PRACTICE. QUALITY IMPROVEMENT REPORT Intraoperative fluid management guided by oesophageal Doppler monitoring

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1 For the full versions of these articles see bmj.com QUALITY IMPROVEMENT REPORT Intraoperative fluid management guided by oesophageal Doppler monitoring Martin Kuper, 1 5 Stuart J Gold, 2 Colin Callow, 3 Tanviha Quraishi, 4 Sarah King, 2 Aundrea Mulreany, 1 Michele Bianchi, 1 Daniel H Conway 4 1 Whittington Hospital NHS Trust, London N19 5NF 2 Royal Derby Hospital NHS Foundation Trust, Derby DE22 3NE 3 NHS Technology Adoption Centre, Manchester M13 9WL 4 Manchester Academic Health Science Centre, Manchester Royal Infirmary, Manchester M13 9WL 5 NHS Improvement Correspondence to D H Conway daniel.conway@cmft.nhs.uk Cite this as: BMJ 2011;342:d3016 doi: /bmj.d3016 bmj.com Previous articles in this series ЖЖEffect of a Lean intervention to improve safety processes and outcomes on a surgical emergency unit (BMJ 2010;341:c5469) Abstract Problem Fluid management during major surgery poses a challenge to the surgical team as postoperative complications are often related to giving the wrong amount of intravenous fluid. Postoperative morbidity can be reduced by using the oesophageal Doppler cardiac output monitor to individualise fluid administration, but this technology has not been widely adopted. Design A campaign for adopting this technology in major surgical specialties explored clinical and managerial barriers throughout the procurement and implementation process. We compared patient outcomes 12 months before implementation and after implementation. Setting Three large hospitals in England with different size, geographical location, and case mix. Strategies for change Project leads at each site included a consultant anaesthetist, a divisional manager, and an audit facilitator. A business case was prepared by each team with support from NHS Technology Adoption Centre, allowing senior management to overcome the unequal spread of costs versus benefits. A survey of anaesthetists revealed concerns about familiarity with the device, which we dealt with by clinicians volunteering to champion the technique, supported by standard training provided by the manufacturer. We encouraged appropriate use of the technology by collecting intraoperative patient related data and postoperative patient outcomes and by giving regular, timely feedback. Key measures for improvement The key outcome measure was length of hospital stay. In-hospital mortality, readmission, and reoperation rates were also recorded. Process measures were use of monitors and change in stroke volume during surgery. Effects of the change We compared 649 patients after implementation across all sites with 658 matched cases before implementation. Use of Doppler increased from 11% to 65% of eligible operations, with a 3.7 day reduction in total length of stay. Length of stay was reduced at each site, and in most specialties. Concurrent improvements in patient care could have contributed to these findings. The only sign of harm from the intervention was one episode of pulmonary oedema. Mortality, readmission, and reoperation rates all fell non-significantly. Lessons learnt Managerial barriers consisted of silo budgeting, difficulties with preparing a business case, and fears about uncontrolled implementation. By collecting outcome data, we convinced senior managers to support and sustain investment. Clinical barriers consisted mainly of scepticism regarding clinical effectiveness and worries about training. Clinicians championing the technology took on responsibility for data collection, education, advocacy, and spanning boundaries. When barriers to adoption of oesophageal Doppler monitoring are overcome, outcome improvements suggested by research can be replicated in the real world. The project generated a web based guide ( to provide tools and resources to support implementation. Context Effective intraoperative fluid therapy is an essential component of enhanced recovery programmes for patients having major surgery. 1 Conventional haemodynamic monitoring of pulse and blood pressure fails to detect occult hypovolaemia, which occurs in many surgical patients 2 and contributes to inadequate tissue perfusion, leading to organ dysfunction and postoperative complications. 3 On the other hand, large volumes of intravenous fluid may cause complications due to unwelcome tissue oedema. After major surgery many patients experience complications, which are associated with prolonged hospital stay and adverse long term outcomes. 