As increasing numbers of patients present for both elective and emergency surgery new and different challenges are emerging. Many of these are outlined in the vision document for the ‘Perioperative Medicine Programme’ created by the Royal College of Anaesthetists. With a clinical focus on collaborative working and a national drive within anaesthesia to conduct large scale perioperative research such as the National Emergency Laparotomy Audit (NELA) and National Audit Projects (NAP) there is increasing focus on the need for, and benefits of, high quality perioperative research.
Locally developed projects focusing on perioperative care of the elderly, pre-assessment, transplant surgery, critical care outreach, and global health are all either active or in development. Such work draws on expertise from both the university and NHS departments of anaesthesia based at Addenbrooke’s Hospital as well as new links with the Healthcare Design Group in the Department of Engineering. A major focus is on the use of large scale data analysis to further perioperative care.
The department has actively participated in national projects coordinated by the Research and Audit Federation of Trainees (RAFT) with participation led by local trainee leads undertaking research fellowships, supervised by substantive consultants within either the university or NHS departments of anaesthesia.
Work in the department is evolving around several key themes including risk stratification (and the potential for subsequent prehabilitation), long term outcomes of perioperative events, systems thinking, transplant surgery, and global health. The department is drawing on pre-existing expertise in large scale data analysis and critical care to pursue these evolving research areas whilst utilising the research potential of the comprehensive electronic health record present within Addenbrooke’s hospital. The work is evolving through close links between the university and NHS departments of anaesthesia at Addenbrooke’s hospital in Cambridge. The pre-operative assessment clinic for frail patients at Addenbrooke’s was recently shortlisted for the 2018 BMJ award for “best anaesthesia and perioperative medicine team”. Work within all of these projects is developing through the forging of strong links with other research divisions including surgery, primary care, and engineering.
Designing Improved Surgical Care for the Older patient
Funding: Wellcome Trust Clinician PhD program (from October 2018)
This is an upcoming project being organised jointly between the Division of Anaesthesia, and the Healthcare Design Group. It aims to inform the design of surgical care systems through the analysis of perioperative data pertaining to the care of older people undergoing surgery.
Physiological Changes of Circulatory Determined Death
This project is looking at the physiological changes that occur during the dying process for patients having their life supporting treatment withdrawn and becoming organ donors.
Perioperative Network Analysis
This work is looking at exploring patient flow in individuals presenting for emergency surgery and developing mathematical and computational techniques for the handling of this information.
Preoperative use of wrist-worn accelerometers to measure physical activity in high-risk elderly patients
Funding: Regional research fellowship
This project is exploring the use of wrist worn accelerometers as a tool to aid in the pre-assessment of high risk surgical patients presenting to a frailty stratified pre-assessment clinic. The work is currently undergoing ethical review with a plan to start patient recruitment in the near future.
Determining the optimum composition of a critical care outreach/’rapid response’ service
This work is exploring the optimum composition of critical care outreach teams as well as determining the best way to assess the impact and performance of such a service. This is a collaborative program between the University Division of Anaesthesia, Critical Care services, and the Healthcare Design Group.
Using smart-phone derived metrics to measure impact of surgery
- Dr Timothy Baker
- Dr A Vuylsteke (Royal Papworth Hospital)
- Prof DK Menon
This proof of concept work is exploring the feasibility of using data obtained from individuals’ smart-phones to assess the impact of both elective orthopaedic surgery and, in the near future, cardiac transplantation. Initial ethical approval for the first phase of the project (on orthopaedic patients) has been obtained and patient recruitment is ongoing
A Systems Improvement Approach to Traumatic Brain Injury (ASIA-TBI):
Developing a participatory approach to the systems improvement of traumatic brain injury care in Yangon, Myanmar
This project is a collaboration between the UDA, the Engineering Design Centre (EDC), and the NIHR Global Health Research Group on Neurotrauma. It seeks to use a Soft Systems Methodology within a wider engineering systems approach to understand and model the care of TBI patients in Yangon, with a view to developing improvement projects.
Pulmonary outcomes in individuals undergoing emergency laparotomy
Funding: Regional research fellowship
This is an ongoing retrospective analysis of pulmonary, and other organ dysfunction occurring in individuals undergoing an emergency laparotomy. It will explore the relationship of perioperative events, and physiological changes with organ specific outcomes of interest.
Participation in these projects was orchestrated by local trainee leads undertaking research fellowships within the university division of anaesthesia. The projects were nationally organised by the Research and Audit Federation of Trainees and aimed to explore the occurrence of important perioperative issues on a national scale. Publication of iHYPE is awaited (see Presentations for initial abstracts submitted by the lead authors) whilst the “Drug Allergy Labels in Elective Surgical Population” (DALES) project is ongoing as of May 2018. As well as these projects the department is an active participant in data collection for ongoing national projects such as NELA.
Trainee lead: Dr L Grimes, Consultant lead: Dr A Ortu
Bashford T, Clarkson PJ, Menon DK, Hutchinson PJA. Unpicking the Gordian knot: a systems approach to traumatic brain injury care in low and middle income countries. BMJ Global Health 2018;3:e000768
Stubbs DJ, Bowen JL, Furness RC, Gilder FJ, Romero-Ortuno R, Biram R, Menon DK, Ercole A. Development and validation of an electronic post-operative morbidity score, Anesthesia & Analgesia, Nov 2018 – ePub ahead of print.
Stubbs DJ, Levy N, Dhatariya K, “Diabetes Medication Pharmacology”, BJA Education, Volume 17, Issue 6, 1 June 2017, Pages 198–207, https://doi.org/10.1093/bjaed/mkw075
Stubbs DJ, Dhatariya K, Levy N, “The rational and strategies to achieve perioperative glycaemic control”, BJA Education, Volume 17, Issue 6, 1 June 2017, Pages 185–193, https://doi.org/10.1093/bjaed/mkw071
Stubbs DJ, Gilder F, Biram R, Menon DK, Ercole A, Romero-Ortuno R: “Frail patients attending a multi-disciplinary surgical pre-assessment clinic: identifying predictors of complex discharge after surgery”. Age Anaesthesia Conference, London, May 18th 2018 (Winner – Oral Presentation Prize)
Stubbs DJ, Bowen JL, Murray R, Gilder F, Biram R, Romero-Ortuno R, Menon DK, Ercole A: “An electronic version of the post-operative morbidity score (E-POMS)”, Age Anaesthesia Conference, London, May 17th-18th 2018 (Poster Presentation)
Kohler K, Stubbs DJ, Burnstein R, Gilder F: “Modelling of anaesthetic dosing in elective orthopaedic patients”, East Anglian Association of Anaesthetists annual meeting, Newmarket, November 2017 (Winner of the Harold Youngman Medal for best oral presentation)
Wickham A et al on behalf of “The Research and Audit Federation of Trainees (RAFT)”: “How low do you go? An investigation of treatment thresholds for intraoperative hypotension in elder patients in the UK” European Society of Anesthesiology, Geneva, 4th June 2017.
These are some select links to other bodies involved in perioperative research or important large scale projects. All links are external.
Ongoing projects involves collaboration with multiple other departments within the university. Links to these departments are included below.
- Dr. Roman Romero-Ortuno (Consultant Geriatrician, Honorary Visiting Fellow in Dept. of Clinical Gerontology): research background in the clinical implications of frailty and its impact on health and social care services. He is a previous winner of the British Geriatric Society’s ‘Rising Star Award’