AAGBI/Anaesthesia Research Grants

Background
Worldwide the burden of emergency surgery is considerable and there is a need for interventions to improve outcomes in this high-risk patient group. The association between general anaesthesia (GA) and worse patient outcomes has been investigated in some areas of emergency surgery like hip fractures, groin hernia repairs, repair of ruptured abdominal aortic aneurysms (a weak swelling in the main artery that carries blood from the heart). While delivering an alternative mode of anaesthesia for suitable emergency surgery procedures is potentially beneficial to patients, it is a complex intervention to evaluate and very little is known about the clinician and patient perspectives and preferences for different types of anaesthesia in emergency surgery. There is also no consensus about the exact way to describe and define the type of anaesthesia used in clinical studies.

Aims
This collaborative project between the anaesthesia and surgical specialties aims to optimise the design of a future large-scale study, which will investigate the effect of type of anaesthesia on outcomes after emergency surgery.

Objectives
1. Summarize systematically the evidence in the literature for the effect of type of anaesthesia on outcomes after emergency surgery
2. Understand the views of clinicians performing emergency surgery on the use of different modes of anaesthesia
3. Explore patient experience of different modes of anaesthesia and preference in the context of emergency surgery
4. Reach consensus about the description of different modes of anaesthesia as an intervention

Methods
1. We will review the literature and publish a summary of the available evidence about the effect of types of anaesthesia on outcomes in emergency surgery
2. Special interviews to find out the views of emergency doctors (anaesthetists, surgeons and radiologists) and theatre staff about choice of anaesthesia for patients who are undergoing emergency surgery
3. Interviews with patients who had emergency surgery about their experience and views about different anaesthesia options
4. Delphi consensus process: The results from the literature review and the patient and staff interviews will be used to compile a long-list of definitions and anaesthetic protocols for various types of anaesthesia. Invited stakeholders, including clinicians, patients and researchers will then rank them. The final consensus about the definitions and exact description of different types of anaesthesia will include those most highly rated across all stakeholder groups.

Outputs
This study will provide the information needed to design a large multicentre trial where the effect of different types of anaesthesia in emergency surgery will be tested. The results will also be of direct relevance to patients and practitioners with potential benefits to patient safety and outcomes across a range of surgical procedures.

Background
Perioperative medicine encompasses the care of a patient from the moment an operation is planned to the completion of recovery. NIAA's priority setting exercise identified the question of how we measure the success of perioperative care as a research priority.

Time taken return to mobilise, sleep patterns and questionnaires e.g. QoR-15, are ways of measuring patient comfort after an operation, however these can be time-consuming to administer, or difficult for patients to recall accurately.

Many individuals wear devices ("accelerometers") that monitor their activity (e.g. Fitbit™). We would like to investigate whether these can be used in perioperative research to measure outcomes. In this pilot study we propose to investigate their feasibility to assess recovery after day case surgery (i.e. where patient goes home the same day as their operation).

This is a collaboration between SWARM (South West Anaesthesia Research Matrix) and OpenLab computer science researchers at Newcastle University who develop the Axivity AX3 accelerometer and software.

Aims
• To investigate the feasibility of using accelerometers to track recovery after day case surgery
• To gain experience with this technology
• To test a methodology that could be deployed at scale across a research network

Methodology
Adult patients for day case surgery will have information about the study sent to them with their operation details, they will have some days to read the information before their anaesthetic pre-assessment clinic. At this clinic there will be the opportunity for a discussion and obtaining written consent. Standard clinical care will not be affected by inclusion in this study. We will recruit for 6 months or until 50 patients have been recruited.

The accelerometer is worn on the wrist for three "Wear Periods" of 7 days. Before the operation (baseline activity), after the operation (recovery), and at 3 months (full recovery). The device will be returned by post, a stamped addressed envelope will be provided.

To facilitate analysis of the movement data a physical activity questionnaire will be completed at the end of each week, and in the postoperative week a daily QoR-15 questionnaire will be administered by telephone. Demographics and details of the operation will be collected on the day of surgery.

Movement data will be transferred to Newcastle by a secure University drop off for analysis. No patient identifiable information will be transferred.

Expected outcomes
Computer scientist collaborators use raw movement data from the Axivity AX3 device to quantify movement.

Candidate measures are:
• Step count
• Intensity of activity
• Sleep
• Energy expenditure
• Proportion of active time
• Character of activity

We will make an assessment of the accelerometer and candidate measures in terms of "reliability and responsiveness", e.g. a reliable and responsive tool will detect a reduction in activity after an operation compared to baseline activity, and will generate a similar recovery profile as the QoR-15 questionnaire.

"Acceptability" will be assessed using feedback questionnaire, analysis of recruitment and dropout rate, and public involvement group.

"Feasibility" will be assessed by collecting data about recruitment rate, compliance, device return rate, and proportion of lost/unusable data.