4 5 The oesophageal Doppler monitor (Deltex Medical, Chichester, UK) measures stroke volume, allowing the anaesthetist to target intravenous fluid replacement to an individual s needs, reducing the risk of giving too much or too little fluid. Evidence from seven randomised controlled trials, a meta-analysis, and a health technology assessment and procurement review shows that such individualised goal-directed fluid therapy with oesophageal Doppler monitoring reduces complications and length of stay after major surgery The NHS Technology Adoption Centre (NTAC) has a remit to facilitate implementation of proved medical technology that can benefit patients and improve the efficiency of systems. The centre supported the implementation of fluid administration guided by oesophageal Doppler monitoring at three hospitals chosen for their different size, geographical location, and case mix. The Whittington is a university associated, district general hospital in London; Royal Derby Hospital is a large regional hospital; and Manchester Royal Infirmary is a tertiary centre. Patient groups included 1256 BMJ 4 JUNE 2011 VOLUME 342

2 Table 1 Surgical specialties in which oesophageal Doppler monitoring was implemented Surgical specialty Royal Derby Hospital: Colorectal Whittington Hospital: Colorectal Orthopaedics Manchester Royal Infirmary: Colorectal Upper gastrointestinal Orthopaedics Gynaecology Kidney or pancreas transplant Urology Timing of surgery Urgent in the implementation programme varied at the three sites (table 1). Various minimally invasive devices for monitoring cardiac output had been trialled at each centre, but no structured programme of implementation had been carried out and actual use of the devices was sporadic. Outline of the problem Although clinical research has indicated that patients having major surgery are likely to benefit from intraoperative fluid management guided by oesophageal Doppler monitoring, its use has been patchy. The project aimed to identify and overcome barriers to the procurement and implementation of oesophageal Doppler monitoring. We also wanted to determine whether benefits suggested by research could be obtained in practice. Key measures for improvement The key patient outcomes were length of hospital stay and postoperative stay. As indicators of potential harm, we assessed oesophageal trauma and pulmonary oedema, along with readmission and reoperation rates and inpatient mortality. Process measures included use of monitors, volume and type of intravenous fluids administered, perioperative change in stroke volume, and the use of invasive arterial and central venous monitoring. Gathering information We systematically assessed the barriers to procurement and the impact of implementation at each site. Qualitative data regarding barriers to implementation of oesophageal Doppler monitoring were recorded and discussed at regular meetings of the project group and local clinical teams. Attitudes of consultant and trainee anaesthetists towards the benefits and risks of this monitoring were surveyed anonymously in Manchester before implementation. We compared prospective data from consecutive patients in the year after implementation with retrospective data from controls matched by specialty and severity of operation, identified from hospital record systems, from the year before implementation. Consultant anaesthetists and audit facilitators collected information on process and outcome measures preoperatively, intraoperatively, and postoperatively by using a standard form. We estimated the risk of complication and death using the POSSUM surgical scoring system, which incorporates patient related and surgical risk factors. 15 Following advice from York Health Economics Consortium, our statistical analysis used the t test for independent samples. For comparisons of smaller numbers (<100) we used the Mann-Whitney test, and for count data we used the χ 2 test. Analysis and interpretation At all three sites, previous business cases prepared by clinicians had failed to be accepted by the hospital management. On review, these unsuccessful business cases did not illustrate how reducing the length of stay could be valued in terms of additional income generation or cost reduction. A recurrent theme was silo budgeting, where directorate managers responsible for fixed, non-transferable budgets were unable to reconcile the unequal spread of costs and benefit across directorates. Managers were wary about the cost of unrestricted use of consumables. Although most anaesthetists surveyed were prepared to accept that oesophageal Doppler monitors were useful, many were concerned that they lacked sufficient training to use the devices confidently. Others questioned whether the results of randomised trials would apply to their individual practice, for example, wondering whether improvements in patient care would fail to reduce length of stay due to inefficient custom and practice on the surgical ward. Strategy for change At each site, a project team combining a lead clinician, managers, and audit facilitator devised a project plan together, with support from an NTAC programme manager. Regular meetings of the project teams