New postoperative pain instrument for toddlers-Secondary analysis of prospectively collected assessments after tonsil surgery.

BACKGROUND: The Children's and Infant's Postoperative Pain Scale (CHIPPS) and the German version of the Parent's Postoperative Pain Measure (PPPM-D) are used to assess postoperative pain intensity in preschool children. However, they have shown low concordance in previous prospective studies on quality improvement. AIMS: Our secondary analysis aimed to estimate the association strength between the pain score items and indication for rescue medication defined as CHIPPS ≥4 and/or PPPD-D ≥ 6. Thus, we intended to create a further developed pain instrument with fewer variables for easier routine use. METHODS: We analyzed 1067 pain intensity assessments of hospitalized children for the development of our novel tool in two steps using modern statistical and machine-learning methods: (1) Boruta variable selection to analyze the association strength between CHIPPS score, PPPM-D items, age, weight, and elapsed time after surgery, including their interactions and pattern stability, and the binary outcome (analgesics required yes/no). (2) Symbolic regression to generate a short formula with the least number of variables and highest accuracy for rescue medication indication. RESULTS: Additional analgesics were required in 19.96% of pain intensity assessments, whereby the PPPM-D showed higher variance than CHIPPS. Boruta identified PPPM-D score, CHIPPS score, 9 of the 15 PPPM-D variables, and time of assessment as associated with the indication for RM. Symbolic regression revealed that additional analgesics are required if CHIPPS is ≥4 OR PPPM-D item "less energy than usual" AND one of the items "more easily cry" or "more groan/moan" are answered with "yes." These PPPM-D items were not redundant and showed nonlinear course over time. The cross-validated accuracy for this assessment tool was 94.94%. CONCLUSIONS: The new instrument is easy to use and may improve postoperative pain intensity assessment in children. However, it requires prospective validation in a new cohort.

The influence of labor epidural analgesia on maternal, uteroplacental and fetoplacental hemodynamics in normotensive parturients: a prospective observational study.

BACKGROUND: Epidural analgesia provides sufficient analgesia during labor but can cause hypotension despite various prophylactic measures. We studied its effects on pre-placental, fetoplacental, and fetal hemodynamics using Doppler ultrasound. The primary endpoint was the pulsatility index of the umbilical artery at 30 min after establishing epidural analgesia. Secondary endpoints included maternal blood pressures and neonatal outcome data. METHODS: We included healthy parturients at a cervical dilation ≥2 cm, with or without a request for epidural analgesia (n=32 per group). Ultrasound studies of the uterine arteries, umbilical artery and fetal middle cerebral artery were performed before insertion of the epidural catheter, and 30, 60 and 90 min after; the same time-points were assessed in the non-epidural control group. Maternal blood pressure was measured by a continuous non-invasive arterial pressure monitor. RESULTS: Ultrasound studies detected no significant differences in pulsatility indices over time in any blood vessel. In contrast to the control group, maternal blood pressures were significantly lower for all measures after the onset of analgesia compared with baseline values (mean systolic pressure decreased from 132.7 ±â€¯15.9 mmHg to 123.1 ±â€¯14.4 mmHg at 30 min, P=0.003). The mean pH value of the umbilical arterial blood was 7.29 (±0.06) in the epidural group versus 7.31 (±0.08) in the control group (P=0.33). The median Apgar score at 5 min was 10 in both groups. CONCLUSIONS: Pre-placental, fetoplacental and fetal hemodynamics remained stable despite a statistically significant decrease in maternal blood pressure in laboring parturients receiving epidural analgesia.

[Transfer of a cockpit strategy to anesthesiology : Clinical example: introduction of canned decisions to solve cannot intubate cannot oxygenate situations]. / Übertragung einer "Cockpit-Strategie" in die Anästhesie : Klinisches Beispiel: Einführung von "canned decisions" zur Lösung von Atemwegsnotfällen.

BACKGROUND: Safety strategies in civil aviation are well-established. The authors present a possible structure for induction of anesthesia, which includes elements of the so-called cockpit strategy. The objective is to reduce anesthesia-related mortality caused by the unexpected difficult airway through early detection and solution of cannot intubate cannot oxygenate (CICO) situations. METHODS: After approval by the responsible ethics committee, a prospective pilot study was conducted to analyze the process quality of uncomplicated induction of anesthesia on a simulator using audiovisual recording. An evaluation list with 44 items was created, which met the following requirements: items were dichotomous, accessible to an audiovisual evaluation and according to current scientific consensus should be considered during induction of anesthesia. Standard induction of anesthesia was supplemented by several crew resource management elements (cockpit strategy). Two canned decisions (CD, CD 1: end tidal CO2, etCO2 < 10 mm Hg, CD 2: SpO2 < 80%) signaled the emergency of an unexpected difficult airway and CICO with emergency coniotomy. This concept was repetitively trained and transferred to the daily routine. After 6 months the process quality was re-evaluated in simulated scenarios. In order to review whether the effect of the cockpit strategy with the CD can contribute to solving the CICO situation, all emergency coniotomies carried out in this clinic between 2010 and 2016 were retrospectively analyzed. RESULTS: The cockpit strategy significantly improved the process quality during the simulated induction of anesthesia (78% vs. 36% items fulfilled), while the duration of induction was reduced by 36%. In the subsequent 6­year study period, 7 CICO situations with emergency coniotomy occurred. All teams performed in accordance with the algorithm and with respect to the CDs. No patient suffered from hypoxia or any other damage. CONCLUSION: The transfer and implementation of a cockpit strategy in anesthesiology for improvement of patient safety is possible. The acceptance of the aviation safety strategy in medicine is a necessary prerequisite. A profound training in technical and non-technical skills and regular team training to solve CICO situations must be an integral part of advanced training in anesthesiology.

Surgeons' exposure to sevoflurane during paediatric adenoidectomy: a comparison of three airway devices.

Although sevoflurane is commonly used in anaesthesia, a threshold value for maximum exposure to personnel does not exist and although anaesthetists are aware of the problem, surgeons rarely focus on it. We used a photo-acoustic infrared device to measure the exposure of surgeons to sevoflurane during paediatric adenoidectomies. Sixty children were randomly allocated to laryngeal mask, cuffed tracheal tube or uncuffed tracheal tube. The average mean (maximum) sevoflurane concentrations within the surgeons' operating area were 1.05 (10.05) ppm in the laryngeal mask group, 0.33 (1.44) ppm in the cuffed tracheal tube group and 1.79 (18.02) ppm in the uncuffed tracheal tube group, (p < 0.001), laryngeal mask and cuffed tracheal tube groups vs. uncuffed tube group. The presence of sevoflurane was noticed by surgeons in 20% of cases but there were no differences between the groups (p = 0.193). Surgical and anaesthetic complications were similar in all three groups. We conclude that sevoflurane can be safely used during adenoidectomies with all three airway devices, but in order to minimise sevoflurane peak concentrations, cuffed tracheal tubes are preferred.

[Leiomyosarcoma of the larynx]. / Leiomyosarkom des Kehlkopfs.

Leiomyosarcoma is usually found in the female genital tract, retroperitoneum, the wall of the gastrointestinal tract and subcutaneous tissues. An appearance of this malignant tumor in the larynx is extremely rare and may be difficult to diagnose. Because of its rarity, little information exists on management and prognosis. We report on a 64-year old male with a supraglottic leiomyosarcoma who was treated with supraglottic laryngectomy and postoperative radiotherapy. After 19 months the patient was well and free of disease. The most commonly used diagnostic and therapeutic procedures are analysed in a review of the 46 published cases of laryngeal leiomyosarcoma.