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High Mortality Rate in Patients of Major Surgical Procedures

Introduction

Life expectancy in the developed world is improving probably due to the improved living standards over the years. Statistics show that in the year two thousand and eight, France had thirty two percent of its citizens with sixty five years of age and seventeen percent was above seventy five years. United States of America has a large elderly population which continues to grow with time. This population data provides useful clues that one can obtain the information required during the conduction of the research. Conduction of a multivariate research is important as it would enable establishment of the independent factors of elderly patients. This will provide further evidence to support the hypothesis statement by comparing data from both young and old population (Walke & Rosenthal 2011).

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Major surgical operations are performed to an ever increasing number of elderly patients. The number of patients in need of major digestive, cardiovascular operations and various bone construction surgery is on the rise. The older group among these is more affected. Most elderly patients that undergo surgery experience high postoperative morbidity and mortality rates despite the constant advancement in medical technology. Preoperative choices worsen the situation since they determine the possible outcome indicators and tend to provide little help eventually. Based on this, the research will base on the various causes of death following major surgery together with the possible solutions. The research will focus on particular operation procedure such as gastrectomy, hepatectomy, pancreatectomy, esophagectomy, colectomy, cardiovascular surgery and bone construction surgery or on a clearly defined age group such as above sixty five years or below. The research will seek to address the solutions to the mortality issue (Chung & Martin 2010).

The hypothesis of this research proposal is there is need of further advancement in medical technology in order to reduce the risk factor associated with postoperative mortality. This has to specifically increase physical and psychological strength to achieve its objective.

Literature review

There is high mortality and morbidity rate among the elderly cause due to major surgeries. Current medication procedures follow the operative medical assessment. This enables detection of patients with high risk of negative postoperative effects. Intraoperative and postoperative management of anaesthesia is important in minimizing these dangerous and possibly fatal effects.

Among the ever increasing population of the elderly, people aged above sixty five years of age, those above eighty five years have the greatest effect on this growth. It is natural for the human body functions to deteriorate with increase in age. The large number of the elderly only serves to increase number of surgeries among people with pre-existing states of weakened immune systems. Ageing normally weakens the cardiac, pulmonary and blood sugar levels. This increases the chances of death following a major operation especially those on the cardiac and cerebral systems. These operations even though necessary at times, they are often accompanied with side effects which if combined with poor body state, the result is catastrophic. In the recent past, various organizations and people conducted research related to this area. These include occurrence of adverse postoperative effects, predictions of possible negative postoperative effects, preoperative check up on elderly patients with possible high health risk and perioperative management. The research will majorly focus on whether improvement of perioperative anaesthesia management can aid in the reduction of these adverse postoperative results (Cook & Campbell 1979).

Death caused by anaesthesia and surgical operation is defined as loss of life within a month after the operation. Continuous technological advancement in medicine reduces the mortality rate due to anaesthesia management. However, the mortality rate due surgery among the elderly is lower than the average mortality rate of the whole population. This mortality rate increases with each age group. For example, emergency operations on the abdomen cause 9.7 percent mortality for patients above seventy years, 17 percent above eighty years and 19 percent above 90 years (Torbert & Lackman 2011).

There are several factors that one can use in determining the state of the body to know whether one can undergo an operation or not. Ageing reduces the functional capacity of various body organs. This in turn increases their vulnerability as they may succumb to stress very easily. Diseases associated with this do more harm as they reduce the functionality of these organs even further. For instance, hypertension, renal failure and diabetes mellitus contribute 5.1 percent of perioperative myocardial infarction. Elderly people suffering from coronary artery disease have a high chance of suffering from preoperative myocardial infarction. This is so because there is a 4.1 percent incidence for patients above sixty five years and 5.5 percent prevalence in the general population. In addition, ischaemic conditions prove their dominance among patients suffering from coronary artery disease and underwent major non-cardiac operation. This condition combined with preoperative myocardial infarction lead to high mortality rates due to surgical operations among the elderly compared to the young in a similar state. Therefore, age is a crucial factor when it comes to surgery since it gives incite on whether to proceed with the operation or not (Katlic 2001).

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Mortality due to respiratory complications ranges between zero and 0.6 percent. This is affected by the surgery site and the occurrence of risk factors associated with the pulmonary system. The mortality rate among the elderly ranges from 0.03 to 0.64 percent for those that undergo hip bone replacement surgery. One of the risk factors for suffering from pulmonary embolism is age. However, research shows that low dose aspirin used as a prophylactic drug or low dose of heparin reduces the mortality rate among the elderly patients suffering from pulmonary embolism. A research group known as PEPTCG (Pulmonary Embolism Trial Collaborative Group) conducted a research and established that aspirin reduces the elderly death rate due to hip bone surgery by thirty percent. However, this increases the prevalence of gastro intestinal bleeding which is less dangerous (Walke & Rosenthal 2011).