allowed common barriers and solutions to be identified. Senior managers at each site were engaged to help overcome problems arising from silo budgeting. Directorate managers prepared business cases, with clinical input and a cost-activity model devised by NTAC based on reduction in length of stay. Controlled implementation and probe requirements were projected from previous years surgical activity. To provide a common price for the project, purchase of Doppler monitors and probes was negotiated between NTAC, a regional NHS procurement hub, and the manufacturer. However, full funding for monitors and disposables came from within each trust s surgical budget. The manufacturer provided written information to support preparation of the business case and standard training in using monitors, but had no active or observational role in study design, data collection, or analysis. Measure stroke volume ml fluid over 5-10 minutes Stroke volume increase >10%? Stroke volume reduction >10% Yes Monitor stroke volume for clinical signs of fluid loss Yes Intraoperative fluid management using stroke volume optimisation technique with oesophageal Doppler monitoring BMJ 4 JUNE 2011 VOLUME

3 Table 2 Preoperative data for surgical patients before and after the implementation of fluid administration guided by oesophageal Doppler monitoring. Values are percentages unless specified otherwise Age Control (n=658) Intervention (n=649) (29.8) 237 (36.5) (26.6) 167 (25.7) (43.6) 245 (37.8) Surgical specialty: Colorectal 339 (51.5) 355 (54.7) Gynaecological 4 (0.6) 9 (1.4) Orthopaedic 139 (21.1) 133 (20.5) Kidney or pancreas transplant 48 (7.3) 33 (5.1) Upper gastrointestinal 79 (12.0) 55 (8.5) Urology 21 (3.2) 45 (6.9) Vascular 28 (4.3) 19 (2.9) Mean (SD) POSSUM score 34.3 (8.3) 34.0 (8.5) ASA physical status grade: 83 (12.6) 108 (16.6) (45.4) 313 (48.2) (37.5) 185 (28.5) 4 26 (4.0) 41 (6.3) 5 1 (0.2) 1 (0.2) Mode of surgery: Urgent or emergency 201 (30.5) 177 (27.3) or scheduled 457 (69.5) 472 (72.7) At each site NTAC funded a nurse or audit facilitator to collect data, and implementation was encouraged by giving regular feedback to the anaesthetists. Data on Doppler use and patient outcomes were compared with controls matched for surgical specialty and type of operation, from the 12 months before implementation. Regular meetings between anaesthetists and the project team at each site encouraged feedback and helped troubleshooting. After training in the classroom and theatre, anaesthetists were encouraged to use oesophageal Doppler monitoring in all eligible cases. The approach to implementation was tailored to the diverse surgical activity at each site. At Royal Derby Hospital, monitoring was implemented in colorectal surgery. The colloid used was succinylated gelatin (Gelofusine; B Braun Medical, Sheffield, UK). Overlapping committee responsibilities were an important hurdle; the equipment, change in practice, audit, and directorate management committees Table 3 Intraoperative data collected for patients who had surgery before and after the implementation of fluid administration guided by oesophageal Doppler monitoring Variable Control (n=658) Intervention (n=649) P value* Mean (SD) stroke volume (ml): Start of surgery 80.7 (27.7) <0.001 End of surgery 97.2 (31.7) Mean (SD) intravenous fluid (ml): (1604.0) (1838) 0.09 Colloid (752.0) (776.1) <0.001 Crystalloid (1003.4) (1165.5) 0.83 Plasma 44.7 (284.2) 34.1 (205.6) 0.44 Blood (454.3) (404.0) 0.97 Monitoring (%): Doppler inserted 74 (11.2) 429 (65.1) <0.001 Central venous catheter 290 (44.1) 221 (34.1) <0.001 Arterial line 274 (41.6) 281 (43.3) 0.58 *Independent samples t test used for fluid volumes; χ 2 test used for monitoring. were all involved in conducting the project. An executive sponsor at the trust s board level proved crucial in encouraging clinicians and managers to work together and generate organisational momentum. A reorganisation that gave one manager responsibility for both surgical wards and operating theatres helped overcome silo budgeting. At Manchester Royal Infirmary, Doppler use was encouraged for a wide range of major elective and emergency surgical procedures, but to maintain control of costs, implementation was limited to a subset of clinical teams. Fourteen consultant anaesthetists volunteered to champion Doppler use and report perioperative outcomes. These data were compared with procedures of similar severity undertaken by the same clinical teams in the 12 months before implementation. The colloid used was hydroxyethyl starch (Volulyte; Fresenius Kabi, Runcorn, UK). At the Whittington Hospital, oesophageal Doppler monitoring was implemented in colorectal and orthopaedic surgery (table 1). The colloid used was succinylated gelatin. Usage by 18 consultants and two staff grades was encouraged in all eligible cases. In addition to training for permanent staff, instruction was introduced into the trainee induction programme. At the Whittington and in elective colorectal surgery only, Doppler use was implemented as part of a multidisciplinary multimodal enhanced recovery programme. 