INTRODUCTION

COVID-19, an infecti= on caused by the SARS-CoV= -2 coronavirus, was first identified in December 2019 in Wuhan, China, = with the occurrence of pneumonia cases as a result of a previously unknown infectious agent. Later, the high power of contagion and infection was identified, and more severe cases of the disease that resulted in Severe Ac= ute Respiratory Syndrome (SARS). In Brazil, the first case was registered in February 2020 in the state of São Paulo. It is currently configured as a pu= blic health emergency due to its high degree of dissemination and mortality (1).

COVID-19 disease is a serious disease, usually presenting with the symptoms of fever, cough, dyspnea, mya= lgia and/or fatigue and can infect anyone at any age, and in some cases may be asymptomatic. It manifests more severely in the elderly and in those with an underlying disease such as hypertension, cardiovascular disease, diabetes mellitus, renal disease from the University Hospital, obstructive pulmonary disease (COPD). It can result in progressive respirat= ory failure contributing to increased mortality rate ⁽²⁾.=

In the context of the pandemic, health systems had to readjust to the new need= to face COVID-19. Many hospital services suspended elective surgical procedures and maintained only priority in urgent and emergency procedures, due to the need to make more beds available for patients with COVID-19. However, the suspension of these elective procedures, but that presented an urgent chara= cter resulted in the increased mortality of patients who needed to undergo some surgical modality ⁽²⁾.

Therefore, in the current context of the SARS-CoV-2 pandemic, a protocol should= be implemented for patients who need to undergo a surgical procedure, defining= how the preoperative preparation, the management of the intraoperative period a= nd the postoperative surveillance should be carried out in order to avoid complications and ensure the safety of patients and of the healthcare team = ⁽³⁾.

The return of elective surgeries= in the stabilization phase of the pandemic of COVID-19 demonstrated the difficulties of health institutions in determining the ideal time to perform surgical procedures in patients who recovered from COVID-19, since the dise= ase can complicate the perioperative course and raise the mortality rate even in small surgeries ⁽³⁾.

Due to the scarcity of informati= on about the clinical characteristics and outcomes of patients infected with COVID-19 undergoing surgery, considering that asymptomatic patients with COVID-19 suffer rapid deterioration of clinical status after surgery and, therefore, the surgical area, in the context of the pandemic, faces a need = for several adaptations. In this sense= , this integrative literature review was proposed with the objective of identifyin= g, in the scientific literature, the available evidence regarding the main post-surgical complications in patients with COVID-19, expanding the knowledge and scientific basis for the care practice to the Coronavirus-infected individu= al with the need to undergo a surgical procedure.

METHODS

This is an integrati= ve review conducted in June 2021, following the following steps: problem identification; literature search; data evaluation; data analysis and data presentation.

The search strategy = for the primary studies and guiding question followed the PICOS strategy (Population, Intervention, Comparison Group, Outcomes and Study Design) (4).

The population (P) of interest consisted of patients undergoing surgical proced= ure after infection by COVID-19; In this study, the intervention (I) was replac= ed by exposure (E) because it was a harmful event to health, therefore, not subject to randomization. COVID-19 infection was considered the exposure (E= ). There was no comparison or control group (C). The outcome (O) was postopera= tive complications after COVID-19. And the type of study (S) was original studies with qualitative synthesis.

Six stag= es were followed to conduct this literature review: 1st stage - Development of= the guiding question; 2nd stage - Literature search or sampling; 3rd stage - Da= ta collection; 4th stage - Critical analysis of the included studies; 5th stag= e - Discussion of results; 6th stage - Presentation of the integrative review.<= span style=3D'color:black'>

The 1st phase "elaboration of the guiding question" can be defined as the most important phase in the development of the review being: What is the current scientific evidence available in the literature regarding postopera= tive complications in patients after COVID-19 infection?

The 2nd phase "Search or sampling in the literature". For this study,= the following electronic databases were chosen for the searches: Medical Litera= ture Analysis and Retrieval System Online (MedLine/P= ubMed), Virtual Health Library (VHL), Electronic Library Online (SciELO), Latin American Literature (LILACS).

