Association of Anaesthetists/Anaesthesia Research Grants

Background
Fluid is often given to patients through a 'drip' during operations to prevent dehydration. This is because patients are not allowed to drink immediately prior to surgery and can lose blood and fluid during the operation. If the fluid given is not warmed, then this will cause the patient to cool down. Getting cold during surgery can increase the number of complications that can occur after surgery. To avoid patients getting cold, it is recommended that all fluids given through a drip are warmed up to body temperature (about 40 degrees Celsius). Fluids can be warmed as they go through the drip by running the fluid over a warm metal plate. However, some recent research has shown that this can cause aluminium from the warm plate to enter the fluid; this may be dangerous to patients and this type of warmer is no longer able to be used. An alternative method is to warm the fluids in advance by placing them in a warming cabinet (like an airing cupboard). If the fluid is given within 30 minutes of being taking out of the warming cabinet, then this method is just as good as using the hot metal plate warmers. Lots of hospitals use these warming cabinets and fluids may be kept in them for up to 30 days. Fluids bags are made of plastic, and heating them for a long time may cause some of the chemicals contained in the plastic to enter the fluid. We have done an early test at the University of Sheffield and the scientific experts in plastics at the university think we should do further tests to check that warming the plastic fluid bags is safe.

Aim
We wish to find out if storing fluid in warming cabinets for 30 days causes plastic chemicals to enter the fluid. We will look at two fluids that are given commonly during operations (saline and Hartmann's solution).

Methods
We will test for plastics in the fluids using a special test that can detect very tiny amounts of plastic (gas chromatography - mass spectrometry). These tests will be carried out by the plastics department of the University of Sheffield. We will test bags of fluid after they have been stored at either room temperature or in a warming cabinet for either 14 or 30 days. The tests will be carried out twice on each sample.

Expected outcomes
The expected outcome is that there will be no plastic found into the fluids after 30 days of warming.

Implications
If no plastic is found in the fluids this would confirm that keeping fluids in warming cabinets is safe and can continue to be done. This is important as this is a very cheap way of warming fluids and this saves the NHS a lot of money each year. The results will be written up for publication in a major anaesthesia journal. If plastics are found in the fluid after warming them then this practice may have to be stopped.

The wellbeing and welfare of NHS staff is hugely important. Improving staff morale and preventing burnout has become a priority for the NHS and many professional medical organisations. Moral distress is a key component and contributor to burnout. Moral distress happens when we know the ethically right thing to do, but cannot do it for some reason. This results in negative feelings such as frustration, anger, anxiety, guilt, and a sense of powerlessness. This can be deeply damaging to the individual and contribute to burnout. Furthermore, moral distress is associated with a tendency to leave to the profession. Staff working on the intensive care unit (ICU) are particularly vulnerable to moral distress. This is because the patients are very unwell and the treatments used are complex with a many different professions involved. Research in North America has shown moral distress is common in intensive care, particularly for nurses. The vast majority of moral distress research has been done in health systems in North America, mainly with nursing staff. Moral distress has not been well studied in the UK NHS system and our knowledge of its impact in this setting is limited.

This piece of research in UK ICUs aims to study the experience of moral distress and identify the common scenarios when it occurs in NHS practice. It also aims to compare moral distress between ICU professions and identify possible ways to improve it. Doctors, nurses, physiotherapists and advanced clinical practitioners at four ICUs in the West Midlands will be asked to take part. Moral distress will be assessed in two different ways. An interview will explore the experience and feelings associated with moral distress along with identifying common causes. It will also explore possible interventions to improve moral distress to inform future research. A previously used questionnaire will measure levels of moral distress. Comparisons by ICU professions and by other factors such as ages and years of experience can then be done. The results of this study will help to understand the prevalence and impact of moral distress in NHS ICUs and help to advise future education, training, practice and policy. It is intended that this study will support a future wider programme of research to develop and investigate interventions to target and reduce moral distress. Alleviating moral distress amongst ICU professionals is highly likely to benefit staff wellbeing and therefore patient care. Improved staff wellbeing is associated with higher quality of care for patients. In addition, if moral distress is alleviated then it is less likely staff will leave the profession and this will improve staff retention. Many areas within the NHS, including intensive care, are suffering from high staff turnover and the negative effects on patient care it can bring. Retention of high-quality staff is the foundation of any high performing department that can facilitate change and provide excellent patient care.

