numa elevada percentagem de casos&#46; Um estudo retrospetivo associou a cateteriza&#231;&#227;o venosa central &#224; duplica&#231;&#227;o do risco de TEV intra&#8208;hospitalar<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a>&#46; Al&#233;m disso&#44; muitos destes doentes s&#227;o internados em unidades de cuidados intensivos e t&#234;m tempos operat&#243;rios e internamentos mais prolongados&#44; fatores adicionais de risco de TEV&#46; A limita&#231;&#227;o ao uso de tromboprofilaxia farmacol&#243;gica&#44; inerente &#224; especialidade de neurocirurgia&#44; mais do que a popula&#231;&#227;o tratada&#44; est&#225; tamb&#233;m de acordo com o aumento de risco constatado&#46; Este facto refor&#231;a a necessidade&#44; j&#225; contemplada em algumas <span class="elsevierStyleItalic">guidelines</span><a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">4&#44;5</span></a>&#44; de fazer tromboprofilaxia mec&#226;nica desde o pr&#233;&#8208;operat&#243;rio no doente neurocir&#250;rgico e de ponderar profilaxia medicamentosa em doentes de maior risco de TEV&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">O TREVO estima o risco de TEV intra&#8208;hospitalar&#46; Embora seja conhecido o elevado risco de TEV em cirurgia ortop&#233;dica <span class="elsevierStyleItalic">major</span>&#44; as taxas de eventos sintom&#225;ticos p&#243;s&#8208;operat&#243;rios at&#233; &#224; alta n&#227;o traduzem o risco global&#44; porque no caso da artroplastia da anca o tempo m&#233;dio de eventos sintom&#225;ticos &#233; ao 17&#46;&#176; dia e no caso da artroplastia do joelho &#233; ao 7&#46;&#176; dia&#44; estendendo&#8208;se o per&#237;odo de elevado risco por 12 semanas no primeiro caso e seis no segundo<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">11&#44;3</span></a>&#46; Estes doentes&#44; com os cada vez mais frequentes programas de <span class="elsevierStyleItalic">enhanced recovery</span>&#44; t&#234;m alta muito antes dos tempos referidos&#44; enviesando ainda mais o registo intra&#8208;hospitalar de eventos como medida de risco&#44; o que pode justificar o aparecimento da ortopedia em 5&#46;&#176; lugar &#40;1&#44;09&#47;1000 epis&#243;dios&#41; no TREVO&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">O risco associado &#224; urologia &#40;1&#44;55&#47;1000&#41; surge em segundo lugar no TREVO&#46; Embora seja um grupo de risco menos documentado&#44; um estudo de coorte recente relata uma taxa de TEV moderada&#47;alta para cistectomia total &#40;3&#44;96&#37;&#41; e parcial &#40;2&#44;35&#37;&#41;&#44; seguindo&#8208;se a nefrectomia aberta radical &#40;1&#44;67&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a>&#46; Outros estudos documentam um elevado risco de TEV associado &#224; transplanta&#231;&#227;o renal &#40;7&#44;9&#8208;9&#44;1&#37;&#41;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">17&#44;18</span></a>&#46; A popula&#231;&#227;o de doentes estudados no TREVO inclui uma unidade de transplanta&#231;&#227;o renal&#44; o que contribuiu para a propor&#231;&#227;o de valores encontrada&#46; Beyer et al&#46; referem uma incid&#234;ncia elevada de EP &#40;5&#44;8&#37;&#41; na prostatectomia<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">19</span></a>&#44; outro procedimento comum na popula&#231;&#227;o estudada&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">A tend&#234;ncia decrescente na evolu&#231;&#227;o anual do risco global de TEV&#44; de 2008&#8208;2012&#44; &#233; favor&#225;vel &#224; hip&#243;tese de uma tromboprofilaxia progressivamente mais adequada&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">A mortalidade encontrada no total dos eventos de TEV &#40;21&#44;1&#37;&#41; foi mais alta do que a descrita na literatura e pr&#243;xima da mortalidade por EP &#40;22&#44;0&#37;&#41;&#44; sendo esta tamb&#233;m elevada&#46; Reis refere uma mortalidade precoce por TEV de 12&#44;6&#37;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">2</span></a>&#46; Dados do <span class="elsevierStyleItalic">Nation wide Inpatient Sample</span> indicam uma mortalidade intra&#8208;hospitalar por EP de 12&#44;3&#8208;8&#44;2&#37;&#44; com tend&#234;ncia decrescente ao longo dos anos<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a>&#46; Num estudo noruegu&#234;s&#44; a mortalidade aos 30 dias por EP foi de 9&#44;7&#37; e a de TVP de 4&#44;6&#37;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a>&#46; A mortalidade encontrada no TREVO em compara&#231;&#227;o com estes valores refor&#231;a a hip&#243;tese de subdiagn&#243;stico de eventos n&#227;o fatais&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">A anestesia do neuroeixo&#44; neste estudo&#44; foi realizada em 12&#44;2&#37; das cirurgias&#46; Numa meta&#8208;an&#225;lise&#44; Rodgers et al&#46; mostraram que a anestesia epidural modifica radicalmente o risco de TEV&#44; com redu&#231;&#245;es de 44 e 55&#37; para a TVP e