To conduct the search strategies with a focus on retrieving the largest number= of studies that answered the guiding question, a structured vocabulary of Health Sciences Descriptors (DeCS) was used, co= mbined with the Boolean operators AND and OR. The foll= owing search strategy was used to list the primary studies: "New coronavirus" OR "Novel Coronavirus" OR "SARS-CoV= -2" OR "COVID-19" AND "Trauma" OR "Emergency trauma care" OR "Emergency trauma care" AND "Emergency surgery" OR "Emergency surgery" AND "Infection prevention" OR "infection prevention".

The eligibility criteria were guided by the research question. Studies that addressed surgical complications in patients after infection by COVID-19, published in Portuguese and English, in the period from 2019 to 2021, which= had the searched descriptors were included. The excluded studies were secondary studies, response letters, editorials, and duplicate articles. Following the search criteria, a flow chart (according to PRISMA) was prepared in the database search ⁽⁵⁾.

The 3rd phase was carried out data collection extracting the identifi= cation data of the articles (title, year of publication and country) and the methodological characteristics of the study (type of study, research subject and main results and conclusions) from a table prepared by the authors.

The 4th phase soon after, after the instrument was filled out, the analysis of the results was performed, describing, and classifying the data. Then, the arti= cles were grouped, according to the main issues addressed.

The 5th phase, "Discussion of results", in which analyses of the data obtained were performed and presented in tabular form, enabling the identification of the theme of this research. The 6th phase "It was the Presentation of integrative review= ", which relates to a presentation of all relevant information in a detailed a= nd objective way, with clear and complete description for the feasibility of t= he critical evaluation of the results.

RESULTS

&nb= sp;

The initial search resulted in 7= 67 studies in the MedLine/PubMed database, = 12 in the Virtual Health Library (VHL), 02 in SciELO and 88 in LILAC, totaling 869 publications. Then the selection was performed, considering the potentially eligible studies, in this step 849 publications were elected. Of this total, 804 publications were excluded for not meeting the inclusion criteria. Then, 65 studies remained for reading of the titles and abstracts, after thorough reading 58 studies were excluded for not answering the resea= rch question, seven studies were selected at the end for the synthesis of evide= nce, according to the PRISMA model (Figure 1).

Table 1 - Distribu= tion of references included in the integrative review, according to year of publication, country, authors, type of study, main results, and conclusions= .

Nº	<= /span> TITLE=	YEAR AND COUNTRY=	TYPE OF STUDY=	RESEARCH SUBJECT	MAIN RESULTS/= CONCLUSIONS= =
01	Emergency trauma care during the outbreak of corona virus disease 2019 (COVID-19) in China (Yang Li) ⁽⁶⁾.	2020, Wuhan, China.	Observational descriptive.	Patients with COVID-19 who required emergency surgical procedure.	Acute lung injury caused by COVID-19 may exist preoperatively or worsen postoperatively; Occurrence of respiratory failure and septic shock postoperatively.<= /o:p>
<= /span> 02	Perioperative Considerations in Urgent Surgical Care of Suspected and Confirmed Coronav= irus Disease 2019 Orthopaedic Patients: Operating = Room Protocols and Recommendations in the Current Coronavirus Disease 2019 Pan= demic (Mohamed) ⁽⁷⁾.	2020, United States.	Cross-sectional descriptive.	Confirmed COVID-19 urgent orthopedic patients.	A severe COVID-19 subset can cause a "cytokine storm syndrome," w= hich is an under-recognized hyperinflammatory syndrome characterized by a fata= l hyper fulminant with multiple organ failure.
03	Emergency Surgery= and Trauma Care During COVID-19 Pandemic. Recommendations of the Spanish Association of Surgeons (Aranda-Narváez) ⁽⁸⁾.	2020, Spain	Descriptive retrospective.	Emergency surgery and care of the polytrauma patient.	The surgical injury itself could be a trigger for a disproportionate immediate inflammatory response that in COVID-19-infected patients can be deleterio= us.
04	The management of surgical patients in the emergency setting during COVID-19 pandemic: the = WSES position paper⁽⁹⁾.	2021, Not informed.	Retrospective descriptive.	Emergency surgeries for surgical patients	Surgery can have a negative impact in COVID-19 patients, even if they are asymptomatic, with mortality of 20.5% and the potential need for postoperative ICU care.
05	Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection⁽¹⁰⁾.	2020, Wuhan, China.	Retrospective descriptive.	Patients undergoing selective surgery during the COVID-19 incubation period.<= /o:p>	COVID-19 is associated with poor prognosis for patients undergoing surgery, especi= ally for those with chronic diseases.
06	Mortality and pulmonary complications in patients undergoing surgery with periopera= tive SARS-CoV-2 infection: an international cohort study⁽¹¹⁾.	2020, China and Singapore.	Cross-sectional descriptive.	Patients undergoing surgery who had confirmed SARS-CoV-2 infection 7 days before o= r 30 days after surgery.	The primary outcome was mortality, followed by pulmonary complications.<= /o:p>
07	Postoperative outcomes in surgical COVID19 patients: a multicenter cohort study^(1= 2).	2021, Canada	Longitudinal descriptive.	COVID-19 patients undergoing surgery.	Pulmonary complications Infectious complications (non-pulmonary) Acute kidney injury Thromboembolic complications

