AAGBI/Anaesthesia Research Grant
To determine general practitioners' views on 'good' postsurgical outcomes utilising mixed qualitative methodology
Dr Rachel Evley
Background
The White Paper 'Equity and Excellence: Liberating the NHS' sets out how the improvement of healthcare outcomes for all would be the primary purpose of the NHS. Outcomes from perioperative care are becoming more and more relevant to the primary care setting; especially following the introduction of the Enhanced Recovery Programme in 2010, whereby patients are discharged back to Primary care earlier.
Aims
The purpose of this study is to use consensus methodology to define the key complications presented to the GP by the patient following surgery, to determine what factors lead to better outcomes in this population of patients and to define what a 'good' outcome is.
Methods
A Consensus method known as the Delphi technique will be used to determine which complications are routinely seen in primary care following surgery and what factors lead to better outcomes. The Delphi technique is an expert survey using two or more questionnaires, known as 'rounds'. The first questionnaire, administered to a panel of experts or specialists, asks for their opinions on a certain issue or topic, in this study semi-structured interviews will be used instead of a questionnaire at this stage. Participants score agreement or disagreement on a Likert scale. These responses are returned to the researchers and analysed for agreement and consensus. This process is repeated with subsequent questionnaires being sent to participants this time containing only the statements that have not reached consensus, participants can also view the opinion of others in percentage form.
Through semi-structured interviews, 20 GPs will be asked to define the expected clinical outcomes for four post-operative clinical scenarios; to describe the current post-operative complications seen within primary care; whether there is a perceived difference in outcome following surgery for certain patient populations, and finally what factors lead to better outcomes.
Following the initial interviews, two questionnaire rounds of the Delphi technique will take place. In order to ensure we recruit GPs who understand the issues, have a vision and represent a substantial variety of viewpoints, sample selection in this Delphi study will be purposive. Previous studies have found that a panel size of 10 has provided a diversity of expert opinion and therefore we aim to recruit 20 GPs, geographically spread across the UK.
Study Outcome
This will produce a consensus across the group on the expected outcomes in the general post-surgical population, the key factors that lead to better outcomes and the expected outcomes for each clinical scenario presented.
Pain relief after colorectal surgery: single-shot spinal combined with Painbuster®; vs. Painbuster®; alone. A double blind pilot randomised controlled trial
Dr Daniel Harper
We aim to establish an anaesthetic technique for patients undergoing major bowel operations including bowel cancer which will provide optimal pain relief during and after the operation and which will reduce the impact that the surgery has on the whole body.
There are many potential benefits to the patient. Patients with less pain are able to mobilise and get back a normal diet more quickly. We know that big operations are more stressful so they take longer to recover from and are associated with more complications. Therefore reducing the stress of surgery will have benefits in both of these areas. Additionally studies in other forms of cancer have shown that reducing the stress of surgery improves long-term outcomes. This is an interesting future direction for our research.
The timing is significant because there is increasing interest in alternatives to traditional anaesthetic approaches such as epidural anaesthesia, which are associated with organisational difficulties and ultimately may delay recovery from surgery.
We will identify potential patients from colorectal surgery clinics and meet with those patients when they attend for their preoperative review. We will contact them after 48 hours to gain consent for recruitment. Randomisation will occur on admission to hospital. The stress response will be measured from a sample of blood taken before, during and after the operation. These samples will be taken at times when routine blood tests are taken so patients will not have blood taken more frequently than if they were not part of the study. A biopsy will be taken from inside the abdomen prior to completion of the operation. Markers of the stress response include cortisol, noradrenaline, heat shock proteins and interleukin 1. Additional information will be gathered from blood tests, routine observations and direct questioning. Patients will remain in the study until discharge from hospital.
The participating centres will be Scarborough General Hospital and we aim to recruit 90 patients.
Overall the patient might benefit from a more rapid and less complicated recovery. Additionally the heathcare organisation might benefit from shorter hospital stays and less capital expenditure.
A study to determine the accuracy of zero-flux and ingestible thermometers in the perioperative setting
Dr James Jack
Background
When a patient is anesthetised and undergoes an operation, their body temperature falls. Managing a body temperature properly by keeping it within normal limits has been shown to improve recovery from surgery.
