2019

Intraoperative Infiltration of Local Anaesthetic with Adrenaline In Sliding Hip Screw Surgery: Does It Reduce the Need for Transfusion? A Comparison of Practice Over Two Hospital Sites (2019)

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Type of publication:
Conference abstract

Author(s):
*T. Banks, *P. Jayawardena, *D. Ford

Citation:
British Journal of Surgery, Sep 2019; vol. 106, S6, p. 108

Abstract:
Aim: Post-operative blood transfusion is frequently required in patients undergoing Sliding Hip Screw (SHS) surgery. This is associated with transfusion related complications, increased cost and length of stay in hospital. We compared practice between two hospitals; pre-incision infiltration of local anaesthetic with adrenaline (LAAd) versus LA without adrenaline prior to wound closure, to evaluate if there was a difference in postoperative haemoglobin drop and the need for postoperative transfusion following SHS surgery.
Method: A retrospective service evaluation was performed using National Hip Fracture Database (NHFD) data in a cohort of 248 patients who underwent SHS surgery between 2017 and 2018; 110 patients had LAAd. Pre and post-operative haemoglobin, postoperative transfusion and local infiltration was recorded from the trust online patient databases. Relationships between groups was determined using z-testing on Excel.
Results: There was no significant difference in postoperative haemoglobin drop between the two cohorts (p=0.119). 32.7% of patients who had LAAd received blood transfusion in contrast with 20.3% without adrenaline.
Conclusion: Whilst surgeons using LAAd may report less bleeding from skin edges and vastus lataralis intra-operatively, and optimised regional anaesthesia, there was no significant difference in haemoglobin drop between the two cohorts. A difference in threshold for transfusion was identified between the
two hospitals.

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A Rare Case of Cavernous Haemangioma of the Larynx Presenting as Dyspnoea – A Case Report (2019)

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Type of publication:
Conference abstract

Author(s):
Teo X.Y.; *Rafie A.; Thompson S.; Jolly K.; Darr A.

Citation:
British Journal of Surgery, 2019, Volume 106, Issue S6, p. 72

Abstract:
Introduction: Haemangiomas are a rare entity and seldom observed within the cavern e.g. larynx. The rarity and nature of these lesions can result in clinical unpredictability and mortality. According to literature, laryngeal cavernous haemangiomas often present as dysphonia. However, we have documented a rare case of cavernous haemangioma presenting as dyspnoea. Case presentation: A 71-year old gentleman presented to the A&E with progressive breathlessness and a history of un-investigated intermittent dysphonia. Medical therapy for suspected heart failure and COPD was ineffective, with worsening stridor identified. Assessment by the Otolaryngology team elicited a pedunculated lesion of the vocal cord. An awake fibre-optic intubation was undertaken, under sedation while spontaneously respiring. The patient subsequently underwent urgent microlaryngoscopy to have the lesion resected. Discussion: Cavernous haemangiomas are relatively rare findings with less than 10 cases being documented in the literature. However, in this case, breathlessness was the main presenting complaint. Histological examination of cavernous haemangiomas demonstrated polypoid tissue surfaced by reactive squamous epithelium and underlying stroma containing large dilated vascular channels.
Conclusion: Laryngeal cavernous haemangiomas in adults are uncommon and rarely seen on the vocal cords. Although benign, their course can be unpredictable and airway obstruction can occur rapidly, warranting urgent
excision.

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Developing an intervention around referral and admissions to intensive care: a mixed-methods study (2019)

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Type of publication:
Journal article

Author(s):
Bassford C, Griffiths F, Svantesson M, Ryan M, Krucien N, Dale J, Rees S, Rees K, Ignatowicz A, Parsons H, Flowers N, Fritz Z, Perkins G, Quinton S, Symons S, White C, Huang H, Turner J, Brooke M, McCreedy A, Blake C & Slowther A.