Source: The authors

From the analysis of Table 1, the research subjects were defined as patients with COVID-19 who needed to undergo emergency surgical procedures ^{(6, 9, 12)}, confirmed COVID-19 urgent orthop= edic patients ⁽⁷⁾, emergency surge= ry and care of the polytrauma (8) patient, patients undergoing selective surgery during the incu= bation period of COVID-19 ⁽¹⁰⁾, pati= ents undergoing surgery who had confirmed SARS-CoV-2 infection 7 days before or = 30 days after surgery ⁽¹¹⁾.

The surgical procedure had a negative impact on the clinical picture of these patients, even those who were asymptomatic in the preoperative period had a significant increase in postoperative mortality <= sup>(9). The main complications identified in the postoperative period of these pati= ents cited in the studies who had active or recent COVID-19 infection were: acute lung injury caused by COVID-19, respiratory failure, septic shock, "cytokine storm syndrome", which is an under-recognized hyperinflammatory syndrome characterized by a hyper fulminant and fatal with multiple organ failure, t= he surgical injury itself as a factor to trigger a disproportionate immediate inflammatory response, acute kidney injury, thromboembolic complications and increased need for admission to Intensive Care Unit (ICU).

DISCUSSION

The pand= emic caused by COVID-19 has worried the authorities and health professionals bec= ause it is one of the greatest challenges currently faced by health services, si= nce little is known about the disease, which is why many of the procedures that have been carried out since the beginning of the disease were based on empi= ricism⁽¹³⁾.

Surgical patients, both those who had contact with COVID-19 before undergoing a surg= ical procedure and those who are exposed to a high risk of contracting the disea= se postoperatively have a high risk of morbidity and mortality and a greater chance of requiring admission to an Intensive Care Unit⁽¹³⁾.

From the analysis of the results, it was found that most of the patients involved in= the studies had a history of previous exposure to COVID-19 before hospital admission, some had symptoms and others did not have any signs or symptoms = of COVID-19 before surgery, however, they underwent surgical procedure due to being emergency situations ⁽¹⁴⁾.

Patients with COVID-19 have a higher postoperative mortality rate, and Postoperative patients with COVID-19 required Intensive Care Unit care in a much higher proportion than in COVID-19 patients hospitalized without surgery, and most patients were older, had more underlying comorbidities and longer surgical time, and underwent more difficult surgeries. This suggests that advanced a= ge associated with comorbidities, surgical time and surgical difficulties may = be risk factors for unfavorable outcomes ⁽¹⁵⁾.

Trauma and surgery can impair the patient's immune function. Clinically, some asymptomatic patients with COVID-19 deteriorate rapidly after surgery. Surg= eons and anesthesiologists should be aware that acute lung injury caused by COVI= D-19 may exist preoperatively or worsen postoperatively⁽¹⁶⁾.<= span lang=3DEN-US style=3D'font-size:12.0pt;line-height:150%;font-family:"Times = New Roman",serif; mso-fareast-font-family:"Times New Roman";mso-ansi-language:EN-US'>

It is noteworthy that postoperative pulmonary complic= ations were identified in half of the patients undergoing surgical procedures with prior COVID-19 infection⁽¹⁷⁾.

Pulmonary complications were defined as pneumonia, acute respiratory distress syndrome (ARDS) or unexpected postoperative ventilation. These are the most frequent pulmonary complications related to COVID-19 in surgical patients. Additional secondary outcomes included pulmonary embolism, ICU admission, reoperation, 7-day mortality, and length of stay⁽¹⁸⁾.

