JAMA surgery
-
The need for integrating palliative care into surgical services has been established within the surgical literature. The ability to effectively screen, obtain an appropriately timed consultation, and determine the effect of consultation remains problematic. ⋯ Our data suggest that a systematic frailty-screening program effectively identifies at-risk surgical patients and is associated with a significant reduction in mortality for patients undergoing palliative care consultation. Analysis also suggests that preoperative palliative care consultations ordered by surgeons are associated with reduced mortality rates.
-
Owing to the phenomenon known as "global graying," elderly-specific conditions, including frailty, will become more prominent among patients undergoing surgery. The concept of frailty, its effect on surgical outcomes, and its assessment and management were discussed during the 38th Annual Surgical Symposium of the Association of VA Surgeons panel session entitled "What's the Big Deal about Frailty?" and held in New Haven, Connecticut, on April 7, 2014. The expert panel discussed the following questions and topics: (1) Why is frailty so important? (2) How do we identify the frail patient prior to the operating room? (3) The current state of the art: preoperative frail evaluation. (4) Preoperative interventions for frailty prior to operation: do they work? (5) Intraoperative management of the frail patient: does anesthesia play a role? (6) Postoperative care of the frail patient: is rescue the issue? This special communication summarizes the panel session topics and provides highlights of the expert panel's discussions and relevant key points regarding care for the geriatric frail surgical patient.
-
Improper mechanical ventilation settings can exacerbate acute lung injury by causing a secondary ventilator-induced lung injury. It is therefore important to establish the mechanism by which the ventilator induces lung injury to develop protective ventilation strategies. It has been postulated that the mechanism of ventilator-induced lung injury is the result of heterogeneous, elevated strain on the pulmonary parenchyma. Acute lung injury has been associated with increases in whole-lung macrostrain, which is correlated with increased pathology. However, the effect of mechanical ventilation on alveolar microstrain remains unknown. ⋯ Increased positive-end expiratory pressure and reduced time at low pressure (decreased T(low)) reduced alveolar microstrain. Reduced microstrain and improved alveolar recruitment using an APRV T-PEFR to PEFR ratio of 75% may be the mechanism of lung protection seen in previous clinical and animal studies.
-
Many hospitals have undertaken initiatives to improve care during the end of life, recognizing that some individuals have unique needs that are often not met in acute inpatient care settings. Studies of surgical patients have shown this population to receive palliative care at reduced rates in comparison with medical patients. ⋯ In the VHA population, surgical patients are less likely to receive either hospice or palliative care in the year prior to death compared with medical patients, yet surgical patients have a longer length of time in these services. Determining criteria for higher-risk medical and surgical patients may help with increasing the relative use of these services. Potential barriers and differences may exist among surgical and medical services that could impact the use of palliative care or hospice in the last year of life.