Another group known as the BHFSG (The Belgian Hip Fracture Study Group) studied and established that the mortality rate of elderly patients that had hip surgery between 1978 and 1983 was twenty four percent. Age together with gender and pulmonary infection affected this data. Recent research provides slightly different data compared to this. Death rate among patients hip bone break is higher at thirty six percent compared to earlier statistics within first year of hospital discharge. Most of the elderly female patients experienced neuropsychiatric disorders in addition to the hip fracture. Patients above eighty five years of age experienced higher mortality rates compared to their younger counterparts at seventy eight years (Shadish, Cook & Campbell 2002).

There exist more causes of postoperative effects such as cerebrovascular complications that cause mortality rates of up to 0.05 percent. All these conditions are related to old age. The postoperative period is normally physiologically stressful. Major body changes characterize this period which include high body temperature, chest congestion leading to breathing difficulties, high adrenaline in the blood and low perception to pain due to numbness. These conditions lead to hypertension which in turn causes death (Sinclair 2009).

Since the perioperative conditions affect the postoperative ones, it is important to be vigilant in dealing with its assessment. There is need of appropriate control of intraoperative conditions to avert disastrous results in cases where the patient has arterial diseases, hypertension, heart diseases and diabetes. Direct postoperative monitoring that in the process ensures pin management will also help reduce the mortality rate. For instance, analgesics can reduce myocardial ischaemia.

Old age has numerous effects on cardiac operations. These include artery stiffening which causes load on the heart after systole and myocardial stiffening leads to poor diastole operation. This eventually affects the diastolic volume output which is important in ensuring supply of body requirements adequately during exercises. Myocardial infarction and ischaemia are cardiovascular disorders that may occur during the first few days after surgery. MI is usually difficult to detect. This is due to the residual effect of the anaesthesia used during the operation procedure. The anaesthetic effects make the recuperating patient numb to pain, hence, causing difficulties in the detection of the condition. Observation of elderly patients with high risk of myocardial ischaemia during and after the operation process is of the essence. A medical practitioner must perform a postoperative examination for ST segment depression, which is a specific indication of the concerned mortality rate (Sinclair 2009).

There are some special cases when the elderly patients experience postoperative delirium. This is a state in which they exhibit incoherence in speech and thought. Short term or distorted memory may also characterize this state. These elderly patients experience this condition within one day after operation and the condition gets worse at night fall. At times, it may be misdiagnosed as lack of rest or depression. This may lead to death since it impedes the normal body function and causes delayed recovery among the affected patients.

Postoperative mortality in elderly patients (people above sixty five years of age) is an important factor to consider in sustaining a healthy elderly population group. Qualified medical practitioners can prevent these problems through preoperative assessment of these patients. This ensures recognition of patients at intraoperative and high risk postoperative effects through patient history taking, physiological examination, and proper body functional capacity examination. It is also of the essence to carry out anaesthesia management and reduce overall cost by reducing the number of preoperative tests. Specific intraoperative and postoperative anaesthesia management such as haemodynamic stability and normothermia, prevention of hypoxaemia and effective postoperative pain control that strives to eliminate body numbness, will minimize postoperative negative effects in the elderly (Pignolo, Keenan & Hebela 2010).

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In summary, the recommendations for intraoperative and postoperative management are: first, preoperative examination to establish whether the elderly patients in question are at high risk of postoperative negative consequences. Second, use of preoperative testing (invasive or non-invasive) to establish whether the test results are likely to determine the course of the surgical procedure or to indicate the need for high risk invasive monitoring system which give real time information on patients condition such as pulmonary artery catheterization. Third, effective perioperative constant observation and control of pre-existing diseases. Fourth, proper maintenance of stable perioperative haemodynamics for all elderly patients, especially those suffering from cardiac, ailments using vasopressor or vasodilator drugs, or beta-adrenoceptor block, or a combination of appropriate therapies. Fifth, use of a less invasive surgical procedure instead of the invasive type which more risky and costly, for example laparoscopy on a mobile basis. Sixth, provision of intensive perioperative monitoring for high risk elderly patients. This applies mainly to those patients with high blood pressure. Seventh, prevention of hypoxaemia, delirium and hypothermia. Finally, effective postoperative pain control through proper anaesthesia management. Through incorporating each of these conditions, many patients on the verge of death due to neglect or unfortunate personal ailments will survive. This will improve the life expectancy of the aged living with pre-existing conditions that prove fatal if combined with surgery (Sessler 2008).

