Can preoperative focused cardiac ultrasound improve morbidity and mortality after emergency noncardiac surgery? a pilot RCT

Research Opportunity
PhD, Masters by Research, Honours, Master of Biomedical Science
Number of Honour Places Available
1
Department
Surgery
Location
Royal Melbourne Hospital
Group Leader Email Number Webpage
A/Prof David Canty dcanty@unimelb.edu.au 0429058878 Personal web page
Primary Supervisor Email Number Webpage
Prof Colin Royse roysec@unimelb.edu.au 0408467548 Personal web page

Project Details

Emergency surgery on elderly patients is often high risk for postoperative death (6 per hundred) and
complications (one in five) as they are often frail from chronic diseases. Major complications after surgery are strongly associated with prolonged hospitalisation, increased hospital costs, and death. Postoperative
complications are often disabling and may require prolonged residential care, which contributes to health care cost. Death and complications are mostly due to patient’s medical problems (heart, lungs and kidneys) rather than the surgery, of which heart disease is a leading cause. Therefore, if patient’s heart disease could be better identified and treated before surgery then this could result in an improvement in postoperative outcome.

A major problem in emergency surgery is that there is not usually enough time to adequately diagnose and optimise heart problems. There is usually only time for basic screening tests such as a 12-lead electrocardiogram and chest x-ray. Standard clinical assessment by a doctor, including results of these tests, will miss clinically important heart disease in up to 50 % of patients, which may lead the treating team of doctors to give the wrong treatment. Transthoracic echocardiography (TTE) is a non-invasive ultrasound test that clearly identifies heart disease that can lead to poor outcome after surgery. A challenge is that formal TTE evaluation by the cardiology department is not immediately available and may delay emergency surgery, and is therefore usually not performed, resulting in 50% of patients having the wrong diagnosis and treatment before surgery.

Our proposed intervention is to routinely use focused cardiac ultrasound (FCU) before surgery to improve
accuracy of diagnosis of heart disease, which should result in improved management and postoperative
outcome. FCU is a goal-directed, and abbreviated form of TTE, which is performed by and improves bedside assessment and important medical decisions by the treating doctors. Focused cardiac ultrasound examination improves accuracy of assessment, which frequently changes the management plan of the doctors in order to prevent cardiac complications, for example more appropriate use of intravenous fluids, advanced monitoring, drugs used to treat heart disease and postoperative intensive care. Studies have already shown hat FCU can be used in time before emergency surgery without causing a delay and may result in few deaths and complications after hip fracture surgery, who are usually elderly (age>70yr).
In our proposed study we want to identify whether preoperative FCU can improve outcome in patients aged>65 yr undergoing major emergency surgery. We have calculated that this trial will require 2,000 patients, representing a significant expense. Before commitment to this important large trial, we propose a preliminary smaller ‘pilot’ study to determine whether the large trial is possible and to look for evidence of improved outcome in patients who receive FCU before surgery. This pilot study is expected to take 12 months to complete the initial study and then another 12 months to complete the follow up study, which will include an economic analysis to determine if FCU is more cost effective than the current standard (no FCU).

In this study, half of the patients will be randomly allocated to receive FCU prior to their emergency surgery and the other half will receive the current standard of care. The outcomes of death and complications for each group will be compared at 1 month, 3 months and 12 months after the surgery. The aims of the study are to identify whether the whether the study design is correct or whether it needs some adjusting and whether there is some suggestion that FCU may result in less death and complications after surgery. If the results are positive then it would strongly support commitment to the larger study, which if positive would result in a major change in medical practice that could save lives and relieve suffering to an enormous number of patients in Australia and the rest of the World.


School Research Themes

Cardiometabolic



Research Opportunities

PhD, Masters by Research, Honours, Master of Biomedical Science
Students who are interested in joining this project will need to consider their elegibility as well as other requirements before contacting the supervisor of this research

Graduate Research application

Honours application

Key Contact

For further information about this research, please contact a supervisor.

Department

Surgery

Research Node

Royal Melbourne Hospital

MDHS Research library
Explore by researcher, school, project or topic.