Lay Abstracts
Can infrared thermal imaging be used to quantify abnormal skin perfusion in sepsis?
Dr Matthew Charlton
Background
Sepsis is a life-threatening condition caused by the body's response to overwhelming infection. Sepsis is common, affects all age groups, and is estimated to cause over 37,000 deaths each year in the UK (more than breast and bowel cancer combined). Because patients often need prolonged treatment and time to recover, and Intensive Care is expensive, the NHS cost of treating sepsis are high, exceeding £2 billion annually.
Previous research has shown that in patients who have sepsis, the small blood vessels supplying oxygen and nutrients to the skin and other organs become abnormal and do not function as they would in health. This can be felt as cool skin and seen as a blotchy pattern, termed clinically as "mottling". Research in 2014 showed that patients who had this clinical sign were much more likely to die in Intensive Care than those who did not. However, this is a late sign and cannot be seen in all skin colours.
Thermal imaging cameras are highly specialized pieces of equipment which record the natural heat waves given off by all objects. They are extremely sensitive, being able to detect temperature changes that are not apparent clinically or by standard thermometers. In patients with sepsis, the altered blood flow leads to an uneven cooling of the skin which can be seen by a thermal imaging camera, producing a picture very similar to the blotchy appearance seen with the naked eye. The difference being however, that due to the sensitivity, this can potentially be seen at a much earlier stage, with skin colour playing no part in its detection.
Aim
We plan to investigate the differences in skin temperature which are seen in patients with sepsis using a thermal imaging camera, comparing them to healthy volunteers.
Methodology
This is an observational study, involving no change in care and no risk. We plan to recruit a total of 105 participants, 35 each of healthy volunteers, uncomplicated sepsis and severe sepsis. Patient will be recruited mainly from the Emergency Department and Intensive Care Unit. with volunteers being recruited from staff and relatives.
Basic information along with any pre-existing medical conditions and treatments will be recorded, along with any details about the patient's acute illness.
A single thermal image of the leg will be taken with the participant lying down in a bed. Participants will not be able to be identified from the images taken. Images will be examined and analysed by doctors and scientists at the University of Leicester.
Expected outcome
We expect that patients with sepsis will have an alteration in the distribution of temperature of the lower leg when compared with healthy volunteers. We predict this derangement will be worse in sicker patients.
Implications
Exploring associations between thermal images and disease severity along with identifying thermal mottling, may allow us to identify those patients at an increased risk of dying earlier in their illness. In the future this may allow us to target treatment, improving patient survival.
Characterising the coagulopathy of postpartum haemorrhage.
Professor Peter Collins
Background
Severe bleeding is the most common cause of major problems at the time of childbirth and affects over 10 000 women every year in the UK. Bleeding may be made worse if the blood clotting system is affected and the blood becomes too thin. There is a lot of information about how major trauma can make the blood too thin and how this should be treated. There is very little information about how bleeding at the time of childbirth makes the blood too thin. Also, it is very likely that the specific cause of the bleeding will make the blood thin in different ways. Because there is so little information about how the blood clots during bleeding after childbirth, women are usually treated in the same way as people who have had major trauma. This is unlikely to be the best treatment and may even cause harm because some women may be given treatment unnecessarily.
Aims of study
We plan to use specialised tests to look in detail at the blood clotting system of women who are experiencing bleeding at the time of childbirth. We will compare the results with women who are having babies but who are not bleeding.
We will look at whether the specific cause of the bleeding affects the blood clotting system differently and also how the changes in blood clotting evolve if bleeds continue and routine treatment is given.
We will also look at what effect treatment designed to thicken the blood has on the blood clotting system to see whether it is working as expected.
Study
Women who are having moderate or severe bleeding can be involved in the study. All women who are bleeding after childbirth have routine blood clotting tests done. If bleeding continues these tests are repeated roughly every 30 minutes. We plan to take extra blood at the time of the routine blood clotting tests and use it to perform specialised tests of the blood clotting system.
The specialist tests will see whether specific clotting factors are working normally and whether any changes have happened that inhibit blood clotting or break down clots more quickly than normal. If any treatment is given to thicken the blood we will check the specialist tests after the treatment to see what effect it has had.
