Postoperative Pain Following Eye Enucleation: A Prospective Observational Study

Background and Objectives: Enucleation of an eye is the most invasive procedure in ophthalmologic surgery. It can be the result of various diseases (malignant/chronic/trauma/infection) and is nevertheless relatively rare, but leads to the loss of a strongly innervated neuronal organ. This study systematically evaluates postoperative pain levels following enucleation of the eye globe. Materials and Methods: This prospective single-center study enrolled twenty-four patients undergoing enucleation of the eye globe. Perioperatively all patients completed (preoperative day, day of surgery, 1st, 2nd, and 3rd day following surgery) standardized questionnaires concerning their pain experience and treatment-related side-effects (internal protocol, QUIPS, painDETECT®). Patients received usual pain therapy in an unstandardized individual manner. Results: Preoperatively, mean average pain intensity of all included patients was 3.29 ± 2.46 (range, 0-8), 3.29 ± 3.24 (range, 0-8) on the day of surgery, 4.67 ± 1.90 (range, 2-10) on day 1, 3.25 ± 1.39 (range, 1-6) on day 2, and 2.71 ± 1.30 (range, 1-6) on day 3 after surgery. Mean maximum pain intensity was 4.71 ± 3.28 (range, 0-10) preoperatively, 4.04 ± 3.78 (range, 0-10) on the day of surgery, 5.75 ± 2.01 (range, 2-10) on day 1, 4.25 ± 1.89 (range, 2-10) on day 2, and 3.88 ± 1.54 (range, 2-8) on day 3 after surgery. Nineteen patients (79.2%) stated that they would have preferred more pain therapy. Conclusions: Patients undergoing eye enucleation report pain sensations in need of intervention in this university hospital. Thus, effective standardized pain treatment concepts are now a high priority to be established in an interdisciplinary manner containing standardized regimens and continuous regional procedures. Awareness of this problem in the medical team should be sharpened through targeted training and information.

Evaluation of a modified paediatric early warning score for children with congenital heart disease

BACKGROUND

Paediatric early warning score systems are used for early detection of clinical deterioration of patients in paediatric wards. Several paediatric early warning scores have been developed, but most of them are not suitable for children with cyanotic CHD who are adapted to lower arterial oxygen saturation.

AIM

The present study compared the original paediatric early warning system of the Royal College of Physicians of Ireland with a modification for children with cyanotic CHD.

DESIGN

Retrospective single-centre study in a paediatric cardiology intermediate care unit at a German university hospital.

RESULTS

The distribution of recorded values showed a significant shift towards higher score values in patients with cyanotic CHD (p < 0.001) using the original score, but not with the modification. An analysis of sensitivity and specificity for the factor "requirement of action" showed an area under the receiver operating characteristic for non-cyanotic patients of 0.908 (95% CI 0.862-0.954). For patients with cyanotic CHD, using the original score, the area under the receiver operating characteristic was reduced to 0.731 (95% CI 0.637-0.824, p = 0.001) compared to 0.862 (95% CI 0.809-0.915, p = 0.207), when the modified score was used. Using the critical threshold of scores ≥ 4 in patients with cyanotic CHD, sensitivity and specificity for the modified score was higher than for the original (sensitivity 78.8 versus 72.7%, specificity 78.2 versus 58.4%).

CONCLUSION

The modified score is a uniform scoring system for identifying clinical deterioration, which can be used in children with and without cyanotic CHD.

Comparing Simulation Training of Bronchoscopy-Guided Percutaneous Dilatational Tracheostomy Using Conventional Versus 3D Printed Simulators (TRAC-Sim Study)