1 Effects of change We compared 649 patients who had major surgery after the implementation of fluid administration guided by oesophageal Doppler monitoring (intervention group) with 658 patients (controls) who had had similar operations in the preceding 12 months. Preoperative POSSUM scores and urgency of surgery were similar in the two groups (table 2). After implementation, oesophageal Doppler monitoring was used in 65% of operations, compared with 11% before implementation. Although Doppler use was encouraged it could not be mandated, so this represented a substantial increase. anaesthetists refused to use the Doppler monitor or stated that they felt unable to use the monitor after training. In the post-implementation group, stroke volume increased from 80.7 ml to 97.2 ml from the start to the end of the case (table 3). This increase of 16.5 ml in stroke volume is consistent with correcting ph ysiological hypovolaemia. 16 The oesophageal Doppler monitor augments clinical judgment to allow individualised fluid administration (figure). We found a modest but significant mean difference in total colloid volume compared to before implementation, coupled with a wide standard deviation, indicating that some patients required much more fluid than others. This concurs with research showing that the optimal fluid volume for perioperative patients varies widely and that a balanced approach reduces complications. 17 The differences in fluid volumes before and after implementation are comparable with the published studies of oesophageal Doppler monitoring, which have also shown that such fluid optimisation improves organ perfusion 3 16 and reduces the stress response to surgery, including release of interleukin-6, 9 thus reducing length of stay Many 1258 BMJ 4 JUNE 2011 VOLUME 342

4 Table 4 Length of stay (days) before and after the implementation of fluid administration guided by oesophageal Doppler monitoring. P values calculated using an independent samples t test Patient group Control Mean (SD) stay Intervention Mean (SD) stay Total (24.4) (16.7) Derby (10.7) (7.3) Manchester (34.8) (23.2) Whittington (13.4) (12.7) Post-operative intensive care (24.0) (15.9) P value anaesthetists reported that after oesophageal Doppler monitoring was implemented they felt more confident giving intravenous fluid proactively. Table 3 shows the use of cardiovascular monitoring. Use of arterial catheters did not change, but use of central venous catheters was reduced by 10% after Doppler monitoring was implemented. The observed lengths of stays before implementation were typical of national outcomes for the type and urgency of surgery studied. In Derby, where only elective colorectal surgery was examined, the mean length of stay before implementation was 11.9 bed days. This represented current practice since in (hospital episode statistics for 161 hospitals in England); the national mean length of stay for colectomy was 11.2 bed days and for rectal resection was 13 bed days. At the Whittington and Manchester hospitals, both elective and emergency surgery were included, and more major surgery was undertaken (table 1), so length of stay was longer. Overall, after implementation the mean length of hospital stay fell by 3.6 days (from 18.7 to 15.1 days; P=0.002) and postoperative length of stay fell from 17.2 days to 13.6 days (P=0.001) (table 4). The mean length of stay in critical care was similar in control and intervention patients (data not shown). Signs of harm arising from the implementation were absent. Critical care readmission, hospital readmission, reoperation, and in-hospital mortality were slightly lower after implementation (table 5). One episode of pulmonary oedema occurred in a patient with sepsis and chronic renal failure. This non-randomised before and after project explored the challenges and the effectiveness of a new approach to implementing technology and its impact on important patient outcomes. Despite matching for specialty and severity of operation, the control and implementation groups had differences in age and physical status scores; however, the perioperative risk indicator (POSSUM, which incorporates age) was similar in the groups, so similar outcomes would be predicted. Table 5 Number (percentage) of readmissions and reoperations after surgery in three hospitals before and after the implementation of fluid administration guided by oesophageal Doppler monitoring Variable Readmission: Control (n=658) Intervention (n=649) To critical care 22 (3.3) 14 (2.2) 0.20 To hospital 36 (5.5) 25 (3.9) 0.20 Reoperation 55 (8.4) 38 (5.9) 0.08 P value (χ 2 test) In-hospital mortality 23 (3.5) 18 (2.8) 0.37 Results could have been confounded