Therefor= e, the characterization and differentiation of symptoms can help the health te= am to identify patients with potential unfavorable outcomes. Thus, the postoperative evaluation aims to identify possible complications arising fr= om the patient's clinical picture⁽¹⁹⁾.

Each hea= lth care institution and surgical team should carefully review all elective procedures with the goal of evaluating the cost benefit of the procedure am= id the risk of likely complications due to COVID-19, preventing adverse events= in these patients of low morbidity and mortality, but that can course as fatal procedures in infected by COVID-19 ⁽²⁰⁾.

Therefor= e, given the current context, one should postpone or cancel non-essential elec= tive surgeries and carefully evaluate the timing and the risks and benefits in performing these essential elective surgical procedures that may have impor= tant clinical repercussions by not performing surgery ⁽²¹⁾.

It is emphasized that the local and regional epidemiological evaluation is a determining and fundamental factor to be evaluated before considering the resumption of elective surgeries, it is recommended as the moment when occu= rs the sustained reduction of new cases of COVID-19 at least 14 consecutive da= ys in the geographical area⁽¹⁵⁾.

Health institutions should formulate strategies and guidelines for surgical quality and safety aimed at the care of these patients, in addition to the evaluati= on of the structural conditions of the health service, availability of several hospital beds to care for post-surgical patients and the demand for cases of COVID-19⁽²¹⁾.

To assist health services, the National Health Surveillance Agency (ANVISA) released a technical note with guidelines for the prevention and control of infections= by the new coronavirus (SARS-CoV-2) in surgical procedures in order to ensure = the safe resumption of elective surgical procedures, defining how the surgical schedule should be made, the composition of the surgical team and safety measures adopted in the surgical environment ⁽¹⁵⁾.

&nb= sp;

CONCLUSION

Surgery has a negative impact on patients with COVID-19, even those who are asymptomatic, raising the risk of mortality and the potential need for postoperative admission to the Intensive Care Unit (ICU).

The research that integrated the present review reveals that the main postoperative complications in patients infe= cted with COVID-19 or who were recovering from a recent infection of the disease are: pulmonary complications, infectious (non-pulmonary) complications, acu= te kidney injury, thromboembolic complications, septic shock and the cytokine storm syndrome, characterized as an under-recognized hyperinflammatory synd= rome resulting in multiple organ failure due to its hyper fulminant state.

Given the results found, it is found that all non-urgent procedures should be postponed until the patient has complied with the isolation and transmission care criteria and the disease has entered the recovery phase. =

It is believed that this study can encourage new scientific producti= ons related to the topic, considering that it is a current problem and of great impact on public health, representing a potential agent of complications for surgical patients.

As a limitation of this study, we highlight the reduced number of bo= th national and international literature on the theme. Therefore, there is a n= eed for future research on the theme in order to contribute to the clarificatio= n of the still unknown complications of COVID-19 in patients submitted to surger= y.

REFERENCES

1.      Brito SBP, B= raga IO, Cunha CC, Palácio MAV, Takenami I. Pandemia= da COVID-19: o maior desafio do século XXI COVID-19. Vigi= l. sanit. debate 2020;8(2):54-63. [acesso em 06 jun 2021]; Disponível em: https://visa= emdebate.incqs.fiocruz.br/index.php/visaemdebate/article/view/1531/1148 =

<= /o:p>

2.      Nahshon C, Bitterman A, Haddad R, Hazzan D, Lavie O. Hazardous Postoperative Outcomes of Unexpected COVID-19 Infected Patient= s: A Call for Global Consideration of Sampling all A= symptomatic Patients Before Surgical Treatment. World J Surg. 2020;16:1-5. [acesso em 07 jun 2021]; Disponível em: https://euro= pepmc.org/backend/ptpmcrender.fcgi?accid=3DPMC7229873&blobtype=3Dpdf

3.      Marques LC, Lucca= DC, Alves, EO, Fernandes, GCM, Nascimento KC. = COVID-19: Cuidados de enfermagem para segurança no atendimento de serviço pré-hospita= lar móvel. Texto & Contexto Enfermagem. 2020; 29: e20200119. [acesso em 07 = jun 2021]; Disponível em: https://www.= scielo.br/j/tce/a/TsWF5LWQStRtzYJCnP9jvvK/?lang=3Dpt&format=3Dpdf

4.&n= bsp;     Methley<= /span> AM, Campbell S, Chew-Graham C, Mcnally R, Cheraghi-Sohi S. PICO, PICOS and SPIDER: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. BMC Health Services Research (2014)<= /span>. [acesso em 10 jun 2021]; Disponível em: https://bmchealthservres.biomedcentral.com/track/p= df/10.1186/s12913-014-0579-0.