Sepsis is a potentially life-threatening condition that arises when the body's response to an infection harms its own tissues and organs. When it happens during pregnancy, during or after giving birth, or after an abortion it is called maternal sepsis.

It is very common that mothers show signs of infection (around the time of giving birth) and require antibiotics to treat this. Infection becomes the more serious illness of sepsis in a small proportion, but it is necessary to treat suspected infection as early as possible to prevent sepsis. Unborn babies can also become septic. They may show signs of distress requiring early delivery and need antibiotics after birth. Sepsis is important cause of deaths of both mothers and babies in the UK and around the world.

At present, making the diagnosis of infection is very difficult because many of the normal changes that happen in pregnancy and labour mimic those of infection (such as monitoring temperature, heart rate and blood pressure). Furthermore, predicting if an infection will turn into serious sepsis is very difficult. There is also a lack of useful blood tests for the identification of pregnant women with maternal infection and sepsis. It currently takes several days before blood, urine and other tissue samples provide information about infection and in some patients these tests fail to give any useful results. The difficulty in detecting and identifying sepsis can contribute to late detection and or the potential for overtreatment.

This research study aims to closely observe what happens to the normal changes in heart rate, blood pressure and temperature in healthy pregnant women and compare these to pregnant women whose healthcare professional think may be developing sepsis. The study will also look at blood tests that are currently available, but have not been fully studied in pregnancy. In addition, a new blood test will be studied that has the potential to give rapid results in the future. The new test is currently a research tool that looks at how the body's immune system responses to pregnancy and infection/sepsis.

This research has the potential to improve the treatment of sepsis and reduce the number of mothers and unborn babies that die because of this illness. In addition, with a better understanding of current tests and with research into future developments, it may be possible to reduce the number of unnecessary antibiotics prescribed with long-term benefit to the mother, baby and society as a whole.

This study should also contribute to a better understanding of how the maternal immune system works and therefore could lead to further advances in our knowledge and treatment.

Background:
Sepsis is a life-threatening complication of infection that can lead to tissue damage, organ failure and death. Sepsis affects approximately 274,000 people per year and is responsible for 52,000 deaths. Up to 40% of patients that are admitted to hospital with sepsis develop atrial fibrillation (AF). AF is an abnormal heart rhythm that causes the heart to beat irregularly. AF can cause a patient's blood pressure to drop, can cause blood clots to develop that can lead to stroke and doubles the chances of death in patients with sepsis. Not all patients with sepsis develop AF and being able to predict patients that will develop AF means that medications can be started early to treat or possibly prevent AF. AF is diagnosed with an electrocardiograph (ECG) which is a trace showing the electrical activity of the heart. Very early changes in parts of the ECG such as the p-wave may be able to predict if patients are going to develop AF. Similarly, patients may experience extra heart beats before the onset of AF or the time interval between heart beats may be altered. It is not known which of these changes are most accurate at predicting AF or if using combinations increase the accuracy.

Aims:
Determine which ECG features changes are able to most accurately predict AF in patients with sepsis.

Methodology:
Our research is a prospective observational study. All adult patients admitted to the intensive care unit with a diagnosis of sepsis will be eligible for inclusion.

Patients enrolled in the study will have ECG monitored using Holter ECG. ECG will be recorded for 72 hours as most patients that develop AF do so within this time. Holter ECG monitoring will be recorded onto a memory card that will be analysed by a cardiorespiratory specialist using specialist computer software. We will look at a number of features of the ECG called the p-wave, QRS complex, variability in the heart rate and the number of extra heart beats patients have over 24 hours. We will compare the ECG features between patients that develop AF and those that do not to assess if any of the ECG features can predict AF before it occurs. We will assess how sensitive and specific each ECG feature is at predicting AF. We will do this for individual features and combinations of ECG features to see if we can increase the accuracy of ECG to predict patients that develop AF.

This research study is purely observational and there will be no change to the patients care.

