Lay Abstracts
The six minute walk test as a predictor of morbidity following major colorectal surgery
Dr Kieran Donnelly
Major surgery causes increased stress on organ systems both during and after surgery. The cardiovascular and respiratory systems are particularly important at this time, as they are responsible for the delivery of supplemental oxygen and nutrients to the healing body tissues.
Patients are at risk of complications during, or more commonly after, major surgery. These can include, among others, chest or wound infections, heart problems or kidney damage. This is more likely if the cardiovascular or respiratory systems are already weakened, often due to pre-existing disease or advanced age.
A thorough assessment of patient cardio-respiratory 'reserve' or 'function' can be achieved via formal exercise testing (CPEX - cardio-pulmonary exercise test), however it is not widely available, being expensive and time consuming. The six-minute walk test (6MWT) is proposed as an alternative; the further someone can walk in a six-minute timeframe, the better their cardio-respiratory function. It is already used to measure cardio-respiratory function in chronic lung disease and is a safe and simple procedure to perform.
Studies have shown the link between the distance walked and cardio-respiratory function can be a predictor of complications after surgery, though this has not been formally assessed using the 6MWT specifically.
We aim to evaluate 100 patients using the 6MWT during a routine pre-operative clinic appointment who are to undergo major bowel surgery. We will be collecting data to help us establish whether;
1. The distance walked during the test can predict the presence of complications, such as infection or organ damage, 30 and 90 days after the operation
2. This prediction is as good as another pre-operative prediction score that is widely used - the POSSUM score
3. Combining the distance walked during the 6MWT with the POSSUM prediction score will improve overall prediction of the presence of complications after surgery
4. The 6MWT is an exercise that patients would generally find 'acceptable'. This would be done via a questionnaire.
The data collected before the operation would include basic information that would routinely be collated during a standard appointment in the Preoperative Assessment Clinic prior to surgery. This includes basic demographic information, certain blood tests results and history of previous medical illnesses.
Data specific to the 6MWT includes vital signs before, during and after the test. Neither the patient nor clinical team treating the patient will know the results of the 6MWT, which will be performed while the patient is in the Preoperative Assessment Clinic.
Further data would be retrieved from patient notes/records and via a structured telephone interview at 30 and 90 days after surgery. It would include any admission to the intensive care unit, any need for further operation and presence of any complications.
Evaluation of benefits, risks and barriers to implementation of an ISO 26825 colour coded anaesthetic drug tray
Dr Iain Moppett
Background
Anaesthetists are relatively unusual in medicine as they are frequently responsible for diagnosis, drug prescription, selection, preparation and administration in a single episode. This often takes place in a non-ideal environment with time pressures and distractions. It is estimated that drug errors occur in around 1 in 140 anaesthetics. Although most of these cause little harm, they can be catastrophic. Patients have died due to inadvertent intravenous administration of local anaesthetics. The recent NAP 5 report into accidental awareness highlighted the distress caused to patients who were inadvertently given paralysing drugs whilst still awake. Previous research into anaesthesia drug errors has helped us to understand the causes, but relatively little progress has been made in reducing errors. Within industry a common approach to routine, high risk tasks is to provide standardisation, structure and visual / verbal cues to assist personnel to do the right thing and highlight errors early.
We have developed a prototype bespoke anaesthetic drug tray (the Rainbow Tray') which uses international standard colour coding for drug types, separates routine and emergency drugs and complies with infection control standards. Initial feedback is generally positive. Experience from industry and from other initiatives in medicine is that even apparently simple initiatives do not always work the way they are intended or expected.
We wish to perform a small observational study which compares how anaesthetists currently prepare and store their drugs with the new system. We also wish to explore anaesthetists' perceptions of factors which would encourage or hinder adoption of this (or similar) systems.
Method
The study will take place in three hospitals in different locations, and limited overlap of trainees. The first part of the study will involve a trained researcher observing anaesthetists unobtrusively whilst they use drugs in their normal practice, and with the Rainbow Tray. The observer will be looking for both positive and negative aspects of practice and unexpected consequences of the new system. The second part of the study will involve asking anaesthetists about their perceptions of current and new practice, as well as key factors which would be important in any future implementation.
Limitations
The evaluation is relatively small scale and cannot identify all effects of the tray. No drug tray can prevent all errors - mislabelling during preparation will only be indirectly affected by the process.
Outcomes
In the short term, the data will be used to make design improvements in the tray. In the medium term, we hope the data will assist organisations such as AAGBI and NHS England in setting practical and realistic guidance, standards and education regarding safe preparation of drugs in anaesthesia. Ultimately, we hope the consequence will be a reduction in anaesthesia related drug errors.
Prevention of Respiratory Insufficiency after Surgical Management (PRISM) Trial: An international pragmatic randomised controlled trial of continuous positive airway pressure to prevent respiratory complications and improve survival after major abdominal surgery
Prof Rupert Pearse
Background: Far from being replaced by new drug therapies, surgical treatments are offered to more patients than ever before. In particular, older patients with serious medical problems are more likely to undergo surgery today than 20 years ago. In a technical sense, surgery and anaesthesia are very safe, yet high-risk patients frequently develop medical complications, especially following major abdominal surgery. These complications have a lasting human and financial cost which may be avoidable. Surgery and anaesthesia have a number of harmful effects on the lungs, and respiratory complications such as pneumonia, are amongst the most important in terms of frequency and severity. However, current standard treatments like physiotherapy and supplemental oxygen do not always prevent complications from developing.
Several small clinical trials have shown that continuous positive airways pressure (CPAP) can reduce respiratory complications after major abdominal surgery. CPAP is a method of supporting breathing using slightly pressurised air, usually delivered using a tight-fitting facemask. This can make it easier for patients to breathe, and may help them recover more quickly from the effects of surgery and anaesthesia, so avoiding complications such as pneumonia. CPAP has been widely used for many years in the treatment of patients with various types of breathing problems and can be delivered safely on hospital wards or even in the patient's home. However, a lack of robust evidence from large-scale clinical trials has prevented the routine use of CPAP for patients after abdominal surgery.
Design: We will recruit 4784 patients into an international, randomised controlled trial to determine whether CPAP immediately after major abdominal surgery can reduce the number of patients who develop serious respiratory complications.
Research impact: We hope that the results of this trial will lead to a step-change in care for patients recovering from major abdominal surgery. Our ultimate aim is to reduce the number of complications following surgery and improve patient survival.
Trial conduct: This trial is an international collaboration led by Professor Rupert Pearse (UK) and supported by Professor Marco Ranieri (Italy) as joint chief investigators. The UK team will be responsible for the majority of the day-to-day trial management. The trial will be evaluated by a research ethics committee and conducted according to the highest standards of participant care (Good Clinical Practice for research).
Case for support: The major strategic reason for this application is to clearly demonstrate that the management costs for the UK arm of the trial are funded in open competition by an NIHR portfolio partner. This will ensure we can leverage vital NIHR Network support for patient recruitment in participating NHS centres, which is crucial to the success of the trial in the UK. The AAGBI would be represented as a key funder of this major international study. The trial will also be supported using existing resources, including Professor Pearse's NIHR Research Professorship and BJA/RCoA research fellowship. If funded we would submit the PRISM trial to the board of the newly formed NIAA Perioperative Medicine Clinical Trials Group, to be considered for adoption.