EP&#44; respetivamente<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a>&#46; Outra meta&#8208;an&#225;lise confirmou o benef&#237;cio da anestesia epidural lombar cont&#237;nua no per&#237;odo p&#243;s&#8208;operat&#243;rio na redu&#231;&#227;o do risco de TEV em cirurgia dos membros inferiores e prostatectomia<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a>&#46; Este facto pode contribuir para a explica&#231;&#227;o da redu&#231;&#227;o de risco encontrada em ortopedia&#44; onde a anestesia do neuroeixo &#233; a t&#233;cnica mais utilizada na cirurgia <span class="elsevierStyleItalic">major</span> dos membros inferiores&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Em rela&#231;&#227;o ao estado f&#237;sico ASA&#44; neste estudo o estado ASA <span class="elsevierStyleSmallCaps">III</span> &#40;55&#44;1&#37;&#41; foi o predominante&#46; Est&#225; descrito&#44; na literatura&#44; um agravamento do risco de TEV com o progressivo aumento do ASA para cirurgia da anca<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a>&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Este estudo tem v&#225;rias limita&#231;&#245;es&#46; A primeira &#233; o facto de ser retrospetivo e&#44; portanto&#44; observacional e dependente da informa&#231;&#227;o dispon&#237;vel no processo cl&#237;nico&#46; A segunda &#233; a exclus&#227;o de casos por inconformidades no registo cl&#237;nico&#46; A terceira &#233; o hipot&#233;tico vi&#233;s de vigil&#226;ncia de eventos entre servi&#231;os&#44; o que&#44; a par da segunda&#44; pode contribuir para subdiagn&#243;stico&#46; A quarta &#233; considerar apenas eventos intra&#8208;hospitalares&#44; desvalorizando os que ocorrem ap&#243;s alta&#46; A quinta &#233; n&#227;o dispor na totalidade dos casos&#44; de dados sobre a administra&#231;&#227;o da profilaxia tromboemb&#243;lica e&#44; nomeadamente&#44; da avalia&#231;&#227;o do risco de TEV pr&#233;&#8208;operat&#243;rio &#40;e da indica&#231;&#227;o &#224; luz da evid&#234;ncia atual&#41; dos doentes em causa&#44; para avaliar com maior precis&#227;o o impacto da tromboprofilaxia&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Dos aspetos positivos do TREVO&#44; h&#225; a salientar&#58; n&#227;o se conhecerem estudos publicados sobre TEV p&#243;s&#8208;operat&#243;rio em Portugal&#44; al&#233;m do ENDORSE&#44; sobretudo com amostras semelhantes&#59; incluir uma amostra de 67<span class="elsevierStyleHsp" style=""></span>635 doentes&#44; com 90 casos documentados de TEV&#44; o que compara com outros estudos internacionais&#59; tratar&#8208;se de um estudo feito com base em <span class="elsevierStyleItalic">outcomes</span> e n&#227;o na avalia&#231;&#227;o do risco&#59; acautelar alguns vi&#233;ses de sele&#231;&#227;o&#44; nomeadamente tendo em conta os c&#243;digos da CID e os crit&#233;rios de TEV definidos pela <span class="elsevierStyleItalic">Joint Commission International</span>&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclus&#227;o</span><p id="par0265" class="elsevierStylePara elsevierViewall">Neste estudo&#44; o risco de TEV sintom&#225;tico p&#243;s&#8208;operat&#243;rio foi de 1&#44;33&#47;1000 epis&#243;dios&#46; A especialidade com maior risco de TEV e de EP foi a neurocirurgia&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">A mortalidade foi de 21&#44;1&#37;&#46; N&#227;o &#233; de excluir subdiagn&#243;stico ou aus&#234;ncia de registo de eventos n&#227;o fatais&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Responsabilidades &#233;ticas</span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Prote&#231;&#227;o de pessoas e animais</span><p id="par0275" class="elsevierStylePara elsevierViewall">Os autores declaram que para esta investiga&#231;&#227;o n&#227;o se realizaram experi&#234;ncias em seres humanos e&#47;ou animais&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Confidencialidade dos dados</span><p id="par0280" class="elsevierStylePara elsevierViewall">Os autores declaram que n&#227;o aparecem dados de pacientes neste artigo&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Direito &#224; privacidade e consentimento escrito</span><p id="par0285" class="elsevierStylePara elsevierViewall">Os autores declaram que n&#227;o aparecem dados de pacientes neste artigo&#46;</p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflito de interesses</span><p id="par0290" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflito de interesses&#46;</p></span></span>"
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    "resumen" => array:2 [