A vital part of managing temperature is being able to measure it properly. There are several ways of doing so, which consist of invasive methods such as temperature probes in the oesophagus and bladder, and non-invasive methods such as infrared scanners and ear canal probes. During an operation, temperature changes as small as 0.5 °C can affect outcomes but, currently, only invasive methods are reliable enough to detect this. Oesophageal probes can't be used in patients who are not anaesthetised during their operations, and it is inappropriate to insert a urinary catheter should it not be otherwise needed.
The purpose of this study is to look at two new methods of measuring a patient's temperature which would help us in these situations. The first is called zero-flux thermometry and involves placing an adhesive pad to the forehead, which gives constant measurement of a patient's core temperature. The second involves swallowing an ingestible capsule that is no bigger than a normal pill. This technique has been very useful in research tracking a patient's core temperature as they are transferred through different areas over a longer period of time.
Whilst these two methods are potentially very useful, they have never been tested on hospital patients.
Aims
We want to determine whether readings from these thermometers are accurate enough to be used in patients before, during and after surgery. Should they prove to be sufficiently accurate it will allow us to improve patient care through both clinical practice and research.
Plan
During operations, temperature is routinely measured in line with NICE guidelines with a thermometer placed in the nose or oesophagus. We will not be changing routine practice in any way, but checking measurements from the new devices against the proven, routine ones.
We plan to record measurements from each device every minute throughout the operation in 20 patients. We will then perform statistical tests to check their accuracy.
Short-term outcomes with intrathecal opioid and patient controlled analgesia versus thoracic epidural analgesia for hepatic resection: a randomised controlled trial
Dr Ramanathan Kasivisvanathan
Background
Hepatic resection is an operation where the part of the liver containing cancer is removed, potentially curing the cancer. Pain relief plays an important part in the patient's recovery following this type of surgery with the potential to improve patient outcomes, such as reducing the length of stay in hospital, improving patient quality of life, and reducing costs.
Aims
Our hospital is a major centre for hepatic resection surgery. Traditionally epidural pain relief (infusing local anaesthesia and painkillers for up to three days through a tube inserted in the upper back (thoracic region has been used. Epidurals offer excellent pain relief, however, they can commonly stop working effectively, and their side effects have been associated with a slower recovery from surgery. In other types of surgery where epidural pain relief would normally be used (such as bowel surgery) using alternative forms of pain relief can improve the recovery from surgery, without compromising pain relief. On such option is spinal (intrathecal) injections (a single injection of local anaesthetic and painkiller around the nerves which lasts for up to 48 hours) combined with other painkillers given orally or intravenously (through a drip). This form of pain relief has been reported as an alternative to epidural pain relief for liver resection but due to the lack of research evidence, it is unclear whether it is a better option for hepatic resection surgery. This trial aims to provide that evidence.
Methodology
We propose to conduct a randomised controlled trial, randomly allocating patients to receive either spinal (and intravenous) or epidural pain relief for hepatic resection. Patients will otherwise receive standardised care for their operation and stay in hospital. Our primary goal is to measure the length time until patients are medically fit for discharge. We also will measure: total length of stay, patients' levels of pain, how much intravenous fluid and transfused blood is required, how long it takes the patient to be able to eat, drink and become mobile, and the patient's quality of life and recovery after the operation.
Expected outcomes
We do not know which form of pain relief produces the best outcomes from hepatic resection surgery because there is insufficient evidence in the medical literature thus far. Based upon the results of an audit that we conducted at our hospital, a reduction of 1.8 days stay in hospital was observed in patients having spinal analgesia instead of epidural analgesia. It is not clear if this was due to the pain relief given or other factors. In other types of surgery (e.g. bowel surgery) patients have had a shorter length of stay with spinal instead of epidural analgesia. We do not know if this finding will be seen in hepatic resection surgery. This study will provide high quality evidence as to whether the choice of pain relief affects the length of time that patients take to recover from hepatic resection surgery.
Implications
Showing the use of either spinal or epidural analgesia to be associated with better outcomes including time until medically fit for discharge will ensure that the most effective form of analgesia is used for this surgery. That, in turn will improve patient care, reduce the amount of time that patients have to stay in hospital, reducing cost to the NHS and improve patients' quality of life after major surgery.