The above data only serve as an example from research carried on by other groups.

Ethical considerations

Most learning institutions have a very well organized system and protocols to follow when it comes to empirical research. As part of the regulations, the administration requires the student to report to a specially formed committee that deals specifically with this issue. Failure to do so will be breach of the school rules and regulations. These committees aim to provide all the relevant information that pertains to the research together with relevant external terms and conditions of operations. Normally, the committee consists of at least one member with experience in research and is a professor. They are important as they provide the technical knowledge required especially for those students conducting research for the first time.

One’s supervisor also contributes significantly to a research. They play a major role in providing guidance to the student on the necessary issues to prevent or reduce time wasting. They are also a signatory in all those forms in which you are a signatory. If they fail to sign the forms are rejected since it is assumed there is no official guidance for the student (Sinclair 2009).

Methods

There are various methods that one can use in research. Sampling will be the method of choice since it is relatively familiar and basic. A sample is a small representation of the whole population. A correct sample should ideally incorporate the general characteristics of each person. The researcher may have a sampling frame which is a theoretical list that constitutes the population. The following five paragraphs describe the major procedures to follow during the sampling process.

First, convenience of the procedure plays a key role. The convenience sample will include those elderly volunteers in the hospitals with various ailments. These ailments are hip bone fracture, cardiovascular complications, pulmonary ailments and gastro intestinal problems, all of which are in line to surgery. This sampling procedure is the most common. Despite this, there arise errors due to biasness. The error arises since not all the elderly patients have an equal chase of selection. This means those patients ready to volunteer may be different from those that are not interested in the procedure yet correct data depends on all these groups (Walke, Byers, Gallo, Endrass & Fried 2007).

There exists another method of sampling known as random sampling. In this type, the elderly patients, who are subjects of study, together with the hospital of operation are sampled out randomly. This means that each of the study elements has an equal chase of selection without bias. This sampling type will be conducted in two main ways. “The first is making use of a random number table and the second is having a computer selected random sample” (Walke, Byers, Gallo, Endrass & Fried 2007, p.59).

Another sampling technique is the systematic sample. “The researcher will randomly select a first element on a post operated elderly population list and proceed every Nth subjects until the selection of a full sample” (Walke, Byers, Gallo, Endrass & Fried 2007, p.59). This technique is helpful especially when the population list is lengthy. For instance, if a population list is available, the researcher picks out a number randomly together with the nth count. If they picked eleven, and forty as the Nth count, the next number will be fifty one. The sample will contain elements having multiples of forty added to eleven (Walke, Byers, Gallo, Endrass & Fried 2007).

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In addition to the other three sampling techniques, there exists stratified sampling. In a stratified sample, the researcher samples depending on the characteristics of the strata mostly in terms of size. For instance, since the research will be in the United States, they will make sure that the sample includes elderly people in all the fifty states present. The sample should also include the elderly from both genders. This proves to be an expensive technique but gives data which is reliable (Franco & Verier 2009).

Finally, there is cluster sampling. In this technique, the researcher takes a random sub population and examines individual members in that group. For instance, since this research involves many hospitals within the United States of America, the researcher selects only a few. He then proceeds to survey all the elderly patients operated on and the postoperative effect experience together with possible solutions applied to prevent life loss.

Methodology

“An important concept relevant to research methodology is research validity” (Panneerselvam 2004, p.21). When one asks whether the data is valid, that means more than one piece of information may be invalid. Statistics generally deals with four types of validity. Therefore, when talking about the validity of data studied, one must one must specify the type. This simply means that validity is completely subjective depending on the type validity selected. This is so because the criteria differ among them.

There is a description of each of the validity types in the paragraphs below. This is a representation of validity in a basic manner without thorough explanations. They can independently pose a several research problems. There are examples that try to explain more on these validity types. For a detailed discussion of the types of validity, one can research further since it is vast topic and can one summarizes it here since due to the topic of discussion (Walke, Byers, Gallo, Endrass & Fried 2007).

Statistical Conclusion Validity: One needs vast knowledge in statistics in order to master this validity type. According to Walke, Byers, Gallo, Endrass and Fried (2007), “statistical conclusion validity refers to inferences about whether it is reasonable to presume covariation given a specified alpha level and the obtained variances” (p. 58). This type seeks to compare and contrast different sets of related data. It the study is conducted well, then the different variables within the data must be related. In this case, the variables that need comparison are the postoperative effects and old age of the patients in question (Walke & Rosenthal 2011).

