RSS 1.0Clinical Support Services
The Clinical Support Services Directorate encompasses a number of patient facing departments as well as a number of associated services (Health Records and Patient Services). This sub-community represents the research outputs of those working within this area.
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Risk of dysglycemia in pregnancy amongst Kenyan women with HIV infection: a nested case-control analysis from the STRiDE studyIntroduction. Gestational diabetes is a common complication, whose incidence is growing globally. There is a pressing need to obtain more data on GDM in low- and middle-income countries, especially amongst high-risk populations, as most of the data on GDM comes from high-income countries. With the growing awareness of the role HIV plays in the progression of noncommunicable diseases and the disproportionate HIV burden African countries like Kenya face, investigating the potential role HIV plays in increasing dysglycemia amongst pregnant women with HIV is an important area of study. Methods. The STRiDE study is one of the largest ever conducted studies of GDM in Kenya. This study enrolled pregnant women aged between 16 and 50 who were receiving care from public and private sector facilities in Eldoret, Kenya. Within this study, women received venous testing for glycosylated hemoglobin (HbA1c) and fasting glucose between 8- and 20-week gestational age. At their 24-32-week visit, they received a venous 75 g oral glucose tolerance test (OGTT). Because of the pressing need to assess the burden of GDM within the population of pregnant women with HIV, a nested case-control study design was used. Pregnant women with HIV within the larger STRiDE cohort were matched to non-HIV-infected women within the STRiDE cohort at a 1 : 3 ratio based on body mass index, parity, family history of GDM, gestational age, and family history of hypertension. The measurements of glucose from the initial visit (fasting glucose and HbA1c) and follow-up visit (OGTT) were compared between the two groups of HIV+ cases and matched HIV- controls. Results. A total of 83 pregnant women with HIV were well matched to 249 non-HIV-infected women from the STRiDE cohort with marital status being the only characteristic that was statistically significantly different between the two groups. Statistically significant differences were not observed in the proportion of women who developed GDM, the fasting glucose values, the HbA1c, or OGTT measurements between the two groups. Discussion. Significant associations were not seen between the different measures of glycemic status between pregnant women with and without HIV. While significant differences were not seen in this cohort, additional investigation is needed to better describe the association of dysglycemia with HIV, especially in Kenyan populations with a higher prevalence of GDM.
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Prilocaine and chloroprocaine spinal anaesthesia in fractured neck of femur surgeryAbstract 60 from the ESRA 2021 Virtual Congress, 8–9–10 September 2021.
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Recurrent tracheostomy cuff leak – out of box managementFrom the virtual 17th World Congress of Anaesthesiologists, September 1–5, 2021.
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Consenting and patient understanding of accidental awareness during general anaesthesia: ignorance is bliss?Abstract 027 from the Trainee Conference 2021, 8-9 July 2021, Newcastle, UK and hybrid conference.
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Anaesthesia for caesarean section in a parturient with systemic mastocytosisAbstract P.175 of the Obstetric Anaesthesia Annual Scientific Meeting 2022, Newport, 5-6 May.
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Peri-operative care of a rare case of Ogilvie's syndrome after lower segment caesarean sectionAbstract 076 from the Association of Anaesthetists Winter Scientific Meeting 2022, 13-14 January 2022.
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B419 Patient outcomes following hip fracture surgery using intrathecal 2% prilocaine alongside peripheral nerve blocksBackground and Aims Regional anaesthesia has increasingly become the mode of anaesthesia for hip fractures in view of the frail, elderly multiple comorbid populations who usually succumb to this significant injury. Bupivacaine is often the choice for spinal anaesthesia however, local anaesthetics like 2% Prilocaine (Prilotekal®) are gaining popularity in recent years due to their fast offset and better side effects profile. We analysed patient outcomes using intrathecal Prilocaine alongside peripheral nerve blocks and Eleveld modelled target-controlled infusion (TCI) 1% Propofol for sedation. Ethical committee approval was deemed unnecessary by our audit and research department as patients receive short-acting spinal anaesthesia with blocks routinely. Methods Data from 84 patients who received intrathecal 2% Prilocaine alongside ultrasound-guided peripheral nerve blocks (Femoral and Lateral cutaneous nerve of thigh) and Elevled TCI Propofol sedation were analysed. We recorded the day 1 post-op systolic blood pressure, pre and post-operative pain score, length of stay and 30-day mortality. Results We noted that no patient required additional analgesia in recovery, no admissions to intensive care and 30-day mortality was found to be 4%, which is better than the UK national average. The mean length of stay in the hospital was found to be 18 days. Conclusions We observed that intrathecal Prilocaine combined with nerve blocks is a reliable technique in hip fracture surgery, offers haemodynamic stability and could improve overall survival. Further study of the use of short-acting intrathecal agents is required in comparison to traditional methods.
