Adverse outcomes of geriatric patients undergoing abdominal surgery who are at high risk for delirium.

HYPOTHESIS: Among geriatric patients undergoing abdominal surgery who are at high risk for in-hospital delirium, clinical factors associated with delirium correlate with adverse outcomes. DESIGN: Retrospective case series study. SETTING: University-affiliated referral hospital. PATIENTS: Among 228 consecutive patients 70 years or older who underwent major abdominal surgery from September 1, 2002, through December 31, 2003, 89 patients with risk factors for delirium were included in the study. MAIN OUTCOME MEASURES: Preoperative, intraoperative, and postoperative clinical factors known to affect the incidence of in-hospital delirium were tested for correlation with adverse outcomes. Incidence of delirium, mortality, and prolonged length of stay (LOS) of 14 days or longer were evaluated as adverse outcomes. RESULTS: Postoperative delirium occurred in 60%, death in 20%, and prolonged LOS in 32% of patients. Multivariate analysis identified independent predictors of adverse outcomes. Poor preoperative functional and nutritional status correlated with postoperative delirium and mortality. Inadequate postoperative glycemic control also correlated with mortality. Complications in 2 or more organ systems and postoperative hypoalbuminemia (albumin level <3.0 mg/dL[<.003 g/dL; to convert to grams per liter, multiply by 10]) correlated with prolonged LOS. Suboptimal care was identified in the following clinical areas: use of precipitative medications, prolonged bedrest, uncontrolled pain, hypoxia, and glycemic control. CONCLUSIONS: In a subset of geriatric patients undergoing abdominal surgery who are at high risk for in-hospital delirium, adverse outcomes correlated only with key clinical variables, such as hyperglycemia and poor nutritional and functional states. A high incidence of suboptimal care was observed in several clinical areas, suggesting opportunities for intervention.

Surgical palliative care of advanced wounds.

The history of surgery is rich with accomplishments in wound care, a legacy that recently has been abandoned by many surgeons only to be taken up by nonsurgical providers. When dealing with advanced wounds at the end of life, such as pressure ulcers or venous stasis ulcers, goals of treatment are relief of pain, elimination of odor, and control of wound exudates and infection. Benefits and risks of surgical intervention must be discussed with the patient and family in terms of the patient's perceived prognosis, extent of tissue necrosis and infection, the rate of deterioration, and the underlying wound pathogenesis. When appropriate, the role of surgery looms large in the treatment of chronic, advanced wounds, especially when minimally invasive surgical techniques are used.

Alterations in mRNA expression and protein products following spinal cord injury in humans.

We examined the effects of spinal cord injury (SCI) on alterations in gene expression and respective protein products in human skeletal muscle 2 days and 5 days post-SCI. Biopsies were taken from skeletal muscle of 9 men and 1 woman (n = 10) (43.9 +/- 6.7 years) 2 days and 5 days post-SCI and from 5 healthy young men who served as controls (20.4 +/- 0.5 years). Global changes in gene expression were analysed using Affymetrix GeneChips on a subsample of subjects (n = 3). Candidate genes were then pursued via qRT-PCR. Western blotting (WB) was used to quantify protein products of candidate genes. Immunohistochemistry (IHC) was used to localize proteins. Groups of transcripts showing the greatest percentage of altered expression, the most robust fold-changes, and indicative of involvement of an entire pathway using the GeneChip included genes involved in the ubiquitin proteasome pathway (UPP), metallothionein function, and protease inhibition. qRT-PCR analysis confirmed increases in gene expression for UPP components (UBE3C, Atrogin-1, MURF1, and PSMD11), the metallothioneins (MT1A, MT1F, MT1H), and the protease inhibitor, SLPI (P < 0.05) at 2 days and 5 days post-SCI. Protein levels of the proteasome subunit (PSMD11) and the metallothioneins were increased 5 days post-SCI. Protein levels of UBE3C, Atrogin-1, MURF1 and SLPI were unchanged (P > 0.05). IHC showed increased staining for PSMD11 and the metallothioneins 5 days post-SCI, along the peripheral region of the cells. IHC also showed altered staining for Atrogin-1 at 5 days post-SCI along the membrane region. Thus, there was a profound increase in gene expression of UPP components, the metallothioneins, and the protease inhibitor, SLPI, within 5 days of SCI. Increased protein levels for PSMD11 and the metallothioneins 5 days post-SCI, specifically along the cell periphery, indicate that proteins in this region may be early targets for degradation post-SCI.

Postoperative futile care: stopping the train when the family says "keep going".

All surgeons must take risks when providing medical care. No guarantees of protection from a lawsuit exist in any guise. Concerning postoperative futile care, the stakes are high when withdrawal of support seems to be indicated but the surrogate believes in sanctity-of-life and demands continued aggressive care. Open-ended questions posed to the family may initiate a dialog that help the surgeon understand their values and negotiate a resolution. Other preventive measures can also reduce the chance of conflict and potential liability. "Do what's right" is a proverbial motto in surgical training and clinical practice. To some surgeons, it may be to honor the wishes of the family surrogate. To others, the right thing may be to withdraw care in the best interest of the patient. If so, "do what's right" is not just to "stop the train." It also consists of a range of clinical activities, including effective communication, emotional care, and pursuing a fair and open negotiation process established by the institution. Properly conducted, "stopping the train" should incur no greater risk for professional liability than any other challenging procedure that surgeons perform. Withdrawal of futile care should be considered as a procedure, and as such, the skills to deliver it should be mastered like any other.

Palliative care: good legal defense.

The perceived risk of legal liability looms large as a major barrier to optimal palliative care among surgeons. Aggressive pain management may cause respiratory depression and death, whereas withdrawal of support may lead to a charge of manslaughter. Citing legal principles and precedents, this article explains why there is legal support for terminal analgesia and sedation, balanced chronic pain management, and effective surgeon-patient communication in the setting of good surgical palliative care.