      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introdu&#231;&#227;o e objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">O tromboembolismo venoso&#44; cujo risco est&#225; aumentado no doente cir&#250;rgico&#44; &#233; uma causa evit&#225;vel de morbimortalidade&#46; O objetivo prim&#225;rio deste estudo foi estimar o risco de tromboembolismo venoso sintom&#225;tico p&#243;s&#8208;operat&#243;rio global e por especialidade cir&#250;rgica&#44; num hospital terci&#225;rio&#46; Secundariamente&#44; foram analisadas a gravidade e mortalidade dos eventos tromboemb&#243;licos&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Foi realizado um estudo retrospetivo para a identifica&#231;&#227;o de casos de tromboembolismo venoso p&#243;s&#8208;operat&#243;rio intra&#8208;hospitalar&#44; codificados pela Classifica&#231;&#227;o Internacional de Doen&#231;as &#8211; 9&#46;&#170; revis&#227;o&#44; pelos crit&#233;rios da <span class="elsevierStyleItalic">Joint Commission International</span>&#46; Foram inclu&#237;dos epis&#243;dios de internamento de doentes adultos&#44; operados&#44; no per&#237;odo 2008&#8208;2012&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Em 67<span class="elsevierStyleHsp" style=""></span>635 epis&#243;dios de internamento com cirurgia identificaram&#8208;se 90 casos de tromboembolismo venoso p&#243;s&#8208;operat&#243;rio &#40;mediana de idades&#58; 59 anos&#41;&#44; correspondendo a um risco de 1&#44;33&#47;1000 epis&#243;dios &#40;intervalo de confian&#231;a a 95&#37; &#91;IC95&#37;&#93;&#44; 1&#44;1&#8208;1&#44;6&#47;1000&#41;&#46; A neurocirurgia apresentou maior risco &#40;4&#44;07&#47;1000&#41;&#44; seguida pela urologia e pela cirurgia geral p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#46; Houve 50 epis&#243;dios de embolia pulmonar&#44; dos quais 11 foram fatais&#46; Dos 90 casos&#44; 12&#44;2&#37; decorreram sob anestesia do neuro&#8208;eixo e 55&#44;1&#37; em doentes em estado f&#237;sico ASA <span class="elsevierStyleSmallCaps">III</span>&#46; Foi administrada dose profil&#225;tica de anticoagulante injet&#225;vel no p&#243;s&#8208;operat&#243;rio a&#44; pelo menos&#44; 37&#44;7&#37; dos doentes&#46; O risco decresceu de 2008 at&#233; 2012&#46; A mortalidade associada aos eventos de tromboembolismo venoso durante o internamento foi 21&#44;1&#37; &#40;IC95&#37;&#44; 13&#44;6&#8208;30&#44;4&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclus&#245;es</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">O risco de tromboembolismo venoso sintom&#225;tico p&#243;s&#8208;operat&#243;rio foi de 1&#44;33&#47;1000&#46; A neurocirurgia apresentou maior risco&#46; A mortalidade foi de 21&#44;1&#37;&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introdu&#231;&#227;o e objetivos"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "M&#233;todos"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction and Objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Venous thromboembolism&#44; risk of which is increased in surgical patients&#44; is a preventable cause of morbidity and death&#46; The primary objective of this study was to estimate the incidence of symptomatic postoperative venous thromboembolism in adults at a tertiary university hospital&#44; overall and by surgical specialty&#46; The secondary objective was to analyze severity of and mortality from thromboembolic events&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">We performed a retrospective study to identify cases of in&#8208;hospital postoperative venous thromboembolism&#44; encoded by the International Classification of Diseases&#44; Ninth Revision&#44; according to the Joint Commission International criteria&#46; Adult patients admitted for surgery in 2008&#8208;2012 were included&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Among 67 635 hospitalizations&#44; 90 cases of postoperative symptomatic venous thromboembolism were identified&#44; corresponding to an incidence of 1&#46;33&#47;1000 admissions &#40;95&#37; confidence interval &#91;CI&#93; 1&#46;1&#8208;1&#46;6&#47;1000&#41;&#46; Neurosurgery had the highest risk &#40;4&#46;07&#47;1000&#41;&#44; followed by urological surgery and general surgery &#40;p&#60;0&#46;001&#41;&#46; There were 50 cases of pulmonary embolism&#44; 11 of which were fatal&#46; Of the 90 cases&#44; 12&#46;2&#37; occurred under neuraxial anesthesia and 55&#46;1&#37; in patients with American Society of Anesthesiology <span class="elsevierStyleSmallCaps">III</span> physical status&#46; At least 37&#46;7&#37; of patients with events received a prophylactic dose of injectable anticoagulant postoperatively&#46; The overall risk decreased from 2008 to 2012&#46; Venous thromboembolism&#8208;associated mortality during hospitalization was 21&#46;1&#37; &#40;95&#37; CI 13&#46;6&#8208;30&#46;4&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">The incidence of postoperative symptomatic venous thromboembolism was 1&#46;33&#47;1000&#46; Neurosurgery showed the greatest risk&#46; Mortality was 21&#46;1&#37;&#46;</p></span>"
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              7 => array:2 [
                "termino" => "TREVO"
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              8 => array:2 [