Outcome of the study
The information from the study will show how the blood clotting system if affected by bleeding after childbirth. It will help us to work out how best to support the blood clotting system of women who are bleeding at the time of childbirth and to stop the bleeding sooner.
Satisfaction and Wellbeing in Anaesthetic Training (SWeAT).
Dr Alex Looseley
Background
Anaesthesia as a medical specialty often produces high levels of job satisfaction. Despite this, 30% of UK anaesthetists feel stressed 'a lot of the time' and 5% feel stressed 'all the time'. For anaesthetists and trainee anaesthetists, high stress levels can lead to depression and burnout syndrome: this consists of feeling emotionally exhausted, having an unfeeling response to one's patients and having a sense that one's work lacks value. Anaesthetic trainees experiencing burnout syndrome are more likely to make medical errors and practice less safely, increasing the risk of harm to their patients. Burnout and depression are also linked with personality change, substance abuse and suicide (suicide is higher in anaesthetists than the general population or other medical specialties). Anaesthetic trainees may be more at risk compared to senior anaesthetists. Working long hours, sleep deprivation, limited ability to control one's work, high levels of work-home interference, pressure to pass exams, female gender and alcohol consumption may all play a part.
Levels of stress, depression and burnout syndrome have never been properly explored in UK anaesthetic trainees. This is an important issue, coming at a time when the pressures and expectations for UK anaesthetic trainees are changing. Job satisfaction, stress, depression and burnout syndrome have an impact not only on the health and wellbeing of this important medical workforce, but also, the patients it looks after.
Aims
1. To assess the levels of job satisfaction, stress, depression and burnout among trainee anaesthetists within Southwest England and Wales.
2. To identify and explore the potential factors which contribute to these traits.
Methods
This study is a collaboration between three regional trainee-led research groups.
Firstly, we will send an anonymous and confidential electronic questionnaire to all anaesthetic trainees in Severn, Peninsula and Wales Deaneries (approximately 500). This will collect demographic, health-related and anaesthetic training information as well as record the time spent on other work in addition to directly looking after patients (and the perceived impact of this). It will also use tried-and-tested assessment tools to work out the levels of depression, burnout, stress and job satisfaction.
Secondly, an experienced psychologist will carry out optional and confidential telephone interviews on a sample of those who score highly for stress, depression and/or burnout. The interviews will be recorded and then later analysed to identify potential factors that contribute to the development of stress, depression or burnout. We appreciate that this could cause distress in some participants so have systems in place to identify and support their welfare if necessary.
Potential benefits of the study
UK anaesthetic trainees will become the future consultant workforce and will play an essential role in providing a high-quality, safe, consultant-led NHS service. This study will provide accurate, current information for those involved in educating, supervising and managing UK anaesthetic trainees. This will help guide appropriate support and mentoring for current and future trainees and hopefully identify ways to improve the health and wellbeing of these doctors and also, improve patient safety.
Effect of spontaneous ventilation versus positive pressure ventilation in patients undergoing diagnostic thoracoscopic biopsy for Interstitial Lung Disease (ILD) under General Anaesthesia (GA).
Dr Guillermo Martinez-Munoz
One of the many causes of lung disease is a family of conditions known as 'Interstitial Lung Disease' or ILD. In ILD, the lungs become progressively scarred, impairing their ability to take in oxygen, and secrete carbon dioxide. It is difficult to control, and frequently fatal.
A key way of diagnosing ILD is to take a biopsy of the lung. For many patients, the taking of the biopsy is essential as the results allow the respiratory physicians to prescribe medications appropriate to the specific type of ILD the patient has.
The biopsy takes place under general anaesthesia. During such an anaesthetic, the patient has a breathing tube inserted, and their normal respiration is taken over by a ventilator, which blows air into the lungs. This form of ventilation is known as "mechanical ventilation".
We know that whilst taking a biopsy from a patient thought to have ILD is sometimes essential to guide treatment and prolong life, we also know that it is not without risk. Up to 4% of patients die following this procedure, usually because of an inflammatory reaction in the lungs following the operation.