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B100 “Dream” tubeless opiate free anaesthesia achieved with peripheral nerve blocks for knee replacement surgery – an observational studyBackground and Aims Perioperative opioids mainstay analgesia for Knee replacement surgery.Spinal opioids cause urinary retention, itchiness and vomiting.Cumulative opioid consumption causes increase CRP and fibrinogen levels- acute phase reactants. High opiate use cause physical dependence hence we planned Tubeless opiate free anaesthesia to fulfill our DREAM((Drink, Eat, Analgesia, Mobilise) . Methods Prospective Study done in 24 Patients undergoing elective Knee replacement surgery . Low dose spinal Bupivacaine heavy 0.5% 2.4 mls.No intrathecal opiates and Urinary Catheters not inserted. Adductor cana l (Figure 1) at apex of femoral triangle(FT)- 15 mls Ropivacaine 0.375%. Genicular blocks - SM,SL,IL-15 mls, IPACK (Figure 2&3) - above condylar level- 12 mls( max total dose Ropivacaine 3mg/kg ). Intraoperative analgesia was Paracetamol, Parecoxib and Mgso4. Tourniquet used for all. Results In patients with Nerve blocks patients length of stay was reduced by 2 days.Median Motor recovery time 3 hours. No Urinary catheter was required in opiate free group. Opiates requirement was reduced in post operative period Tubeless “DREAM “ was achieved postoperatively (No IV , Oxygen tubes & urinary catheters required). Only patients with high Preoperative pain scores asked for further pain relief 24 hrs postoperatively & 16 patients didn’t require opiates. Conclusions Opiate free Anaesthesia gives better results for enhanced recovery in post operative knee replacement patients. Ultrasound guided Adductor canal/IPACK blocks indicated to spare intrathecal opiate and postoperative opiate requirements. DREAM for Knee replacement patients can be realised . Our mission was to wean patients from preoperative opioids. Our technique of RA is the mainstay in achieving that. ( Ethical committee approval granted audit number 841_341 Georgeeliothospital )
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B85 The first use of liposomal bupivacaine in a UK NHS hospital: the future of opiate-free surgery?Abstract Background and Aims The development of an opioid-free, enhanced-recovery service is the goal of many regional anaesthetists. The use of peripheral nerve blockade using traditional local anaesthetics has allowed opiate-free anaesthesia in the intra-operative period, however, patients often require opiate analgesia post-operatively with related complications1. We report the first use of liposomal bupivacaine (Exparel®), outside of the private sector, in a UK hospital. This allows for long-acting (>48 hrs) analgesia with minimal motor blockade after a single procedure2. Methods This case series looked at the first 8 patients to receive the drug undergoing elective knee replacement surgery. All patients received spinal anaesthesia containing 0.5% Heavy Bupivacaine alongside motor sparing blocks of the knee, including the Adductor canal, nerve to Vastus Medialis, Genicular nerves and interspace between popliteal artery and capsule of the knee (IPACK). They were reviewed post-operatively and by telephone at 72 hours and 1 week post-operatively. Results All patients in the series had adequate post-op analgesia (average scores 2/10) with no patients requiring PRN morphine over 48 hrs. There were no reported anaesthetic-related complications. All patients had good physiotherapy outcomes with early mobilisation. The majority of patients were fit for discharge within 24 hours. Overall patient satisfaction with the procedure was very high with written compliments received by the trust. Conclusions The use of liposomal bupivacaine has demonstrated excellent outcomes on analgesia requirements, patient satisfaction and hospital length of stay. The data from this case series will be used to further develop an opiate-free orthopaedic surgery and promote further research in the use of this drug.
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Novel use of ultrasound-visible needle when performing thoracocentesis for low volume pleural effusionA letter to the Editor suggesting a novel use of ultrasound-visible needle when performing thoracocentesis for low volume pleural effusion.
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Early serratus plane block for rib fracture management could avoid intensive care unit admissionLetter to the Editor reporting that early serratus plane block for rib fracture management could avoid intensive care unit admission.