Study involved patients at Shrewsbury and Telford Hospital NHS Trust

Citation:
Health Services and Delivery Research 2019, Vol 7, Issue 39

Abstract:
Background: Intensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.
Objectives: To explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.
Methods: A mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.
Results: Influences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.
Limitations: Limitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.
Conclusions: Decision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.
Future work: Further research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.
Study registration: The systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.
Funding: The National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.

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Magseed for Localisation of Impalpable Breast Cancer is associated with High Patient Satisfaction and Lower Re-excision Rates (2019)

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Type of publication:
Poster presentation

Author(s):
*L.Deane, *B.Lake, *M.Wilson, *S.Williams, *M.Metelko, *G.Thomas, *S.Lewis, *L.Norwood, *T.Usman

Citation:
Poster presented at the International Cambridge Conference on Breast Cancer Imaging, July 2019

Link to poster [PDF]

Elevated BMI Significantly increases recurrence rate of Breast Cancer; a district general hospital experience (2019)

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Type of publication:
Poster presentation

Author(s):
*Blossom Lake, *Albert Mansoor, *Donna Appleton

Citation:
British Journal Surgery; September 2019; Vol 106(S5), p.20 (Poster presentation at Association of Surgeons of Great Britain May 2019)

Abstract:
Aims: Excess body weight has been shown to be a risk factor for breast cancer recurrence. The aim of this study was to evaluate the effect of BMI on recurrence rate of Breast cancer in Shropshire.
Methods: Retrospective analysis of Somerset Database of all new breast cancers diagnosed from January 2012 to December 2012 at the Shrewsbury & Telford NHS Trust. Clinical portal and pre-op database were used to obtain patient demographics including BMI and recurrence rate. Excluded patients from analysis: no surgery performed, or operated at another hospital. Overall recurrence rate, local recurrence, distant metastasis rate and 5 year disease free survival (DFS) were compared for 3 groups: BMI< 25, overweight; 25.1-29.9,and obese; >30.
Results: 498 new breast cancers were diagnosed in 2012, of these 132 were excluded as per criteria. 366 records were analysed; 40 patients had recurrent breast cancer 10.9%. 97.5% of recurrent patients had one or more prognostic factor, size> 3cm, node positive or Grade 3, with no significant difference between BMI groups for adverse prognostic factors. Overall Recurrence rate for BMI <25 was 5.9%, this was significantly higher in BMI> 25, 13.3% p<0.05.BMI Overall Recurrence rate Local recurrence Distant Metastasis rate 5 year DFS<25 5.9% 0.8% 5.9% 94.1% Overweight 14.4% 4.2% 10.2% 85.6% Obese 12.3% 2.3% 11.5% 87.7%
Conclusion: Our experience suggests a significant increase in Breast Cancer recurrence with increasing BMI. Further studies are needed to clarify this and whether methods of reducing BMI may improve disease free survival

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Mortality of in-patient medical admissions to a DGH Critical Care Unit (2019)

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Type of publication:
Conference abstract

Author(s):
*Sunil Tailor, *Ade Adiamou, *Omu Davies, *Roger Slater

Citation:
State of the Art 2019. Intensive Care Society Conference. Birmingham December 9-12.

Abstract:
Increasing clinical demand and reorganisation of hospital services may result in “stable” medical in-patients being “cohorted” into hospital locations without ready access to critical care services on site. The NEWS tool is recognised to provide warning of deterioration and a trigger for escalation of care [1]. Current EWS tools perform well for predicting death and cardiac arrest within 48 hours, although the impact on in-hospital health outcomes and utilization of resources remains uncertain [2]. In a retrospective case review, we examined the outcome of medical patients who had been hospital in-patients for more than 48 hours, whose condition deteriorated, requiring admission to our critical care unit (Princess Royal Hospital). The aim was to identify “red flag” observations for their deterioration and to measure mortality (overall: hospital + 30-day) in this patient group. During 2016-17 we identified 51 patients, of whom 39 patients were analysed because of a complete data set. We classified 48% (19 patients )as hot: defined as having a NEWS of 5 or more on one or more occasions in the 48-hours prior to ITU admission.
52% (21 patients) were classified as warm; defined as having a NEWS no greater than 4 on one or more occasions in the 48hr prior to ITU admission.
Red flag parameters (individual score of 3) were: Respiratory rate <8 or >25; SpO2 < 91%; temperature < 35C; SBP < 90 or > 220 mmHg; HR < 40 or > 131; AVPU: VPU.
Results:

  • The most common predictive red flag indicator for ITU admission was a raised respiratory rate.
  • 11 of the 39 patients did not score any red flag indicators. The mortality of this group was 33%.
  • The mortality rate of the 39 patients was 66%. The mortality for hot and warm classifications was 71% and 46% respectively.
  • The majority (>80%) of patients were aged 51-80 years .
  • The mean duration of ITU stay was 7.4 days (warm) vs 9.5 days (hot).
  • Over the same time period, ICNARC data demonstrated that 80% of all admissions to the ITU were non-surgical; overall ITU and hospital mortality was 15.7% and 22.5% respectively.

Conclusions

  • Medical inpatients with a persistently high NEWS of 5 or more during 48 hrs prior to ITU admission had a very high 30-day mortality despite ITU care.
  • 11 patients had no red flag indicators in the 48 hours prior to ITU admission despite their subsequent deterioration.
  • There are significant resource implications in managing such patients.
  • Care must be taken in defining stability in respect of medical in-patients in order to avoid later deterioration.

Limitations: Not all patients could be analysed because of incomplete data.

References:

  1. Thompson R. National Early Warning Score (NEWS). Report of a Working Party, Royal College of Physicians,UK, July 2012.
  2. Beth Smith M, Chiovaro J, O'Neil M, et al. Early Warning System Scores for Clinical Deterioration in Hospitalized Patients: A Systemic Review. Ann Am Thorac Soc 2014; 11:1454-1465.

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Severe Hypercalcaemia in Intensive Care: An unusual cause (2019)

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Type of publication:
Conference abstract

Author(s):
*Zi Hao Reuel Heng, *Rhys Parry, *Omu Davies, *Roger Slater

Citation:
State of the Art 2019, Intensive Care Society Conference, Birmingham, December 9-12.

