Association of Anaesthetists/Anaesthesia Research Grants

Background
Central Lines (Or Central Venous catheters) are plastic tubes that are inserted into a large vein, generally into a vein in the neck or groin. They are most often inserted in hospital for patients who are acutely unwell that needs intravenous fluids quickly. They are also used to give medication that needs to be given directly into a large vein or if patient need access to renal dialysis. For acutely unwell patients, the central lines are generally inserted in the Emergency Department, Operating theatres or Intensive Care by a trained healthcare professional.

Traditionally, they were inserted using palpation & landmark technique (look & feel). Unfortunately, some insertions can be difficult and the risk of complication was high-up to 20% in some studies. These can include accidental puncture of lung (pneumothorax) or artery (bleeding), irregular heart rhythm (if wire is too long) and infection.

In 2002, the National Institute for Clinical Excellence (NICE) published guidance (Technology Appraisal 49) and recommended that all central lines should be inserted using ultrasound guidance. The use of ultrasound allows clinicians to identify layers of tissue and help guide needle insertion, potentially lowering the risk of complications.

Since then, there have been many small studies on central line insertion. However, these small studies have not been big enough to pick up uncommon complications. We propose a national audit to find out how many central lines are inserted and how many complications there are in the UK. We also want to conduct a survey to find out about the training and experience of the clinicians who are inserting central lines.

We did a small pilot study at 6 hospital sites in 2017 to test our data collection platform for 2 weeks. The feedback from participating sites was very positive, and our data collection platform worked well.

This project is being supported by the Intensive Care Society (Our national body)

Method
We will form a network of local leads across all acute hospitals nationally, and during the study period, ask for all central lines inserted nationally in Emergency Department, Theatres and Intensive Care to be entered on to the secure database. This will give us a baseline number of how many central lines are inserted in the UK; and with a large number of responses (expected to be >5000), will allow us to have a better idea of complication rates We will also survey all the operators about their experience and training.

Expected benefits
Give us a better idea of complication rates of central lines; and how they relate to
Site of central line (neck, groin etc)
Experience of operator
Training received
Use of ultrasound
Area of insertion (ED, theatres, ICU)

The results will be published, and widely disseminated to healthcare professionals.

They may then help development of guidelines for central venous access.

This will enable us to inform future practice, quality improvement at various hospitals, and training; ultimately improving patient safety through safer, more effective clinical practice.

Background
Broken ribs are very painful and if this pain is not controlled it can increase the risk of serious complications such as chest infections (pneumonia) and death.

Morphine is the most commonly used drug for pain, but it causes nausea, vomiting, confusion and respiratory depression. Thoracic epidurals were once considered the gold standard of pain management for broken ribs. They work by continuously infusing local anaesthetic around the spinal cord, blocking the nerves conducting pain. However, thoracic epidurals are only suitable to be used in a small number of patients (less than 20%) because of side effects that restrict their use.

The Serratus anterior plane block (SAP) is a new technique where local anaesthetic is injected between two muscles (serratus anterior/lattismus dorsi) on the side of the chest. This blocks the nerves that supply the front and side of the chest and reduces the pain caused by broken ribs. They have very few side effects and can therefore be inserted in the majority of patients. This has led to a rapid increase in the use of this form of pain relief for rib fractures.

However, the way in which SAP blocks produce their pain relief is not fully understood. Current research performed on people who have donated their bodies to medical science after death (cadavers) has confirmed that the nerves supplying the skin over the chest wall, the lateral cutaneous nerves are numbed. However, the spread of local anaesthetic to the deeper nerves that supply the ribs (intercostal and spinal nerves) has only occasionally been seen. It is believed that chest wall movement caused by breathing and injury to muscles and tissues around the broken ribs may increase local anaesthetic spread to the intercostal and spinal nerves. These factors have not be controlled for in previous studies.

Aim
To investigate how broken ribs effect the spread of local anaesthetic and if trauma to the front, side or back (anterior/lateral/posterior) also influences spread. We hope to answer whether there is a consistent spread of local anaesthetic to the intercostal nerves and which pattern of broken ribs would be most successfully treated by SAP blocks.

Methodology
A total of 6 cadavers would be used. One side would have pressure applied to produce broken ribs whilst the other side would remain injury free. SAP blocks would be inserted on both sides and local anaesthetic with dye would be injected. The lungs would be inflated to produce the chest wall movement seen during breathing.

Dissections would be performed where the skin and muscle layers are removed in stages and the spread of dye across the chest and to the different nerves is examined.

Expected Outcomes
We hope to show that injury to surrounding muscles and tissues from broken ribs increases the spread of local anaesthetic to the deep intercostal nerves.

Implications
Increased knowledge as how trauma effects the spread of local anaesthetic would help doctors decide which patients would benefit most from SAP analgesia and assist with guideline development and clinical trial design.

Background
Caesarean section (CS) refers to surgery to deliver a baby by making a cut in the lower abdomen. Almost one in four pregnant women have a CS and over 200000 CS took place in the year 2017-2018 in the United Kingdom (UK). The common surgical complications that occur during the CS include pain, bleeding, infection and damage to surrounding structures such as bladder, bowel or uterine tubes. Occasionally the woman might have to return back to theatre to re-open the CS wound (re-exploration) to control the bleeding, remove the focus of infection or go in the abdomen to repair the organs that could have been damaged. Incidence of re-exploration following CS in the developing world varies between 0.12 - 0.72%. No study has been undertaken in the UK to look at re-exploration following CS.