Background: Individual implementation rate of bronchoscopy-guided percutaneous dilatational tracheostomy (PDT) varies among intensivists. Simulation training (ST) can increase the safety of medical procedures by reducing stress levels of the performing team. The aim of this study was to evaluate the benefit of ST in PDT regarding procedural time, quality of performance, and percepted feelings of safety of the proceduralist and to compare conventional simulators (CSIM) with simulators generated from 3D printers (3DSIM). Methods: We conducted a prospective, single-center, randomized, blinded cross-over study comparing the benefit of CSIM versus 3DSIM for ST of PDT. Participants underwent a standardized theoretical training and were randomized to ST with CSIM (group A) or 3DSIM (group B). After ST, participants' performance was assessed by two blinded examiners on a porcine trachea regarding time required for successful completion of PDT and correct performance (assessed by a performance score). Percepted feelings of safety were assessed before and after ST. This was followed by a second training and second assessment of the same aspects with crossed groups. Results: 44 participants were included: 24 initially trained with CSIM (group A) and 20 with 3DSIM (group B). Correctness of the PDT performance increased significantly in group B (p < .01) and not significantly in group A (p = .14). Mean procedural time required for performing a PDT after their second ST compared to the first assessment (p < .01) was lower with no difference between group A and group B and irrespective of the participants' previous experience regarding PDT, age, and sex. Moreover, percepted feelings of safety increased after the first ST in both groups (p < .001). Conclusions: ST can improve procedural skills, procedural time, and percepted feelings of safety of the proceduralist in simulated PDT.

Nalbuphine as analgesic in preschool children undergoing ophthalmic surgery and the occurrence of emergence delirium

BACKGROUND/AIMS

Perioperative pain in children is often inadequately treated, and emergence agitation is common. The purpose of this analysis was to determine whether nalbuphine is suitable for perioperative eye pain and to analyse if it influences the occurrence of emergence delirium/agitation (EDA) in children undergoing ophthalmic surgery in general anaesthesia.

METHODS

Retrospective cohort analysis of 50 children in preschool age undergoing general anaesthesia for ophthalmic surgery receiving nalbuphine as a postoperative analgesic in a German university hospital from June 2020 to February 2021.Scores and values for pain and EDA were routinely recorded after awakening and during the stay in the recovery room. Data were evaluated retrospectively from the medical records.

RESULTS

A total of 50 children (17 girls and 33 boys) underwent general anaesthesia for ophthalmic surgery. The median age of the children included was 20.5 months (range, 1-68 months), the median body weight was 12.25 kg (range, 2.9-29 kg). All patients received ibuprofen (10 mg/kg1) during induction of anaesthesia and nalbuphine (0.1 mg/kg) at the end of surgery. All patients had an Paediatric-Anaesthesia-Emergence-Delirium-I-score (PAED-ED-I Score) of less than 6 and acceptable Face-Legs-Activity-Cry-Consolability-scores (FLACC less than 3) on waking and on leaving the recovery room.

CONCLUSION

Nalbuphine shows a sufficient analgesic effect for pain therapy following ophthalmic surgery in preschool children. Nalbuphine seems to reduce the incidence of EDA in children undergoing ophthalmic surgery.

Immediate postoperative topical lidocaine gel for the treatment of eye pain following corneal abrasion in descemet membrane endothelial keratoplasty (DMEK) under general anaesthesia: a pilot retrospective analysis

BACKGROUND

Patients undergoing corneal abrasion as part of Descemet membrane endothelial keratoplasty (DMEK) under general anesthesia suffer from early burning pain postoperatively. This pain appears to be poorly treatable with systemic analgesics. This study aims to evaluate postoperative pain management using topical lidocaine gel after DMEK with iatrogenic corneal abrasion.

METHODS

Retrospective analysis of 28 consecutive patients undergoing DMEK with corneal abrasion from October 19, 2021, to November 12, 2021, at a German university hospital. Patients during week 1 and 2 received peri-operative standard pain treatment (cohort S) and additional local lidocaine gel during week 3 and 4 immediately postoperatively (cohort L).

RESULTS

13 patients were included in cohort S and 15 patients in cohort L. At awakening all patients (100%) in cohort S reported burning pain, and six of 15 patients (40%) in cohort L reported burning pain. Burning pain scores were significantly lower in cohort L (p < 0.001 at awakening, p < 0.001 at 10 min, p < 0.001 at 20 min, p < 0.001 at 30 min, p = 0.007 at 40 min after awakening, and p < 0.001 at leaving recovery room). No significant differences between cohort S and cohort L were detected concerning surgical outcome during 1-month-follow-up (p = 0.901 for best corrected visual acuity).

CONCLUSION

Patients undergoing DMEK with corneal abrasion suffer significant pain in the recovery room. A single dose of topic lidocaine gel reduces the early postoperative burning pain sufficiently and does not affect the surgical outcome.