We know from studies in patients with ILD on a ventilator in the intensive care unit that mechanical ventilation can accelerate the scarring of the lungs, leading to worsening lung function. Whilst there are many differences between the critically ill patient in the ICU receiving mechanical ventilation and the otherwise well patient with ILD attending hospital for a lung biopsy, it is possible that the short period of mechanical ventilation required during the anaesthetic for the lung biopsy could be responsible for the inflammatory reaction we see in some patients after the operation.
There are alternatives to mechanical ventilation during general anaesthesia for lung biopsy surgery. Most of these allow the patient to keep breathing on their own, meaning that PPV is not required. They are well researched, and appear safe when compared with what we do currently. However, no researchers have yet compared allowing the patient to breathe on their own (known as "spontaneous ventilation") with mechanical ventilation in properly designed trial examining patients with ILD. Our group proposes to do just this.
We plan to conduct a small trial, where patients are randomly assigned to receive a general anaesthetic with mechanical ventilation, or a general anaesthetic with spontaneous ventilation for their lung biopsy surgery. We will then follow these patients whilst they are in hospital to compare their quality of recovery, and then for six months afterwards to see if there are any detectable differences in their lung function, and whether or not there are any detectable differences in the length of time in hospital.
Modifiable perioperative risk factors for postoperative delirium in older adults undergoing major elective non-cardiac surgery: a feasibility cohort study (PODIUM 1 study).
Dr Iain McCullagh
Background and current knowledge
Over the last ten years, there has been a 27% rise in surgery performed in the UK and increasing numbers of older people are having major surgery for a wide range of conditions. Unfortunately, older people are more likely to develop complications after surgery, in particular postoperative delirium. Delirium is a distressing state of confusion which typically develops in people in the first few days after they have had surgery. The symptoms can vary from person to person with some people feeling disorientated and not able to remember why they are in hospital, whilst others may see things which aren't there or feel withdrawn or paranoid.
Although postoperative complications such as pneumonia and heart attack are well understood, postoperative delirium is not. We know certain things increase a person's risk of getting delirium, such as already having dementia or drinking excess alcohol, but we know much less about the things that lead to delirium in previously healthy people. This is important because people who develop delirium have a delayed recovery and may be at risk of developing memory and thinking problems later in life.
Aims and objectives
This "feasibility study" will provide the vital groundwork for a large, national multicentre study of postoperative delirium. The aim is to see how the study design works in practice and identify any issues prior to undertaking a bigger study. The small study will also give us an estimate of how often delirium occurs. Ultimately in the larger study we hope to find a group of factors that we can change in order to make postoperative delirium less likely to happen.
Patient involvement, study design and methods
We have benefitted from patient involvement in the design of this study and will continue to do this when we design our patient information leaflets and consent forms. We will also invite a patient representative to join the Study Steering Committee.
Our study will follow a group of people undergoing major, planned surgery. Before the operation we will do some simple memory tests along with screening tests for depression and alcohol consumption and a baseline delirium test. Then, for the first four days after the operation, we will repeat the delirium screening test on a daily basis. We will also collect information on general health as well as details of the anaesthetic, surgery and any medication given afterwards. The postoperative and preoperative assessments will be performed by the same individual wherever possible.
Ethical issues
We will ensure all potential participants have enough information to make an informed decision on whether or not to take part in this study. We are aware of the potential burden to patients of taking part in this study and have given much thought to the number of tests involved. If a participant develops delirium we will make sure the clinical team are aware so they can assess and treat as required. We will ask patients for feedback on their experience of the study after their final assessment in hospital.
Future research
The results of this study will inform the design of PODIUM 2, a large-scale, observational study to find out if there are things we could do differently to reduce the likelihood of postoperative delirium. These small changes in practice - a care bundle - could then be tested in a clinical trial.
Recovery after emergency laparotomy (REmLap). A prospective observational feasibility study.