Implications: what are the practical implications of your results likely to be?
At present we are not able to predict which patients will develop AF. If we can determine which ECG features can be used to predict AF it may allow doctors to administer medications earlier with the aim of potentially preventing AF from occurring in the first place. Preventing AF may reduce intensive care admissions, shorten hospital stay and result in fewer deaths from sepsis.

Undergoing major abdominal surgery places great stress upon the body, fitter individuals are better able to deal with this stress and have been shown to have better outcomes than those who are less fit.

Our aim is to assess the usefulness of the 6-minute walk test as a fitness test for those destined for major abdominal surgery when they attend our hospital for the first time. The hope is that by testing all the patients for 6 months who are being considered for major abdominal surgery we will be able to work out for Sheffield the distance than can be walked by those that are the fittest.

The fittest patients are expected to do better after major abdominal surgery and would need less time and resources directed at them than those less fit. The less fit have been shown in other centres to benefit from strategies to improve fitness before major abdominal surgery. If we can find Sheffield's less fit patients at first visit this should give us more time to improve their fitness before surgery, which should see them have better results after surgery. We would check that those we think are the fittest by the walk test are indeed the fittest by comparing how far they walked to how well they do on their routine bike test. The bike test is the most reliable way to assess fitness but it takes us in Sheffield at least 45min to do and usually involves another visit to the hospital by the patient. There is also a waiting list for the bike test, we fall we expect to be asked to undertake more bike test in the future. If we could quickly identify those individuals who need our attention and resources more then we could start the process of improving their chances of a good recovery from surgery at their very first visit to the hospital.

One centre has reported that for them it was possible to spot the fitter patients from the distance walked. What is not known is wither the distance walked by the fittest in Middlesbrough would be the same as Sheffield. We also don't know if it is practical to have patients do the walk test on their first visit to hospital and if they did would we be able to identify the fittest patients so that we could focus resources on the less fit at the time of first visit. We would need to see how much time that would give us to get patients fitter before surgery and finally we would need to check that those that walked the furthest were in fact the fittest.

The group from Middlesbrough calculated that a sample size of 100 was adequate for their needs. Six months of data should provide us with 250 sets of six-minute distance covered data for analysis.

Background
During anaesthesia for repair of a broken hip, many patients experience low blood pressure. There have been many studies showing that patients who experience low blood pressure during anaesthesia are at increased risk of sustaining kidney or heart damage, strokes, having a post-operative infection, or dying. During anaesthesia, in most cases blood pressure is monitored using a cuff which inflates on the arm (the 'normal' way blood pressure is measured in a GP practice or hospital ward). This gives a reading each time the cuff goes up and down, every 3-5 minutes typically. There is a less well used way to measure blood pressure, using an additional cuff on the finger which gives a constant, continuous measure of blood pressure. We think that using this monitor, rather than the 'standard' monitor, will mean that low blood pressure is recognised more quickly, therefore treated more quickly, and will lead to patients having less exposure to dangerously low blood pressures. If this is the case, we hope that it will reduce how often patients experience kidney or heart damage, have an infection after surgery, suffer a stroke, and reduce the risk of death.

Methodology
To test this, we would need to run a large clinical trial comparing the continuous monitor to the standard monitor. This would be expensive and involve a great deal of work in a large number of hospitals, and so first we wish to determine whether the trial we would like to run is practical, and possible to deliver in the real world. To do this we plan to run the trial first on a small-scale feasibility (pilot) study, where we will recruit 30 patients, half of whom will have the standard monitor, and half of whom will have the continuous monitor. We will see what proportion of the patients who could enter the trial actually do so and complete it, and use it as an opportunity to iron out problems with the trial. If we find it is possible to run the trial on a small scale, we will apply for funding to run a full study. This will aim to answer the question of whether the continuous monitor improves the patient outcomes which were agreed during development with the patient public involvement group locally; rate of kidney damage, heart damage, stroke, post-operative infections, risk of death, and hospital length-of-stay.

Expected outcomes and implications
We anticipate we will find the trial to be feasible with amendments to the way it is run, and if this is the case, we will apply to run the full-scale trial. If this shows that using the continuous monitor improves the patient outcomes above, then it would represent new, significant evidence that may lead to the NHS adopting it's use as 'standard care' during anaesthesia for repair of a broken hip, and would like lead to similar trials in other operations where patients may benefit in a similar way.