Internal Validity: “Once established that these two variables, old age and postoperative effects are related, the next problem is to establish which one causes the other” (Walke & Rosenthal 2011, p.268). This determines whether old age leads to these postoperative effects. If the study lacks internal validity, the researcher cannot make statements that give the cause together with the corresponding effect. The study must instead describe the findings without inclusion of this statement. There are quite a number of possible treats to this type of validity. For instance, history affects internal validity in a number of ways. In this research, data retrieved from hospital records will compared to data from elderly patients directly. These pieces of information depend on each other for validity butt they may differ. The differences may be due to advancement in technology over time or implementation of recommended solutions to the patients experiencing postoperative effects (Mulholland & Doherty 2010).

Finally, there is external validity. This type of validity tries to ensure that comparison is possible between the data collected and archived information retrieved from hospital. It also tries to give a general picture of the population in different places. For instance, if one conducted a study to establish that a certain disease associated with old age caused a high death rate after operation; can the researcher compare this with postoperative effects among the youth? If the researcher obtains the result, then he one only satisfy external validity if they can obtain the same results with a different sample within the population or in different environment. This type of validity may receive threats if the sample doesn’t give a true representation of the area under study.

There are various methods that one can use in data collection. These include use of Registration, questionnaires, Interviews and direct observations. The researcher will majorly focus on questionnaires and interviews as methods of choice in collecting necessary data for this research (Voisin, Walke & Jeffery 2009).

Proposed findings

One expects to prove that indeed there is high mortality rate among those elderly patients following an operation. The solution to these may lie mostly on how the medical practitioners handle the preoperative effects as the most basic way of avoiding post-operative death among the elderly. The patient must undergo preoperative examination to determine the contraindications already existing. If they exist, the medical practitioner must provide the necessary pre-emptive measures such as determining the most appropriate surgical procedure. They may also decide to introduce a condition monitoring system that provides crucial information that could be lifesaving (Wedin 2001).

Reference List

Chung, EH & Martin, DT 2010, “Management of postoperative arrhythmias”, in JM O’Donnell & FE Nacul (eds), Surgical Intensive Care Medicine, 2nd edn, Springer, New York, pp.209–227.

Cook, TD & Campbell, DT 1979, Quasi-experimentation: Design and analysis issues for field settings, Houghton Mifflin Company, Boston, MA.

Franco, K L & Verier, E D 2009, Advanced Therapy in Cardiac Surgery, 2nd edn, PMPH-USA, New York.

Katlic, M 2001 “Principles of Geriatric Surgery”, in Rosenthal RA, Zenilman ME & Katlic MR. (eds), Principles & Practice of Geriatric Surgery, Springer, New York, 2001, pp. 767-779.

Mulholland, MW & Doherty, GM 2010, Complications in Surgery, 2nd edn, Lippincott Williams & Wilkins, Chicago.

Panneerselvam, R 2004, Research Methodology, PHI Learning Pvt. Ltd, Delhi.

Pignolo, R J, Keenan, MA & Hebela, NM 2010, Fractures in the elderly: A guide to practical management, Springer Science+Business Media, LLC, New York.

Sessler, D I 2008, “Perioperative thermoregulation”, in JH Silverstein, GA Rooke, JG Reves & C H McLeskey (eds), Geriatric anaesthesiology, 2nd edn, Springer, New York, pp. 123–36.

Shadish, W R, Cook, T D & Campbell, D T 2002, Experimental and quasi-experimental designs for generalized causal inference, Houghton Mifflin, Boston, MA.

Sinclair, AJ (ed) 2009, Diabetes in Old Age, 3rd edn, John Wiley & Sons, New York.

Torbert, JT & Lackman, RD 2011, “Pathologic fractures”, in RJ Pignolo, MA Keenan & NM Hebela (eds), Fractures in the Elderly: A Guide to Practical Management, 1st edn,. Springer Science and Business Media, New York, NY, pp. 43-53.

Voisin, JM, Walke, LM & Jeffery, SM 2009, “Home is where the heart is: Living arrangements for older adults”, Consultant Pharmacist, vol. 24, no.2, pp.134-145.

Walke, LM, Byers, AL, Gallo, WT, Endrass, J & Fried, TR 2007, “The Association of Symptoms with Health Outcomes in Chronically Ill Adults”, Journal of Pain and Symptom Management, vol.33, pp.58-66.

Walke, LM & Rosenthal RA 2011, “Preoperative Evaluation of the Older Surgical Patient”, in RA Rosenthal, ME Zenilman & MR Katlic (eds), Principles and Practice of Geriatric Surgery, 2nd edn, Springer, New York, NY, 2011, pp. 267-288.

Wedin, R 2001, “Surgical treatment for pathologic fracture”, Acta Orthop Scand Suppl., vol.72, pp.1-29.

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