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Hybrid anesthesia for fractured neck of femur surgery using intrathecal prilocaineLetter to the Editor sharing experience of implementing hybrid anesthesia for fractured neck of femur surgery using intrathecal prilocaine.
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Combining femoral triangle block with infiltration between the popliteal artery and capsule of the posterior knee in anterior cruciate ligament reconstructionComment on Martin R, Kirkham KR, Ngo THN, Gonvers E, Lambert J, Albrecht E. Combination of femoral triangle block and infiltration between the popliteal artery and the capsule of the posterior knee (iPACK) versus local infiltration analgesia for analgesia after anterior cruciate ligament reconstruction: a randomized controlled triple-blinded trial. Reg Anesth Pain Med. 2021 Sep;46(9):763-768. doi: 10.1136/rapm-2021-102631.
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The vicious cycle of functional neurological disorders: a synthesis of healthcare professionals' views on working with patients with functional neurological disorderPurpose: The objective of this review was to synthesise studies which address the views of healthcare professionals (HCPs) towards patients with functional neurological disorder (FND). Methods: An interpretive systematised review was conducted. Seven databases were searched using a comprehensive search strategy (MEDLINE, EMBASE, AMED, CINAHL, PsychINFO, ProQuest Nursing and Allied Health, and Scopus). Qualitative studies and those using survey methods were included. An inductive approach to thematic analysis was used to identify concepts from the data and to synthesise the results. Results: The views of 2769 HCPs were represented in 11 included articles. The overarching theme across the articles was uncertainty: about making the diagnosis of FND, about professional roles, and about optimum management. Fear was also a common theme: of saying the wrong thing, of offending patients, or of breaking the therapeutic relationship. Conclusions: If all HCPs felt uncertain about how to manage patients with FND and avoided them by passing them on to another discipline, then a "vicious cycle" is formed in which patients are passed from one professional to another but without receiving clear, honest information, or effective treatment. HCPs would benefit from increased training on FND and clear clinical pathways to alleviate feelings of uncertainty.Implications for rehabilitationEvidence-based or, at the very least, consensus-based multi-disciplinary care pathways for the assessment and treatment of patients with functional neurological disorder are required to improve equitability of services.Training packages for healthcare professionals need to be developed, evaluated and implemented in order to improve confidence of making and explaining the diagnosis and to reduce stigma of functional neurological disorders.Improved input for patients with functional neurological disorder is likely to occur if healthcare professionals are open, honest and use effective communication skills, both with their patients and fellow healthcare professionals.
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Spinal cord stimulation for visceral pain--a novel approachBackground: Spinal cord stimulation and dorsal column stimulation have been used successfully in the management of visceral pain for many years. A novel technique of ventral column stimulation has been used in our institute with good outcomes since 2007. We describe a retrospective series of 26 patients with visceral neuropathic pain who were treated with neuromodulation. Methods: Patients with either dermatomal hyperalgesia or sympathetically mediated neuropathic abdominal pain who had been treated with spinal cord stimulation were assessed. An independent observer conducted a face-to-face interview with each patient to collect data including demography, electrode placement, electrode mapping, and outcomes. Results: There was significant reduction in visual analog pain scores from a median 9 at baseline to 4 at 26 months (p ≤ 0.05). Reduction in opioid consumption was very significant from a baseline median oral morphine equivalent of 160 mg to 26 mg (p < 0.001). In addition, quality of life, activities of daily living, and patient global impression of change improved. Conclusion: There is a need to further investigate the use of ventral stimulation for visceral pain syndromes. This would need multicenter trials to collect adequate numbers of patients to allow hypothesis testing to underpin recommendations for future evidence-based therapies.
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Using Facebook™ as a Platform for Remote Patient Care to Address Rehabilitation Needs in a Resource-Limited Environment During a CrisisThe Covid 19 Pandemic affected Physiotherapy Clinics as much as it did all Clinical Services Provisions all over the world. This paper discusses a model where Facebook social media platform was successfully used as an emergency platform to deliver clinical services to the clients of a Physiotherapy Clinic in a Developing Country, during the Covid 19 pandemic.
