AAGBI/Anaesthesia Research Grants

Assessing how different levels of frailty affect recovery from an operation for bowel cancer

Background: Frailty is a condition often associated with getting old. It describes the process of gradual reduction in our bodies' in-built reserves to respond to insults such as illness or surgery. People who are frail are more likely to suffer from weight loss, low mood, reduced muscle strength, and slowing up in everyday tasks. We know that frail individuals are more susceptible to sudden deterioration in their health, often precipitated by events such as surgery. However, there is little information about how differing levels of frailty affect recovery after bowel cancer surgery. We aim to find out about how surgery has affected our patients' quality of life and functional ability and how their level of fitness before surgery affects this.

Methods: This is an observational study. The study will be conducted across 3 hospital sites (Middlesbrough, North Tees and York). All patients with potentially curable colorectal cancer aged over 65 will be sent a letter inviting them to participate in this study. The letter will include a patient information leaflet outlining the study details and that the pre-assessment clinic will likely take 30 minutes longer than usual. Further information will be provided at the clinic, and interested patients will be asked to sign a consent form. In patients with memory problems, consent may be obtained from a family member. The researcher will state explicitly that their care will not be any different if they choose not to take part, knowing that this may be a time of great anxiety for patients and their families.

The researcher will complete two questionnaires about frailty and one short physical task to assess mobility (rise from a chair, walk three meters, turn around, walk back to the chair and sit down). The researcher will then assist the participant or their carer in completing two short questionnaires about their current quality of life and functional abilities.

At six and twelve weeks after surgery (or after the surgical outpatient appointment in those who decline or are unfit for surgery), participants will be contacted (by letter or phone) to repeat the quality of life and disability questionnaires. At the 12-week surgical follow up clinic, the frailty questionnaires will be repeated.

After this, the researcher will look at the participants' case notes and they will take down details about the operation, any chemotherapy or radiotherapy used, how well the participant was after surgery and what stage of cancer they had.

At the middle and end of the study, we will invite participants to an afternoon session with refreshments to feedback results and invite comments about how to use the information for future patients.

Expected outcomes and implications: We will have a greater understanding of how the level of fitness before surgery has an impact on how patients feel and function after surgery, and whether we should incorporate such questionnaires into routine practice.

Background
During anaesthesia, the anaesthetist inserts an 'airway tube' (tracheal tube), into the patient's wind pipe (trachea). This is called intubation and ensures the patient's airway - the pathway oxygen travels between the nose/mouth and the lungs - is protected and does not block. The tracheal tube stays in place throughout anaesthesia to enable safe transit of oxygen to and from the lungs.

During intubation, a metal blade (laryngoscope) is inserted into the mouth moving the tongue to one side, enabling the anaesthetist to view the vocal cords (the opening to the trachea) into which s/he will place the tracheal tube. Intubation is a high-risk phase of anaesthesia. Poor views of the vocal cords can lead to delays or failure to correctly insert the tracheal tube with consequent problems delivering oxygen to the body with potential for brain damage, heart damage or death. While poor views of the area round the vocal cords (larynx) are common - 1 in 16 patients - major complications of intubation are very uncommon. Other laryngoscopy complications include sore throat, hoarseness, trauma to the lips, teeth, mouth or airway structures and passage of stomach contents into the lungs.

Laryngoscopes with a camera at their tip (videolaryngoscopes) are now available, allowing the patient's vocal cords to be seen on a screen. Research suggests improved view of the larynx, making intubation easier and safer. However, current research is limited and largely restricted to studies of <100 patients in specialised trials.

Aims
We will collect data on videolaryngoscope use in several thousand patients, enabling analysis of its true performance - benefits or complications - in a real-world setting. It will identify rarer events that previous smaller trials cannot. The Royal United Hospitals Bath is the first anaesthetic department in the UK to use videolaryngoscopes for all intubations in operating theatres, the intensive care unit and the emergency department and is therefore ideally placed to collect this information. The information on device performance will be of value in itself. Further we hope that analysis, feedback and refinement of techniques will directly improve patient safety locally.

Methods
The clinicians will input data on each intubation into a dedicated app via smartphone or hospital computer. No patient identifiable data will be collected. Data collected will include the ease of viewing the vocal cords, success rates, delays, and complications including reduced oxygen levels, airway injury and all other major complications. Data will be held in and backed-up to the hospital's secure servers. The project team will review findings and decide whether practice needs adapting and will implement relevant changes.

Expected Outcomes
The database of several thousand cases of adults and children will enable assessment of device performance and identification of any areas of concern or increased risk. We will use the information locally to drive improved patient care. We will disseminate this information widely through publications.

Implications
Once established, we aim to expand use of the app to all airway management and to other hospitals to create a national airway database.