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          "pt" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Risco de tromboembolismo venoso &#40;TEV&#41; com ou sem embolia pulmonar &#40;EP&#41;&#44; por especialidade cir&#250;rgica&#46; C&#46; geral&#58; cirurgia geral&#59; C&#46; pl&#225;stica&#58; cirurgia pl&#225;stica&#44; reconstrutiva e maxilofacial&#59; C&#46; tor&#225;cica&#58; cirurgia tor&#225;cica&#59; C&#46; vascular&#58; cirurgia vascular&#59; NC&#58; neurocirurgia&#59; OTL&#58; otorrinolaringologia&#46;</p>"
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          "pt" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Evolu&#231;&#227;o anual do risco global de tromboembolismo venoso &#40;TEV&#41;&#44; 2008&#8208;2012&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">CID9&#58; Classifica&#231;&#227;o Internacional de Doen&#231;as&#44; 9&#46;<span class="elsevierStyleSup">a</span> revis&#227;o&#59; NCOP&#58; n&#227;o compreendido em outra parte&#59; TVP&#58; trombose venosa profunda</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">C&#243;digo CID9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Descri&#231;&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">415&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Embolia&#47;enfarte pulmonar iatrog&#233;nicos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">451&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Flebite de veia femoral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">451&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Outra flebite profunda da perna&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tromboflebite il&#237;aca&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tromboflebite NCOP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">453&#46;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TVP&#47;embolia distal membros inferiores NCOP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TVP&#47;embolia proximal membros inferiores&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">453&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Embolia tor&#225;cica veia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">453&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Embolia veia NCOP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">453&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trombose venosa NCOP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">DPOC&#58; doen&#231;a pulmonar obstrutiva cr&#243;nica&#59; EP&#58; embolia pulmonar&#59; <span class="elsevierStyleSmallCaps">I</span>&#58; insufici&#234;ncia&#59; n&#58; n&#250;mero de casos por caracter&#237;stica&#59; N&#58; n&#250;mero total de casos de eventos&#59; ND&#58; casos sem informa&#231;&#227;o dispon&#237;vel&#59; NYHA&#58; <span class="elsevierStyleItalic">New York Heart Association</span>&#59; TEV&#58; tromboembolismo venoso&#59; TVP&#58; trombose venosa profunda&#59; SD&#58; desvio padr&#227;o&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">EP n&#227;o fatal &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TVP &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>33&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Masculino&#47;feminino&#44; n</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">1</span></span><span class="elsevierStyleItalic">&#47;n</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#47;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&#47;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#47;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#47;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Idade &#40;anos&#41;&#44; m&#233;dia</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#43;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8208; SD</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">&#205;ndice massa corporal</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#62;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">30</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Kg m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">m&#8208;2</span></span><span class="elsevierStyleItalic">&#44; n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;11 &#40;ND 2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#47;39 &#40;ND 8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#47;33 &#40;ND 5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Doen&#231;a aguda associada</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Card&#237;aca <span class="elsevierStyleSmallCaps">III</span>&#47;<span class="elsevierStyleSmallCaps">IV</span> NYHA&#44; n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;11 &#40;18&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;39 &#40;5&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;7 &#40;14&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">R</span>espirat&#243;ria &#40;DPOC ou