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A cadaver study to measure the adult glottis and subglottis: defining a problem associated with the use of double-lumen tubesObjective: To test the hypothesis that the adult cricoid diameter is the same or less than that of the glottis. Design: Prospective. Setting: A city mortuary. Participants: Adult cadavers undergoing autopsy. Interventions: After removal of the organs, the trachea was opened above the first ring to allow access to the cricoid from below, and the cricothyroid membrane was cut so that passage of measuring sounds through the vocal cords from above could be confirmed. Measurements and main results: In 79 male and 55 female cadavers, the largest of a graduated series of cylindrical sounds that the cricoid ring would accommodate was noted. Then the biggest size possible that could pass through the glottis was measured. Height and weight were recorded. In 68% of males and 76% of females, glottic diameter was greater than subglottic; in all other cases, it was the same. In none was it smaller. Correlation between height and cricoid diameter was 0.24 for male cadavers and 0.21 for female cadavers. Regression analysis showed females to average a cricoid diameter 3.5 mm less than males of the same height. Conclusions: The ruling diameter of the adult larynx is not the glottis but the cricoid ring. Its correlation with height is extremely poor, and it averages 3.5 mm less in females than males of the same height. These findings are important for thoracic anesthesiologists.
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Evaluation of a model for maximizing interprofessional education in an acute hospitalA one-year planning phase established a rolling programme of bi-monthly interprofessional clinical teaching workshops derived directly from patient experiences in an acute hospital. Pre-registration healthcare students from 8 professions spent an afternoon in the hospital training centre, randomly allocated to one of 6-8 small working groups. Using a problem-based methodology they analysed a ward case with patient consent, chosen to reflect the input of a wide range of health professionals. Students worked through a prepared workbook facilitated by a range of tutors from all disciplines. Each small group reported back on one aspect of team working to the entire cohort entering into debate and discussion with the support of clinical and academic tutors. Post course patient details were found on a website enabling students to progress their uni-professional knowledge, e.g., on anatomy, physiology, pharmacology etc. The questionnaire evaluation on over 126 students and 11 tutors identified that interprofessional competencies were understood and valued. Students related principles of team working and collaborative practice to their placement experiences of team work. Interactive learning enables further appreciation of professions roles and responsibilities and the importance of teamwork to optimize patient care (82.0 - 90.5%). The half-day learning model can be easily supported by busy clinical staff, led by hospital educators and accessed by students on hospital placements, at a mid-point in training, with learning supported by consenting in-patients or recent admissions prepared to share their experiences.
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Research teaching in learning disability nursing : exploring the views of student and registered learning disability nursesBackground: Whilst there is a need to develop the research base within learning disability nursing it is also significant that currently there is little published data as to how research is taught to this group of nurses. Objectives: To increase understanding of how research is currently taught to learning disability nurses within the UK. Design: A survey design was used. Setting: The research was undertaken at a conference held in the UK in March 2014. Participants: 310 learning disability nurses attending the conference of which 212 completed the free text question. This comprised student nurses (n=158), registered nurses working in practice settings (n=25) and registered nurses working in educational institutions (n=24). Five participants did not specify their background. Methods: Participants were invited to complete a questionnaire that included a free text question regarding the teaching of research to learning disability nurses: it is the responses to this question that are reported in this paper. Responses were transcribed and thematically analysed. Findings: Eight themes emerged: Teaching approach--the good and the bad; finding the right level; right from the start; we need more time; generic versus specialist; there's not enough; getting research into practice; and what should we focus on? Conclusions: Variations exist in terms of the timing of research education, the teaching approaches used, and hence the quality of student experience. Of particular concern is the apparent gap between research teaching and the use of research in practice, and the reported lack of support for research within practice settings. However, enthusiasm for research is evident and hence recommendations are made both to enhance teaching and to strengthen links with practice.
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The oasis project, exploring the concept of reducing anxiety & stress in a hospital settingComments written in a prayer book in a hospital Chaplaincy Centre, about the area being a 'quiet oasis' in the middle of a busy hospital amid lots of anxiety and stress led to a focus group forming to explore ideas on how this could be addressed; a short term vision was the creation of an area (Oasis) in the Chaplaincy centre and longer term in other areas across the whole hospital. These areas would have an ambience of calm and relaxation where the use of colour, sound, aroma's and touch would be used to help in the reduction of stress and anxiety, this may be from forthcoming surgery, procedures or life in general from traumatic circumstances. The potential impact of this would be to aid recovery, potentially reduce other stress related illness and improve general well-being using strategies to include relaxation, breathing and visualisation techniques and aromatherapy hand massage.