Abstract:
Background: Severe hypercalcemia is defined as serum calcium > 3.5 mmol/l.
Major causes of hypercalcemia in adults include primary hyperparathyroidism, milk-alkali syndrome and malignant neoplasms. Neoplasms cause hypercalcaemia either by direct invasion (metastasis) or through factors that stimulate osteoclasts (Parathyroid hormone related peptide or PTHrP). Very rarely a benign tumour can be responsible. Clinical features of hypercalcemia correlate with degree and rapidity of rise of serum calcium. Severe hypercalcemia is associated with neurological, renal and gastrointestinal symptoms.
The differential diagnosis of the cause is determined by measuring parathyroid hormone (PTH) levels.
The case: A 33-year-old woman 37/52 pregnant presented with epigastric pain, vomiting, proteinuria and hypertension and a deteriorating GCS (11/15). A CT head was normal. Blood showed hyperuricaemia and acute kidney injury. She was transferred to the operating room for caesarean section with suspected fulminating pre-eclampsia following a fall in GCS to 8. Immediately prior to general anaesthetic induction she had a generalized seizure. She was induced, intubated and commenced on IV magnesium and labetolol. Following successful delivery, a large pedunculated fibroid was noted on the left side of the uterus. She was transferred to intensive care sedated, intubated and ventilated. Routine blood testing demonstrated severe hypercalcaemia, corrected serum calcium of 5.05 mmol/l. PTH was at the lower limit at 1.3 pmol/l (normal range 1.3 – 7.6 pmol/l). Treatment consisted of IV rehydration with 0.9% sodium chloride 4 litres in 24hr, IV Pamidronate (a bisphosphonate) 60mg over 2 hours. Over the next 3 days the serum calcium returned to normal. A literature search uncovered 3 reports of benign uterine leiomyomas having been the source of ectopic PTHrP leading to hypercalcaemia [1,2,3]. In this case, the uterine fibroid was presumed to have been the source of PTHrP. Unfortunately, direct measurement of PTHrP was not possible at the time of presentation. In view of the fact that the calcium had returned to normal with medical treatment and post-delivery, it was decided to defer further surgery. The patient was successfully weaned from ventilatory support after 5 days. She was monitored and calcium remained within normal limits. 3/12 later the fibroid was removed. The histology showed a mitotically active smooth muscle leiomyoma.
Conclusion: Uterine leiomyoma can rarely be a cause of hypercalcaemia in the critically ill obstetric patient. Severe hypercalcaemia can present in a similar manner to pre-eclampsia, and can worsen pre-eclampsia. Intensivists need to be aware of this condition.
Discussion: The clinical picture was strongly suggestive of severe hypercalcaemia associated with a uterine fibroid. The history did not reveal ingestion of excessive calcium-containing antacids sufficient to cause hypercalcaemia. A hypercalcaemic crisis can occur during pregnancy; the immediate postpartum period being the most likely time,. At this time, relative dehydration and an abrupt decrease in placental transport of calcium to the foetus can coexist. Severe hypercalcaemia can rarely produce seizures, the mechanism is thought to be due to cerebro-vasospasm.
References
1.Ravakhah K, Gover A, Mukunda B. Humoral Hypercalcemia Associated with a Uterine Fibroid. Annals of Internal Medicine 1999; 130: 702.
2.Tarnawa E, Sullivan S, Underwood P et al. Severe hypercalcemia Associated with Uterine Leiomyoma in Pregnancy. Obstetrics & Gynecology 2011;117: 473-476
3.Garcha A, Gumaste P, Cherian S et al. Hypercalcemia: An Unusual Manifestation of Uterine Leiomyoma. Case Reports in Medicine 2013; Article ID 815252.

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Categorising sub-massive pulmonary thromboembolism: No isolated role for shock index or its modified form (2019)

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Type of publication:
Conference abstract

Author(s):
*Abdulsamad S.P.; *Crawford E.; *Makan A.; *Ahmad N.; *Srinivasan K.; *Moudgil H.

Citation:
European Respiratory Journal; Sep 2019; vol. 54, PA1469

Abstract:
Background and Objectives: Managing sub-massive pulmonary thromboembolism (PTE) remains a therapeutic challenge and efforts have been made to sub-categorise continued risk based on clinical assessment and objective measures such as a raised serum lactate (>4 mmol/l) or abnormal Shock Index (Heart rate/systolic blood pressure, SIndex). The objective here was to investigate the SIndex and its modified form (MSIndex) to (1) report frequency of abnormal results in a population being investigated for PTE and (2) assess potential benefits in avoiding adverse outcome.
Method(s): Retrospective analysis of 1505 CT pulmonary angiograms undertaken over a 12 month period. Abnormal SIndex was taken as outside limits 0.5-0.9. MSindex was calculated conventionally as heart rate divided by (2xdiastolic blood pressure+systolic blood pressure)/3 and considered abnormal if <0.7 or >1.3. Analysis was on Excel.
Result(s): Mean age for the population was 67.7 (range 17-101) years. 337/1505 (22.4%) scans showed PTE and of this population 19 patients had adverse outcome either died within 3 months (7 had malignancy) or requiring Intensive Care during the admission. For patients without PTE (n=1168), the SIndex was abnormal in 334(28.6%) and the MSindex in 293 (25.1%). For patients with PTE (n=337), respectively these figures were 89 (26.4%) and 68 (20.2%). Of those with adverse outcomes, 13/19 Sindex and 17/19 MSIndex values were not abnormal.
Conclusion(s): Neither the SIndex not the MSIndex are discriminatory in helping distinguish the at risk groups with PTE and therefore cannot be used as an isolated criteria.