by other changes occurring over the same time period. However, both total and postoperative length of stay fell on all three sites and these reductions were significant on two of the sites, strengthening the evidence for an effect of the in tervention. At the Whittington, in elective colorectal surgery only, a multidisciplinary enhanced recovery programme was introduced and may have contributed to the observed improvement. other enhanced recovery pathway elements were introduced in Manchester or Derby. With all elective colorectal patients at the Whittington excluded, the reduction in postoperative stay for remaining patients remained unchanged (3.6 days; P=0.003). We did not identify other important confounding factors for example, availability of critical care beds did not change, nor did admission policy or provision of outreach. One trial found that oesophageal Doppler monitoring may not benefit patients receiving enhanced recovery care, 19 but excellent results have been reported within an enhanced recovery colorectal pathway using such m onitoring. 20 Any implementation study of this type is vulnerable to a Hawthorne effect, whereby performance improves as a result of close observation. So although use of oesophageal Doppler monitoring rose from 11% to 65%, with patients achieving a 20% rise in stroke volume, these improvements may not be replicated when clinical performance is not being closely observed. Even though patient groups differed at the three sites in the type and urgency of surgery, a consistent benefit was seen. This indicates that implementing oesophageal Doppler monitoring may produce benefits in diverse healthcare settings. Next steps Patient outcomes improved after managerial and clinical barriers to implementation were identified and overcome. Preparation of the business case was improved by partnership with local managers, coupled with external support from NTAC and supportive literature from the manufacturer. Illustrating the benefits from reductions in length of stay required two business models, based either on increasing activity or on reducing bed base with resulting cost savings. Silo budgeting, with unequal spread of costs and benefits across directorates, was overcome with the support of senior executives. Clinical reluctance to adopt oesophageal Doppler m onitoring technology revolved around three aspects: scepticism about utility; confidence with using the BMJ 4 JUNE 2011 VOLUME

5 mo nitor; and reluctance to change usual practice. These issues were overcome by a campaign comprising departmental meetings, reminder s, education and training of senior and junior doctors separately, and advocacy by clinical champions to support use of the technology. The project team kept records of anaesthetists who had undergone the standard training. The stroke volume maximisation technique (figure ) introduced with oesophageal Doppler monitoring facilitates individualised fluid administration. We found a small increase in colloid administered after implementation, but a wide standard deviation, indicating that some patients needed more fluid than others to maintain fluid balance. 17 Many anaesthetists reported that after oesophageal Doppler monitoring was implemented they felt more confident giving intravenous fluid proactively. It may be that early administration of colloid is as important as the total volume, with monitoring preventing giving excessive fluid. The project team did not dictate whether anaesthetists should continue to use traditional methods of assessing volume status, such as central venous pressure. netheless, the use of central venous catheters fell by 10%, perhaps as a result of recognition of the limitations and associated risks of this practice. 21 This project, commissioned and facilitated by NTAC, shows that organisational support and a systematic approach to technology adoption, can help clinicians implement evidence based care that benefits patients. We have helped NTAC produce a guide ( nhs.uk) that contains links to clinical research, teaching resources, details of the project sites and patient outcomes, and an interactive business case with cost-activity modelling. Individualised fluid therapy has been adopted as one of the recommended elements for major elective surgical pathways by the National Enhanced Re covery P rogramme. 1 The project sites have also received regional innovation funding to help support diffusion and a doption of oesophageal Doppler monitoring. Independent statistical advice was provided by York Health Economics Consortium at York University. Contributors: CC, DC, SG, and MK conceived and designed the project. All authors collected, analysed, and interpreted the data. CC, DC, SG, MK, and TQ drafted the manuscript and take full responsibility for its integrity. DC and MK are the guarantors of the project. Funding: This project was supported by the NHS Technology Adoption Centre. Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: TQ received a reimbursement from Deltex Medical Group plc for attending a congress. Financial support for the project came from the NHS Technology Adoption Centre; no other relationships or activities that could appear to have influenced the submitted work. Provenance and peer review: t commissioned; externally peer reviewed. 1 Enhanced Recovery Partnership Programme. Delivering enhanced recovery. Helping patients to get better sooner after surgery, documents/digitalasset/dh_ pdf 2 Bundgaard-Nielsen M, Jorgensen CC, Secher NH, Kehlet H. Functional intravascular volume deficit in patients before surgery. Acta Anaesthesiol Scand 2010;54: Mythen MG, Webb AR. Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg 1995;130: Grocott MP, Browne JP, Van der Meulen J, Matejowsky C, Mutch M, Hamilton MA, et al. The postoperative morbidity survey was validated and used to describe morbidity after major surgery. J Clin Epidemiol 2007;60: Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg 2005;242: Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ 1997;315: Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth. 2002;88: McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M. Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. BMJ 2004;329: blett SE, Snowden CP, Shenton BK, Horgan AF. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg 2006;93: Gan TJ, Soppitt A, Maroof M, el-moalem H, Robertson KM, Moretti E, et al. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology 2002;97: Conway DH, Mayall R, Abdul-Latif MS, Gilligan S, Tackaberry C. Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Anaesthesia 2002;57: Wakeling HG, McFall MR, Jenkins CS, Woods WG, Miles WF, Barclay GR, et al. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth 2005;95: Abbas SM, Hill AG. Systematic review of the literature for the use of oesophageal Doppler monitor for fluid replacement in major abdominal surgery. Anaesthesia 2008;63: Mowatt G, Houston G, Hernandez R, de Verteuil R, Fraser C, Cuthbertson C, et al. Evidence review: oesophageal Doppler monitoring in patients undergoing high-risk surgery and in critically ill patients: Centre for Evidence-based Purchasing, jan_10/nhs _cep08012%5B1%5D.pdf 15 Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. Br J Surg 1991;78: Hamilton-Davies C, Mythen MG, Salmon JB, Jacobson D, Shukla A, Webb AR. Comparison of commonly used clinical indicators of hypovolaemia with gastrointestinal tonometry. Intensive Care Med 1997;23: Varadhan KK, Lobo DN. A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right. Proc Nutr Soc 2010;69: Walsh SR, Tang T, Bass S, Gaunt ME. Doppler-guided intra-operative fluid management during major abdominal surgery: systematic review and meta-analysis. Int J Clin Pract 2008;62: Senagore AJ, Emery T, Luchtefeld M, Kim D, Dujovny N, Hoedema R. Fluid management for laparoscopic colectomy: a prospective, randomized assessment of goal-directed administration of balanced salt solution or hetastarch coupled with an enhanced recovery program. Dis Colon Rectum 2009;52: Levy BF, Scott MJ, Fawcett WJ, Rockall TA. 23-hour-stay laparoscopic colectomy. Dis Colon Rectum 2009;52: Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 2008;134: Accepted: 24 March 2011 CORRECTIONS AND CLARIFICATIONS Climate change, ill health, and conflict The date published in this editorial by Lionel Jarvis and colleagues (BMJ 2011;342:d1819, print publication 9 April, pp 777-8) for the climate change conference was 20 June The date has been changed to 17 October For more information on the meeting, see com/bmj/about-bmj/media-partnerships/climatechange2014how-to-secure-our-future-wellbeing-ahealth-and-security-perspective or contact Geetha Balasubramaniam at geetha@bmj.com BMJ 4 JUNE 2011 VOLUME 342

6 10-MINUTE CONSULTATION Otorrhoea Miran Pankhania, 1 Owen Judd, 2 Andy Ward 3 1 Department of ENT, Milton Keynes General Hospital, Milton Keynes MK6 5LD, UK 2 Department of ENT, Leicester Royal Infirmary, Leicester LE1 5WW, UK 3 South Wigston Health Centre, Leicester LE18 4SE Correspondence to: M Pankhania pank@doctors.org.uk Cite this as: BMJ 2011;342:d2299 doi: /bmj.d2299 This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs. bmj.com Previous articles in this series ЖЖGilbert s syndrome (BMJ 2011;342:d2293) ЖЖEpididymo-orchitis (BMJ 2011;342:d1543) ЖЖFrequent exacerbations in chronic obstructive pulmonary disease (BMJ 2011;342:d1434) ЖЖMalaria (BMJ 2011;342:1149) A 49 year old woman presents to her general practitioner with discharge from her left ear and otalgia. She had used olive oil drops for ear wax and completed a course of amoxicillin for presumed otitis media. Her symptoms have persisted despite treatment. What you should cover Ask about: Otorrhoea Otalgia Tinnitus Vertigo Hearing loss. Most ear disorders will present with one or more of these five symptoms. What is the link between otorrhoea and otalgia? Otitis externa presents with pain and discharge simultaneously. Patients with acute otitis media present with increasing otalgia. Otorrhoea starts when the tympanic membrane perforates, which resolves the earache. Acute otitis media is more common in children than in adults. Both otitis externa and acute otitis media carry a risk of intracranial disease if inappropriately treated. 