5.      Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010; 8(5):336-41. doi: 10.1016/j.ijsu.2010.02.007. Epub 2010 Feb 18. Erratum in: Int J Surg. 2010;= 8(8):658. PMID: 20171303. [acesso em 10 jun 2021]; Disponível em: https://read= er.elsevier.com/reader/sd/pii/S1743919110000403?token=3D31548CA75EF5E

6.&n= bsp;     Li Y, Zeng L, Li Z, Mao Q, Liu D, Zhang L, et al. Emergency tr= auma care during the outbreak of corona virus disease 2019 (COVID-19) in China. World Journal of Emergency Surgery (2020). [acesso em 23 jun 2021]; Disponível em= : https://wjes.biomedcentral.com/articles/10.1186/s1= 3017-020-00312-5

7.      Awad ME, Rumley JCL, Vazq= uez JA, Devine JG. Perioperative Considerations in Urgent Surgical Care of Suspected and Confirmed COVID-19 Orthopaedic Pa= tients: Operating Room Protocols and Recommendations in the Current COVID-19 Pandem= ic. J Am Acad= Orthop Surg. 2020; 28(11): 451-463. doi:10.5435/JAAOS-D-20-00227 [acesso em 23 jun 2021]; Disponível em: https://www.= ncbi.nlm.nih.gov/pmc/articles/PMC7197335/=

8.      JM, Tallón-Aguilar L, Pareja-Ciu= ró F, Martín-Martín G, González-S= ánchez AJ, = Rey-Simó I, et al. Em= ergency Surgery and Trauma Care During COVID-19 Pandemic. Recommendations of the Spanish Association of Surgeon= s. cirugía española. 2020; [acesso em 24 jun 2021]; Disponí= vel em: https://pubmed.ncbi.nlm.nih.gov/324391= 39/=

9.      Simone BD, Chouillard E, Sartelli M, Biffl WL, Saverio SD, Moore EE, et al. The management of surgical patients in the emergency setting during COVID-19 pandemic: the WSES position paper. = [acesso em 24 jun 2021]; Disponível em: https://www.= scienceopen.com/document?vid=3D6414e1b0-99fd-41d7-905a-ccce0c81f621<= /a>=

10. Lei S, Jiangb F, Sua W= , Chen C, Jingli Chen, Mei W, et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. EClinicalMed= icine 21 (2020) 1= 00331. [acesso em 25 jun 2021]; Disponível em: = https://www.= thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30075-4/fulltext

11. COVID Surg Collaborative. Mor= tality and pulmonary complications in patients undergoing surgery with perioperati= ve SARS-CoV-2 infection: an international cohort study. The Lancet.com Vol 396 July 4, 2020. [acesso em 25 jun 2021]; Disponível = em: https://www.= thelancet.com/journals/lancet/article/PIIS0140-6736(20)31182-X/fulltext=

12. Carrier FM, Amzal= lag E, Lecluyse V, Côté= G, Couture EJ, D’A= ragon F, et al. Postoperative outcomes in surgical COVID19 patients: a multicenter cohort study. Carrier et al. BMC Anesthesiology = (2021) 21:15. [acesso em 26 jun 2021]; Disponível em: https://bmca= nesthesiol.biomedcentral.com/articles/10.1186/s12871-021-01233-9= <= /span>

13. Nunes VRT, D= ias JSR, Nogueira HPP, Assis AC, Brenck LF, Andrade= GL, Aguiar-Jr MC. Cuidados cirúrgicos durante a pandemia mundial do COVID-19: rotinas alternativas para minimizar os riscos. Rev Med Minas Gerais 2021; 31: e-31701. [acesso em 07 jul 2021]; Disponível em: http://www.rmmg.org/artigo/detalhes/27= 74=