Human metapneumovirus infection in the cardiac paediatric ICU before and during COVID-19 pandemic: a retrospective cohort analysis

INTRODUCTION

This study investigates the hygiene standards in the context of the COVID-19 pandemic and their impact on the perioperative incidence of human metapneumovirus as well as the typical symptom burden of human metapneumovirus-infected children with CHDs.

MATERIALS AND METHODS

Between March 2018 and July 2021, all patients of a cardiac paediatric ICU of a German university hospital were included in this retrospective cohort analysis.

RESULTS

A total of 589 patients with CHD were included in the analysis. Three hundred and fifty-two patients (148 females and 204 males) were admitted before the introduction of social distancing and face masks between March 2018 and 15 April 2020 (cohort A). Two hundred and thirty-seven patients (118 females and 119 males) were admitted after the introduction between April 16 and July 2021 (cohort B). In cohort A, human metapneumovirus was detected in 11 out of 352 patients (3.1%) during their stay at cardiac paediatric ICU. In cohort B, one patient out of 237 (0.4%) tested positive for human metapneumovirus. Patients who tested positive for human metapneumovirus stayed in cardiac paediatric ICU for a median of 17.5 days (range, 2-45 days). Patients without a detected human metapneumovirus infection stayed in the cardiac paediatric ICU for a median of 4 days (range, 0.5-114 days). Nine out of 12 (75%) human metapneumovirus-positive patients showed atelectasis.

CONCLUSION

Perioperative human metapneumovirus infections prolong cardiac paediatric ICU stay in children with CHD. In affected patients, pulmonary impairment with typical symptoms appears. Under certain circumstances, a complication-rich perioperative infection with human metapneumovirus could be prevented in paediatric cardiac high-risk patients by prophylactic hygiene intervention.

[Principles of acute pain therapy-An overview taking special features in the patient collective of ophthalmology into consideration]

For many years the quality of perioperative pain management in general has been repeatedly reported as inadequate and there is significant evidence to indicate that this is also true after surgical procedures in ophthalmology. The patient population in ophthalmology is quite challenging due to numerous comorbidities and a high average age resulting in numerous contraindications and organ dysfunctions and requiring special knowledge to ensure high quality acute pain management. The following overview covers basic knowledge of acute pain management, with a particular focus on analgesic approaches and the specifics of the patient population and the associated limitations in terms of analgesic and co-analgesic pharmacological options.

[Anaesthesia and Sedation for Diagnostic Procedures in Children]

Constant medical progress leads to an increasing range of indications and consequently increasing number of diagnostic procedures in (early) childhood. To prevent lasting traumatization of children (and parents) and to ensure proper examination conditions, adequate (analgo-)sedation or general anesthesia is usually required for the appropriate management of diagnostic procedures in childhood, whether painful or not. The safety of young patients is the first priority. Administrations, hospitals, and each individual anesthesiologist are responsible for establishing structures, experience, and knowledge in this area so that children of all ages receive optimum care. In this article, the authors provide an overview of basic principles (structures, requirements, recommendations), currently used drugs, and procedure-specific examples for providing procedural analgosedation/anesthesia in children.

[Pain therapy in children following ophthalmic surgery]

Pain following eye surgery is often described as being relatively moderate; however, there are also procedures that lead to a pronounced pain experience. Particularly in pediatric patients, pain therapy is often insufficient due to a lack of knowledge and fear of complications. These individual and organizational deficits lead to unnecessary discomfort for children and parents. Each institution providing surgical treatment must have pain management concepts in its portfolio for the appropriate age groups. This includes a child-oriented setting, age-appropriate information, systematic pain assessment, and pain protocols. Pain management should be planned prior to surgery and individually adapted as it progresses. Children have a right to a perioperative course with low stress and pain.