1 2 Secondary symptoms such as headache, diplopia, pyrexia, neurology, and unrelenting pain indicate the need for more aggressive management. Risk factors Psoriasis, eczema, previous otitis externa or otitis media, and ear surgery all increase the chance of future ear disease. The patient s hobbies, occupation, and activities provide insight into potential ear disease, in particular: Water exposure: canal abnormalities and otitis externa Use of ear defenders, hearing aids, or headphones: otitis externa Flying: barotrauma and perforation Diabetes or immunodeficiency: necrotising otitis externa Use of cotton buds: many patients use these to try to remove wax from the ear Hopi candles: some patients use these to try to remove wax from the ear. Prevalence and incidence 10% of people have otitis externa at some point in life. Only 2% of primary otitis externa is fungal. 1 Acute otitis media is commonest in children, with 80% having at least one episode by age 3 years. 2 Cholesteatoma presents in 10 new patients per a year. A general practitioner with 2000 registered patients might see one new case in five years. 3 Examination te the colour of any discharge. Blood or clear fluid is important in patients with a history of trauma. If a purulent discharge is refractory to treatment, sending a swab for microhistological culture may guide further treatment. Tragal pressure causes deformation of the ear canal, and is a good indicator of otitis externa. Pain over the mastoid or the temporal bone on percussion should ring alarm bells as it suggests bony involvement. 2 Use otoscopy to systematically assess the external and middle ear: Ear canal: is there erythema, discharge, structural abnormality, or stenosis? In the tympanic membrane inspect for colour, retraction or bulging, and perforation. Carefully inspect the upper part of the tympanic membrane for cholesteatoma or crusting. A normal tympanic membrane is translucent with well defined anatomy. Obstructive debris can be removed with a wax hook or suction where available. The whole tympanic membrane may not be visible, but other clinical findings should be sufficient to enable a diagnosis. What you should do Careful history and examination is essential in differentiating otitis externa from otitis media. 1 2 Pseudomonas spp cause 40% and Staphylococcus aureus 30% of cases of otitis externa. Aminoglycoside based drops are a good treatment option for both organisms unless they are resistant. 4 Aminoglycoside based ear drops are safe for short term use (one to two weeks) in patients with a perforated tympanic membrane as the concentrations in the solution are not sufficient to be ototoxic. However, the drops will remain in the inner ear fluid for up to 6 months so repeat courses should be used with caution. 4 The use of fluoroquinolone drops (such as ciprofloxacin and ofloxacin) for patients with otitis externa is based on good evidence, and they are safe with perforations. 4 Check for a foreign body, particularly in children, but also in adults with a history of cotton bud or candle use (advise them against further use). A foreign body can precede otitis externa. Otitis externa responds best to ear drops that contain an antibiotic and a steroid. Empirical treatment with drops containing an aminoglycoside (such as framycetin, dexamethasone, and gramicidin) will cover the most common pathogens and reduce inflammation. 1 4 When otitis externa causes canal stenosis, wick insertion or prolonged treatment is needed, plus specialist input from an ear, nose, and throat emergency clinic. Patients with acute otitis media may need oral antibiotics to cover respiratory pathogens such as Streptococcus pneumoniae and Haemophilus influenzae. 2 In patients with otitis externa that need more than two treatment attempts, swab the ear and refer the patient for specialist input and microsuction toilet. Never syringe a discharging ear. BMJ 4 JUNE 2011 VOLUME