Background:
Frailty is increasingly common. Frail people have low activity levels, poor strength, exhaustion, slow pace and unplanned weight loss, with lower physical reserve. They are at risk of deterioration with relatively small triggers such as infection or injury. Outcomes following surgery are often worse:
- longer stay in hospital
- more postoperative complications
- higher chance of re-admission following discharge
- increased risk of dying.

'Prehabilitation' involves interventions to improve strength and physical resilience prior to surgery, including increasing physical activity, optimising nutritional intake, stopping smoking and limiting alcohol. Research suggests this may improve outcomes.

Aims:
Our aim is to identify frail patients scheduled for bowel cancer surgery and investigate an individualised 'prehabilitation' pathway. This will be tested using quality Improvement processes involving regular analysis of data, review and adaption of pathways and involving patients.

The project involves:
- Ensuring all frail patients are identified using a frailty score assessment in all over 70years who require bowel surgery for cancer;
- Patients with high frailty scores receiving a preoperative anaesthetic assessment;
- Identifying those with high frailty scores will enable improved discussion regarding expectations, risks and outcomes of surgery, and facilitate improved shared decision-making between patients, family/carers and healthcare professionals;
- Anaesthetic assessment will identify patients who may benefit from increasing their activity to improve muscle, heart and lung reserve preoperatively. This will be facilitated through an individualised coached/mentoring activity programme
- Patients will be provided with advice on improved nutritional intake to increase their muscle strength

Methodology:
A multi-professional team has been established to support the project. Feedback will be obtained from patients participating in the programme and they will be given opportunity to help design the future programme.

We plan to trial the 'KiActiv' coaching and mentoring programme. This consists of an on-body device that records data on all activity. Following monitoring of 'baseline' usual activity, the KiActiv coaching team contact the patient, advising how level of activity can be increased safely prior to surgery. They continue to work with the patient until eight weeks after surgery. The KiActiv programme facilitates recording of all the patients'
activity enabling robust measures that can be analysed. We seek funding to purchase the 'KiActiv' devices. This intervention will be supervised by a senior physiotherapist. The programme has been used in Gloucestershire with good success.

We plan to provide nutritional advice, aiming to improve muscle mass ,by creating recipe cards, menu planners and provide web based nutritional advice. We seek funding to assist with supporting this. This intervention will be supervised by the Lead Dietician.

Outcomes that will be measured include:
- how long a patient stays in hospital after surgery
- complications after surgery
- whether the patient is re=admitted
- how many patients die 30-days and 90-days after their operation.

Expected Outcomes & Implications:
The project predicts that outcomes will be improved for frail patients undergoing bowel cancer surgery participating in the 'prehabilitation' programme. If successful, the programme will be offered to all frail patients planned for surgery.

Teicoplanin is an antibiotic used very commonly to prevent infection during surgery. Its use has expanded rapidly in the last few years, in response to changing patterns of antibiotic resistance. There has been a parallel increase in the rate of life-threatening allergic reactions to the drug, and it is now proven to be the commonest cause of allergy and anaphylaxis during surgery. These reactions can result in admission to intensive care, prolong hospital stay, or even be fatal.

It is vital that patients who suffer anaphylaxis have tests to accurately identify the cause, so they can avoid the drug in future. However, these tests are currently very limited, because we don't have any diagnostic tools proven to confirm or refute a diagnosis of teicoplanin allergy. We therefore have to make a 'best guess' diagnosis. This leaves patients vulnerable to harm in the future. Where a diagnosis of teicoplanin allergy is missed, patients are at risk of being exposed to this drug again with very serious consequences. In addition, if an allergic reaction is mis-attributed to teicoplanin, this means the correct cause of the reaction has been missed (which might be any of the drugs used during a general anaesthetic); patients may therefore be exposed to that drug in the future, again with serious consequences. We need to reliably diagnose teicoplanin allergy to reduce this harm. Where a diagnosis of teicoplanin allergy is confirmed, patients and their doctors know to avoid it. Importantly, where allergy is excluded, teicoplanin can be safely used, avoiding alternatives that may be less effective, more toxic, and more expensive. This directly benefits individuals, saves the NHS money by reducing avoidable harm, and helps improve antibiotic stewardship at a population level - which in the long term helps reduce antibiotic resistance. The clinical need for this work has become imperative.

Collaborating with our industry partner ThermoFisher (significant expertise in this area), we aim to:

1. Standardise the current skin testing protocols being used when testing patients with suspected teicoplanin allergy.

2. Develop laboratory tests to support the skin tests, and give a more confident diagnosis to patients.

3. Understand how and why people develop allergy to teicoplanin, to better predict and modify the allergic response.