[Children need sustainability]

The reduction of greenhouse gases such as CO2 emissions and their equivalents (CO2e) generally has three aspects: Fugitive direct emissions (anesthetic gases, exhaust gases), indirect emissions through the purchase of energy (electricity, heat) and emissions in the supply chain (supply of consumables, disposal). Since pediatric anesthesia has a traditional affinity with inhalation, the use of anesthetic gases should be repeatedly questioned and, if possible, avoided on the way to net zero emissions in addition to general measures to conserve resources. In children, analgosedation, total intravenous anesthesia (TIVA) and establishment of venous access prior to the induction of anesthesia are particularly suitable for this purpose. In addition to avoiding greenhouse gases, the methods mentioned offer other significant medical advantages and can also be profitable in terms of safety and comfort. Nevertheless, anesthetic gases are required in pediatric anesthesia in some situations. For this reason, it is important to save anesthetic gases through minimal fresh gas flow and a rational approach to inhalation induction. To facilitate implementation in clinical practice, this article provides recommendations for mask induction and choice of anesthetic procedure.

Dexmedetomidine as a sole sedative for procedural sedation in preterm and neonate infants: A retrospective analysis

BACKGROUND

Many different sedation concepts for magnetic resonance imaging have been described for prematurely and term-born infants, ranging from "no sedation" to general anesthesia. Dexmedetomidine is an alpha-2 receptor agonist that is frequently used to sedate older children, because the anesthesiologist can easily adjust sedation depth, the patient maintains spontaneous breathing, and awakens rapidly afterwards.

AIMS

The present study evaluates whether dexmedetomidine could safely be used as the sole sedative for prematurely and term-born infants less than 60 weeks postconceptional age undergoing diagnostic procedures.

METHODS

We performed a retrospective monocentric analysis of n = 39 prematurely and term-born infants (<60 weeks postconceptional age or a body weight <5 kg) who were sedated with dexmedetomidine for an MRI at a German university hospital from August 2016 to November 2018.

RESULTS

Successful imaging was achieved in all cases. The median initial bolus of dexmedetomidine administered over 10 min was 1.39 μg kg^-1 body weight (range 0.34-3.64 μg kg^-1 ), followed with a continuous infusion at a median rate of 1.00 μg kg^-1  h^-1 (range 0.5-3.5 μg kg^-1  h^-1 ); however, 3 patients (7%) needed some additional sedation (ketamine or propofol). All patients, including 10 infants who had previously required respiratory support, underwent the procedure without any relevant desaturation or apnea. Bradycardia was observed in up to 15 out of 39 cases (38.5%), but only four (10.3% in total and 26.7% of bradycardia) required atropine.

CONCLUSIONS

These results indicate that dexmedetomidine can be safely used for procedural sedation in the high-risk cohort of prematurely and term-born infants less than 60 weeks postconceptional age. Apnea during procedural sedation and subsequent stay in the recovery room is avoided, but bradycardia remains a relevant risk that may require treatment.

Real-time, large-depth holographic 3D head-up display: selected aspects

Today's state-of-the-art automotive head-up displays (HUD) possess single- or double layer focal planes that limit the observers' eye focus to these planes when crucial information is shown. Other visual 3D cues such as motion parallax also suffer from this limitation. The resulting viewing experience contradicts the natural way of viewing during driving or interaction, when alerts and hints should appear at the correct projection depth where real objects of interest are located. Here we present a real-time holographic HUD with continuous depth that supports the intuitive and natural way of viewing and interacting with virtual environments outside and inside the car. We demonstrate full-color, 3D real-time encoding within a field-of-view of 5^∘×3^∘.

B-Lines for the assessment of extravascular lung water: Just focused or semi-quantitative?

BACKGROUND

B-lines as typical artefacts of lung ultrasound are considered as surrogate measurement for extravascular lung water. However, B-lines develop in the sub-pleural space and do not allow assessment of the whole lung. Here, we present data from the first observational multi-centre study focusing on the correlation between a B-lines score and extravascular lung water in critically ill patients suffering from a variety of diseases.

PATIENTS AND METHODS

In 184 adult patients, 443 measurements were obtained. B-lines were counted and expressed in a score which was compared to extravascular lung water, measured by single-indicator transpulmonary thermodilution. Appropriate correlation coefficients were calculated and receiver operating characteristics (ROC-) curves were plotted.

RESULTS

Overall, B-lines score was correlated with body weight-indexed extravascular lung water characterized by r = .59. The subgroup analysis revealed a correlation coefficient in patients without an infection of r = .44, in those with a pulmonary infection of r = .75 and in those with an abdominal infection of r = .23, respectively. Using ROC-analysis the sensitivity and specificity of B-lines for detecting an increased extravascular lung water (>10 mL/kg) was 63% and 79%, respectively. In patients with a P/F ratio <200 mm Hg, sensitivity and specificity to predict an increased extravascular lung water was 71% and 93%, respectively.