7 Hearing aids should not be worn in an ear being treated for otitis externa. Some ear, nose, and throat departments may have a nurse led suction clinic, which is ideal for troublesome, recurrent, or impacted wax. However, if suction is needed in an ear with infection, discussion may be needed with an emergency clinic. The following advice should be given to patients: If you are prone to recurrent ear infections, avoid getting water in your ears. Keep your ears dry when showering, bathing, or washing your hair by gently placing cotton wool in the ear and covering with Vaseline to make a splash-proof barrier. Wax can be softened by putting olive oil drops into the ears regularly for one or two weeks. The ears are self cleaning, and wax will gradually work its way out without the need for cotton buds. Do not wear a hearing aid in an ear that is infected as this encourages bacteria to grow in a moist environment with little ventilation. Referral to an ear, nose, and throat specialist Patients with immunodeficiency or diabetes who have pain when sleeping, focal neurology, or unrelenting otalgia should be admitted immediately to exclude necrotising otitis externa, a severe pseudomonal osteomyelitis. Crusting may indicate cholesteatoma, which should prompt routine outpatient referral. Cholesteatoma is a collection of locally erosive keratinising epithelium, often accompanied by an unpleasant smelling, longstanding, off-white discharge. Focal neurology or pain requires urgent referral. Aural toilet is a useful adjunct in removing debris, infected tissue, pus, and impacted wax. These all perpetuate infection, and removal facilitates treatment. Removal of wax alone may FURTHER RESOURCES Patient UK ( Website contains sections on otitis externa and otitis media NHS Clinical Knowledge Summaries ( Website contains sections on otitis externa and otitis media be suitable for a nurse led suction clinic where available. Otitis externa that is not amenable to treatment in the community may require advice from an ear, nose, and throat surgeon. Fungal otitis externa is evident as spores on otoscopy, and treatment should be with antimycotic drops such as clotrimazole. Fungal otitis externa may be precipitated by long term use of antibiotic drops containing steroids. Contributors: MP highlighted the absence of a recent article of this nature and wrote the article. Both OJ and AW reviewed, edited, and approved the final submission. Competing interests: All authors have completed the Unified Competing Interest form at and declare that all authors (1) have support from the University Hospitals of Leicester NHS Trust for the submitted work; (2) have no relationships with any companies that might have an interest in the submitted work in the previous 3 years; and (3) have no non-financial interests that may be relevant to the submitted work. Provenance and peer-review: t commissioned; not externally peerreviewed. 1 Beers SL, Abramo TJ. Otitis externa review. Pediatr Emerg Care 2004;20: Grevers G. Challenges in reducing the burden of otitis media disease: an ENT perspective on improving management and prospects for prevention. Int J Pediatr Otorhinolaryngol 2010;74: McHugh TP. Intracranial cholesteatoma: a case report and review. J Emerg Med 2007;32: Phillips JS, Yung MW, Burton MJ, Swan IR. Evidence review and ENT-UK consensus report for the use of aminoglycoside-containing ear drops in the presence of an open middle ear. Clin Otolaryngol 2007;32: Accepted: 28 February 2011 ANSWERS TO ENDGAMES, p For long answers go to the Education channel on bmj.com STATISTICAL QUESTION n-inferiority trials Answer c is the best description. ANATOMY QUIZ Coronal computed tomography of the chest A Right common carotid artery B Main pulmonary artery C Left atrium D Left inferior pulmonary vein E Right mitral valve leaflet PICTURE QUIZ A case of recurrent ventricular tachycardia 1 The heart is enlarged with dilation of the left ventricle and left atrium (figure). Extensive curvilinear calcification is seen overlying the cardiac apex consistent with myocardial calcification within a longstanding left ventricular aneurysm. A left sided pacemaker and an implantable cardioverter defibrillator were fitted after further episodes of ventricular tachycardia occurred on the coronary care unit. These are also seen in the chest radiograph, with leads placed in the right atrium and both ventricles. 2 Established coronary artery disease and a previous myocardial infarction predispose this patient to arrhythmia and conduction abnormalities. Another explanation for her ventricular tachycardia might be the presence of the apical ventricular aneurysm. A third of all patients with left ventricular aneurysm present with arrhythmias that cause palpitations, syncope, or sudden death. It is important to rule out a new myocardial infarction. 3 Such patients need maximum medical treatment for ischaemic heart disease and heart failure. An antiarrhythmic drug such as amiodarone (as used in our patient) is indicated. Patients should also be considered for placement of an implantable cardiac defibrillator and cardiac resynchronisation. In some patients surgical resection of the aneurysm and reconstruction of the ventricle can improve overall function and is considered if adequate residual segment function is present and medical treatment does not control symptoms BMJ 4 JUNE 2011 VOLUME 342