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 ± 15.9 mmHg to 123.1 ± 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.

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.