14. Wang D, Hu B, = Hu C, Zhu F, Liu X, Zhang J et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020. [acesso em 07 jul 2021]; Disponível em: https://jama= network.com/journals/jama/fullarticle/2761044= . <= /span>

15. Nota Técnica GVIMS/GGTES/ANVISA nº 06/2020 Orientações para a prevenção e o controle das infecções pelo novo coronavírus (sars-cov-2) em procedimentos cirúrgicos - Revisão: 30/03/2021 (complementar à nota técnica GVIMS/GGTES/ANVISA Nº 04/2020). [recurso eletrônico]; [acesso em 08 j= ul 2021]; Disponível em: https://amec= i.org.br/wp-content/uploads/2021/04/NOTA-TECNICA-06_2020-CIRURGIAS-30.03.20= 21-para-o-site.pdf=

16. = Hojaij<= /span> FC, Chinelatto LA, Boog GHP, Kasmirski JA, Lopes JVZ, Sacramen= to FM. Surgical Practice in the Current COVID-19 Pandemic: A Rapid Systematic Review. <= span style=3D'font-size:12.0pt;font-family:"Times New Roman",serif;color:black'>= Clinics= (São Paulo), 2020;75:e1923. [acesso em 09 jul 2021]; Disponível em: = https://www.= scielo.br/j/clin/a/BqHnTftSkJcqCZ4zJZ8RZdP/?lang=3Den=

=

17. Jinpeng= Li, Rongfen Gao, Gaosong Wu, = Xiaolin Wu, Zeming Liu, <= span class=3DSpellE>Hongjing Wang, Yihui Huan= g, Zhenyu Pan, Jincao Chen,<= span style=3D'mso-spacerun:yes'> Xiaohui Wu.= Clinical characteristics of emergency surgery patients infected with coronavirus disease 2019 (COVID-19) pneumoni= a in Wuhan, China [acesso em: 09 jul 2021]. Disponível em: https://www.= sciencedirect.com/science/article/pii/S0039606020302865= . <= /span>

<= /o:p>

18. Aminian A, Safari S, = Razeghian-Jahromi A, Ghorbani M, Delaney CP. COVID-19 Outbreak and Surgical Practice: Unexpected Fatality in Perioperative Period. Ann Surg. 2020 Mar 26. [a= cesso em: 09 jul 2021]. Disponível em: https://www.= ncbi.nlm.nih.gov/pmc/articles/PMC7188030/pdf/ansu-publish-ahead-of-print-10= .1097.sla.0000000000003925.pdf =

<= /o:p>

19. Coccolini F, Perrone = G, Chiarugi M, Di Marzo F, Ansaloni L,&nb= sp;Scandroglio I, et al. Surgery in COVID-19 patients: operational directives. World J Emerg Surg. V.15, n.25, 2020. [acesso em: = 09 jul 2021]. Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7137852/= .

<= /o:p>

20. Pereira X, Lima Dl, Moran-Atkin E, Malcher F. Para onde foram os pacientes cirúrgicos durante a pandemia de COVID-19? = Rev Col Bras Cir 47: e2020273= 3. [acesso em: 12 jul 2021]. Disponível em: https://www.= scielo.br/j/rcbc/a/NdcQdjmT9HwVqmzC8vdkX9w/?format=3Dpdf&lang=3Dpt.

<= /o:p>

21. Nunes VRT, Dias JSR, Nogueira HPP, Assis AC, Brenck L= F, Andrade GL, Aguiar-Jr MC. Cuidados cirúrgicos durante a pandemia mundial do COVID-19: rotinas alternativas para minimizar os riscos. Rev Med Minas Gera= is 2021; 31: e-31701. [acesso em: 12 jul 2021]. Disponível emhttp://www.rmmg.o= rg/artigo/detalhes/2774

Corresponding author

Aline Sousa Falcão, Rua Z, quadra 01, casa 07 Planalto Anil III, CEP: 65050879. Telefone: +55(98) 98784-5286, e-mail: alinesousafalcao19@gmail.com / alinefalcao.rims@huufma.br<= span style=3D'font-size:12.0pt;font-family:"Times New Roman",serif;background:wh= ite'>

Submission= : 2021-09-06

Approval: 2021-10-28