pneumonia&#41;&#44; n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;11 &#40;18&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#47;39 &#40;23&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#47;33 &#40;9&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;7 &#40;28&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Renal aguda&#44; cr&#243;nica ou terminal&#44; n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#47;11 &#40;27&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#47;39 &#40;17&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#47;33 &#40;9&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#47;7 &#40;71&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Doen&#231;a maligna associada&#44; n&#47;N &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#47;11 &#40;36&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#47;39 &#40;17&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#47;33 &#40;27&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">S&#233;psis&#44; n&#47;N &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;11 &#40;18&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#47;39 &#40;12&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#47;33 &#40;18&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;7 &#40;14&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Geral<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>NE&#44; n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#47;33 &#40;9&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Outra&#44; n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;39 &#40;2&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">C&#46; venoso central</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Jugular interna&#44; n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;39 &#40;5&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Subcl&#225;via&#44; n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Imobilidade p&#243;s&#8208;op&#46;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#62;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">2 dias&#44; n&#47;N &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#47;11 &#40;63&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#47;39 &#40;23&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#47;33 &#40;45&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#47;7 &#40;42&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Tromboprofilaxia p&#243;s&#8208;operat&#243;ria</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Enoxaparina dose profil&#225;tica ou<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span> n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#47;11 &#40;36&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#47;39 &#40;33&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#47;33 &#40;42&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;7 &#40;28&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Enoxaparina<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>dose profil&#225;tica&#44; n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#47;39 &#40;15&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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    "bibliografia" => array:2 [
      "titulo" => "Refer&#234;ncias"
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        0 => array:2 [
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            0 => array:3 [
              "identificador" => "bib0125"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology of venous thromboembolism"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46;A&#46; Heit"
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                        ]
                      ]
                    ]
                  ]
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Nature Reviews Cardiol&#46;"
                        "fecha" => "2015"
                        "volumen" => "12"
                        "paginaInicial" => "464"
                        "paginaFinal" => "474"
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                    ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Preven&#231;&#227;o e tratamento do tromboembolismo venoso&#58; o lugar dos novos anticoagulantes orais"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "A&#46; Reis"
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                        ]
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                    0 => array:2 [
                      "doi" => "10.1016/S0870-2551(12)70039-2"
                      "Revista" => array:7 [
                        "tituloSerie" => "Rev Port Cardiol&#46;"
                        "fecha" => "2012"
                        "volumen" => "31"
                        "numero" => "Supl"
                        "paginaInicial" => "45"
                        "paginaFinal" => "50"
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