Aims
We aim to find:
How many women in the UK have this complication after CS?
Did any of the women have certain characteristics that would make them have a higher risk of re-exploration?
What investigations were undertaken before and what were the main reasons and findings on re-exploration?
How long did the woman stay in hospital and was she admitted to intensive care?
Were there any systemic or wound infections or deaths from re-exploration after CS?

Methodology
There is already a specialised system, which has been established by UKOSS (UK Obstetric Surveillance System) for collecting data from every hospital in the UK. We have already gained their support to conduct this study across consultant-led delivery units in the UK. Each month UKOSS will send a reporting card to all hospitals asking them to report any women who went back to theatre for re-exploration following CS. The UKOSS representative is then sent an anonymous data collection form to gain more information about these women. Anonymous data will also be collected from women who have not had a re-opening of the abdomen (controls). This will help us identify women at risk of re-exploration.

Expected Outcomes
We expect to identify women who are at increased risk of going back to theatre, and the investigations a woman had (such as ultrasound abdomen, and computerised tomography scan) prior to their re-exploration. The additional anaesthetic and surgical risks associated with re-exploration such as difficulty in passing a tube down the throat whilst putting them off to sleep, blood transfusion rates, infection rates, surgery details, consultants input, and how frequently the women are admitted to critical care following re-exploration would also be determined. The length of hospital stay and whether the re-exploration leads to any maternal deaths would also be ascertained.

Implications
We are keen to undertake this study, for once we know answers to the above questions, we will be able to provide information to mothers having a CS that will facilitate informed consent. We also hope to design treatment strategies and pathways that could reduce this complication. This could potentially lead to earlier discharge, decrease hospital costs, improve wellbeing of mothers and promote earlier bonding with the baby and family.

As anaesthetists, one of our primary roles is maintaining the patient's airway under anaesthesia. This can be achieved by doing simple manoeuvres with our hands, or by utilising various plastic tubes. Very rarely (1/50,000 anaesthetics) an anaesthetist is unable to either insert one of these tubes or provide oxygen to the patient in any other way ("Can't intubate, can't oxygenate"). These situations, if not resolved will result in brain damage due to harmfully low oxygen levels ("hypoxia") or death. The solution to these situations, involves accessing the airway through an incision in the front of the neck ("emergency Front of Neck Airway").

All anaesthetists are taught the practical steps involved, and the procedure itself is relatively easy to perform. The delay in making this decision is often the most common problem, yet very little research has been done looking at the actual decision making required to perform this life saving procedure.

Aims

• To understand the thought process undergone by people needing to perform this task
  
• To identify reasons for any delay in making this decision

Methods
An experienced psychologist will carry out confidential semi-structured interviews with individuals whom have performed or attempted this emergency procedure within the past 2 years. The interviews will be recorded and then later analysed to identify potential factors that contribute to the decision-making process and any potential delays. As this could cause distress in some participants, there will be systems in place to identify and support welfare if necessary. The methods employed are standard for this type of research, and are designed to be robust and as reliable as possible.

Implications
It is hoped that the reasons why anaesthetists are reluctant to make this lifesaving decision could be elucidated. In doing so, these factors could be addressed in education and training of the workforce with the ultimate intention of making airway management and therefore anaesthesia safer for all patients.

Background
Burn injuries are often life changing with many patients suffering persistent pain, mobility problems and loss of independence. Psychological problems such as depression, anxiety and post-traumatic stress disorder (PTSD) can occur not only from the acute incident, but also the treatment required and sometimes disfiguring scars.

The consequences of burn injuries extend beyond the skin and tissues damaged, often causing damage to other organs which can require prolonged stays in intensive care.

Existing research has shown that survivors of burn injuries have a shorter life expectancy, with an increased risk of dying from heart problems, strokes and infections. This may be due to ongoing effects on the body long after the initial burn injury.

Aims
We aim to investigate the long-term health effects of sustaining a burn injury by comparing these patients to two groups; patients admitted to hospital with pancreatitis and patients from the general population.

Pancreatitis is a condition with similar effects on the body as a burn. Inflammation of the pancreas from a variety of causes can result in damage and failure of other organs including the lungs, heart and kidneys. Such an illness may have similar long-term effects on the body, but no research to date has asked this question.

By also comparing survivors of burn injuries with a general population (with a similar health profile by matching to social deprivation markers) we will be able to examine the impact of lifestyle factors such as drug use, alcohol and smoking.

We want to better understand why individuals that survive a burn have such long lasting consequences. By comparing these groups, we will better understand whether these effects are common among patients with a similar inflammatory disease, or are these effects unique to burn injuries?

Methods
We will use existing national data collected from a variety of sources to carry out this study. Following application to and approval by the Public Benefit and Privacy Panel, the electronic Data Research and Innovation Service (eDRIS) will link multiple national data sources. This will include:

• Acute hospital admissions
  
• Psychiatric hospital admissions
  
• Census data
  
• Death certificate data
  
• Drug prescriptions
  
• Scottish Index of Multiple Deprivation (SIMD)
  
• Scottish Intensive Care Society audit data
  
• Care Of Burns In Scotland (COBIS) data

Patient identifiable information will be removed prior to use by the project investigators. All datasets will be stored in a secure "safe haven" environment, complying with General Data Protection Regulations (GDPR).

Outcomes
We expect that sustaining a burn injury puts patients at increased risk of:

• Increased admission to hospitals (both general and psychiatric)
  
• Increased use of pain killers and anti-depressant medications
  
• Increased risk of death

Implications
By exploring the above outcomes, we can better understand the burden that a burn injury places on patients. By informing the better use of hospital resources we can help improve patients' lives following discharge, provide psychological support and prevent multiple hospital attendances and readmissions.