Implications
This is a pilot. The results from this study will inform possible future research projects; we believe this tool may have utility to be used at scale across our research network (which covers the South West) to test the effect of interventions.

Surgery to repair a swelling of the main blood vessel in the body, the aorta, can result in paralysis; this happens in about a fifth of cases. This can be due to a reduction in the amount of blood going to the spinal cord and can be likened to a "heart attack" of the spine. There are several measures which can be introduced during the surgery to reduce the likelihood of this occurring. However, these are often based on the judgement of the clinical team rather than objective real-time measures.

Currently, the most common monitoring technique measures the sizes of small electrical signals recorded from muscles in the legs following a large electrical stimulus to the brain. This tests the effectiveness of the connections between the brain and the muscles and a reduction in the size of the responses can indicate a reduction of the blood flow to the spinal cord. The technique involves the insertion of small needles into the scalp and muscles. This, together with the electrical stimulus, is very painful and is therefore usually only performed whilst the patient is anaesthetised. A proportion of the patients who undergo this surgery may also become paralysed during the recovery period, when they are awake; the above technique cannot be used during this time. This 'late' paralysis is more associated with keyhole surgery to repair the swelling of the aorta, a technique employed more and more with an increasingly older population in whom major open surgery is not advocated. It is therefore essential to develop a way to monitor the spinal cord in patients who are anaesthetised during surgery or awake following it.

An alternative method, 'Transcranial Magnetic Stimulation' activates the brain using a magnet; this is painless and can therefore be performed when the patient is awake before or after surgery as well as during the surgery itself. It is a safe technique which has been used for many years for predominantly research purposes, but it has not yet been used as a monitor in patients undergoing the surgery described above. In our proposed research project, we will use magnetic stimulation to further characterise muscle responses in patients with long-standing disease of the arteries and in patients undergoing surgery of the arteries in the legs. This research is critical to interpreting the changes which may occur in the muscle responses during surgery of the aorta.

To this end, we have recently begun to use magnetic stimulation to compare muscle responses in healthy volunteers and in patients with long-standing disease of arteries in the legs. In addition, we have used this technique to address technical issues and safety concerns in a theatre environment on a patient undergoing surgery of the aorta.

Continuation of this research is essential before magnetic brain stimulation can be used to prevent paralysis in patients undergoing aortic surgery. Successful completion of this work will lead to the development of a monitor which could detect and prevent this devastating complication.

Background
Lung cancer is the second most common type of cancer in the UK and the leading cause of cancer related death. Surgery to remove the tumour and the surrounding lung (lung resection) often provides the best chance of cure. Frequently, patients are smokers with related lung or heart problems increasing the risks associated with surgery. Whilst surgery for lung cancer is considered the best chance of 'cure', patients may suffer long term breathlessness, lowering quality of life. This is important; public engagement work we have performed demonstrates repeatedly that second only to "being alive and cancer free" exercise capacity is the main priority of postoperative patients.

Prediction of breathlessness is difficult and not solely caused by lung removal but also from decreased performance of the heart. Although the surgery does not directly involve the heart, it is thought the damage is caused indirectly by the surgery and by removal of part of the lung. Current methods for predicting the risk of breathlessness after surgery are inaccurate. Some patients are refused surgery based on these methods yet may have had successful surgery. Furthermore, no specific treatment exists for patients considered to be at increased risk of breathlessness.

By identifying patients at risk of breathlessness, we believe an opportunity exists to intervene. A small study we completed (a 'pilot study') suggests measuring a hormone called 'BNP' (B type-natriuretic peptide, released by the heart) will improve prediction of postoperative breathlessness.

Aims
Can BNP be used alongside current risk prediction methods to accurately identify those at risk of breathlessness and poor quality of life following lung resection?

Methodology
With consent at pre-assessment clinic, BNP blood levels will be measured before and after lung resection in 250 patients at 4 hospitals across the UK. Validated questionnaires will be distributed following surgery measuring breathlessness and quality of life and returned via post at three months. Questionnaires were selected via patient and public involvement to represent what matters most to patients following surgery. This data will be integrated into current scoring systems to prove it increases identification of patients who will suffer from breathlessness and poor quality of life following surgery. Creation and testing of a risk prediction tool, or 'score', requires complex statistical techniques; we are therefore working alongside specialist biostatisticians.

Expected outcomes
BNP will improve the prediction of those likely to suffer from breathlessness and poor quality of life after surgery. In the pilot study of 25 patients BNP testing was useful but this must be proved in a larger population at several hospitals before considered sufficiently reliable to use in patient care.

Implications
Improved prediction of breathlessness could:
- Provide a new risk prediction tool that can be used in hospitals and incorporated into national guidelines
- Improve patient information when choosing to undergo surgery
- Allow patients previously believed to be too high-risk access to curative surgery
- Allow targeted treatments to be tested in patients most at risk to prevent disabling postoperative breathlessness and its effects on quality of life