CONCLUSIONS

Assessment of B-lines does not accurately reflect actual extravascular lung water. In presence of an impaired oxygenation, B-lines may reliably indicate increased extravascular lung water as cause of the oxygenation disorders.

Severe Hyponatraemia Associated with the Use of Arginine-Vasopressin in Two Neonates with Complex Congenital Heart Disease

We report two cases of neonates with complex congenital heart disease and volume, catecholamine, and corticosteroid refractory shock treated with arginine-vasopressin. Arginine-vasopressin was able to reverse critical hypotension, but both patients developed severe hyponatremia, which recovered after discontinuation of arginine-vasopressin. Close control and prompt substitution of serum sodium is required in neonates with advanced heart failure on high-dose vasopressin therapy.

Transporter (TAP)- and proteasome-independent presentation of a melanoma-associated tyrosinase epitope

The melanosomal protein tyrosinase is considered as a target of specific immunotherapy against melanoma. Two tyrosinase-derived peptides are presented in association with HLA-A2.1 [Wölfel et al., Eur. J. Immunol., 24, 759-764 (1994)]. Peptide 1-9 (MLLAVLYCL) is generated from the putative signal sequence. The internal peptide 369-377 is posttranslationally converted at residue 371, and its presentation is dependent on functional TAP transporters and proteasomes [Mosse et al., J. exp. Med.187, 37-48 (1998)]. Herein, we report on the processing and transport requirements for the signal sequence-derived peptide 1-9 that were studied in parallel to those for peptide 369-377. After infection of TAP-deficient (T2) and TAP-positive (T1) cells with a Modified Vaccinia Ankara construct carrying the human tyrosinase gene (MVA-hTyr), we found that recognition by CTL against peptide 1-9 did not require TAP function as opposed to recognition by CTL against peptide 369-377. When target cells with intact processing and transport functions were infected with MVA-hTyr, lysis by CTL against peptide 1-9 was not impaired by lactacystin, a specific inhibitor for the proteasome, whereas lysis by CTL against peptide 369-377 was completely abrogated. Taken together, peptide 1-9 derived from the signal sequence of tyrosinase is presented in a TAP-independent fashion and does not require proteasomes for processing. Cellular immune responses against this hydrophobic peptide can be monitored with lymphokine spot assays as documented in the case of a patient with metastatic melanoma, in whom we observed a preferential T-cell response against tyrosinase peptide 1-9 subsequent to chemoimmunotherapy. Independence of cytosolic processing and transport pathways and potentially enhanced expression levels make signal sequence-derived peptides and their carrier proteins important candidates for specific immunotherapy.

The use of computer-assisted video image analysis for the quantification of CD8+ T lymphocytes producing tumor necrosis factor alpha spots in response to peptide antigens

Enzyme-linked immunospot (ELISPOT) analysis is a sensitive technique for the detection and quantification of single T lymphocytes forming cytokine spots after antigen contact in vitro. Herein computer-assisted video image analysis (CVIA) was applied to automatically determine the number and size of tumor necrosis factor alpha (TNF-alpha) spots formed by single blood-derived CD8+ T cells after contact with peptide-loaded target cells. With CVIA and TNF-alpha ELISPOT analysis we quantified CD8+ T cells responsive to HLA-A2.1-binding tyrosinase and influenza matrix peptides in healthy donors. We followed the course of the virus-specific T cell response in two HLA-A2-positive patients with reactivation of latent cytomegalovirus (CMV) infection during immunosuppressive therapy. The test proved sufficiently sensitive to detect in the blood of both patients a temporary expansion of CD8+ T lymphocytes reactive with a known immunogenic HLA-A2.1-binding peptide from glycoprotein B of CMV. Reactivity to peptide antigens was not only reflected by numeric increases of spot formation, but also by the appearance of larger spot areas, presumably formed by strongly peptide-reactive CD8+ T cells. We conclude that the combined use of the TNF-alpha ELISPOT assay and CVIA allows reliable monitoring of the T cell responsiveness to peptide antigens in peripheral blood.