Dr Julian Sonksen
Laparotomy is a major surgical operation undertaken to treat a range of diseases inside the abdomen. When the disease progresses to a sudden life threatening stage the patient can become very ill, rapidly and need an emergency laparotomy. About 30000 - 50000 emergency laparotomies are carried out each year in the UK. This type of major abdominal surgery often has a life-changing impact on the patient and their family. Therefore, return of quality of life (QoL) to levels before the onset of symptoms which led to this operation is vitally important. Our knowledge on how patients recover, the time scale of this recovery, the use of support services as well as the factors that contribute to suboptimal recovery or loss of function is currently limited. To date no study has reported in detail the QoL in patients following emergency laparotomy. We aim to conduct such a study using a two part design. The first part (this study) will be a feasibility study undertaken at The Dudley Group NHS FT. The hospital has a well-established Emergency Laparotomy pathway and has a strong track record with data submission to the National Emergency Laparotomy Audit (NELA). The anaesthetic department is research active with dedicated research doctors and nurses well supported by the Clinical Trials Unit. We aim to recruit 75 patients who have undergone an emergency laparotomy and describe in detail the quality of their recovery over 1 year. This will be utilising the following questionnaires.
Whilst the patient is in hospital their recovery will be tracked by the use of the quality of recovery (QoR-15) questionnaire. We will also utilise the Post-Operative Morbidity Survey (POMS) to capture the onset of important complications during the study. After discharge patients will be followed up at one, three, six and twelve months' by use of the medical Short Form-36 (SF-36) and World Health Organisation Disability Assessment Scale (WHO-DAS). The patient will also be asked if they have had to visit their general practitioner or were admitted to hospital at any time during this period, if so they will be asked to provide details. These interviews and review of notes will be structured using POMS questions. Information regarding any support services including rehabilitation services after hospital discharge will also be collected. We aim to describe in detail the levels of activity the patient was able to achieve before their surgery (when they were well) and at one, three, six and twelve months after their operation. We will assess how the WHO-DAS tool performs compared to the SF-36 as well as describe associations between key elements of perioperative care and HRQoL at 1 year. During the feasibility stage we will develop an in-house data entry web-tool to collect all patient related data in a secure way. If the feasibility study (this study) proves achievable, we aim to roll out the study to 20 centres across the UK, collecting the same data on 1000 patients. The choice of these centres will primarily be based on their compliance with data entry to the NELA database and ability to support a NIHR portfolio research project such as this.
Producing a Physical Prototype Patient-specific Epidural Simulator for Training
Professor Michael Y.K. Wee
Aims and Objectives
This AAGBI funding would enable us to produce a working prototype epidural simulator and interface it with our existing virtual reality graphics.
Our related work
Our existing 3D graphics models allow trainees to visualise the path of the epidural needle through skin, fat, ligament and the epidural space. A PhD has already been completed which has provided the building blocks for the proposed simulator and won the best PhD research in the UK amongst 90 entries in 2014. This research has already won numerous prestigious national and international awards, including being shortlisted in the final 8 entries for the NHS Patient Safety Awards, 2013. We published a review of 31 existing epidural simulators identifying their merits and shortcomings to propose a novel and improved epidural simulator.
Clinical Data Measurements
We conducted a clinical trial to measure epidural insertion pressures from obstetric patients. This unique data will be used to configure our simulator to provide a realistic feel which hasn't been achieved before.
Proposed Epidural Prototype
The design of our proposed prototype simulator will use various technologies including providing realistic force feedback similar to practicing on actual patients.
Injury Risks from Epidural
Epidural is a form of anaesthetic which is used for pain relief during childbirth, surgery and chronic pain. Over 1000 epidurals are given every day in the UK, that's one every two minutes. Currently 2.8% of all epidurals result in injury which highlights the clinical need for improved safety. These injuries can be painful headaches which last for several days or in the worse case injuries can include nerve damage or paralysis.
Patient Benefits
Due to reduction in training time, the increase in obesity and litigation culture, there is an urgent need for a realistic epidural simulator to assist in harm free training for the procedure prior to practicing with patients under supervision. The proposed epidural simulator, will allow the trainees to gain skills and experience in a safe controlled training system. This could ultimately reduce harm to patients and reduce NHS costs.
Future Commercialisation Plan (not within the grant application)
After the prototype is produced, outside scope of the AAGBI, we will trial the simulator with anaesthetists to test if this improves efficacy and safety. Subsequently we aim to gain CE mark from MHRA. We will then attempt to find an industry partner to mass produce and make our simulator available to the NHS and beyond. In future our simulator will also combine MRI, ultrasound, scoring and performance analysis, trainee feedback, programmed patient characteristics. Our ultimate aim is to produce an epidural simulator will provide an immersive training experience similar to flight simulators for aircraft pilots.
