The development and validation of a risk score to predict the probability of postoperative vomiting in pediatric patients.

Risk scores to predict the occurrence of postoperative vomiting (PV) or nausea and vomiting that were developed for adult patients do not fit for children, because several risk factors are difficult to assess or are usually not applicable in pediatric patients (e.g., smoking status). Thus, in the present study, we sought to develop and to validate a simple score to predict PV in children (POVOC-score). Development and validation of the new score was based on data from 4 independent institutions of 1257 children (aged 0-14 yr) undergoing various types of surgery under general anesthesia without antiemetic prophylaxis. Preoperatively, several potential risk factors were recorded. Postoperatively, the occurrence of PV was observed for up to 24 h. The dataset was randomly split into an evaluation set (n = 657) that was analyzed using a forward logistic regression technique and a validation set (n = 600) that was used to confirm the accuracy of prediction by means of the area under a receiver operating characteristic curve. Four independent risk factors for PV were identified in the final analysis: duration of surgery >/=30 min, age >/=3 yr, strabismus surgery, and a positive history of PV in the children or PV/postoperative nausea and vomiting in relatives (mother, father, or siblings). The incidence of PV was 9%, 10%, 30%, 55%, and 70% for 0, 1, 2, 3, and 4 risk factors observed. Using these incidences as cut-off values in the validation dataset, the area under the receiver operating characteristic curve was 0.72 (95% confidence interval: 0.68-0.77). Our data suggest that PV can be predicted with an acceptable accuracy using a four-item simplified risk score.

Applicability of risk scores for postoperative nausea and vomiting in adults to paediatric patients.

BACKGROUND: Scores to predict the occurrence of postoperative vomiting (PV) or nausea and vomiting (PONV) are well established in adult patients. The aim of this survey was to evaluate the applicability of risk scores developed and tested in adult patients in 983 paediatric patients (0-12 yr) undergoing various surgical procedures. METHOD: The predictive properties of five models were compared with respect to discriminating power (measured by the area under a receiver operating characteristic curve) and calibration (comparison of the predicted and the actual incidences of the disease by weighed linear regression analysis). RESULTS: The cumulative incidence of PV was 33.2% within 24 h. The discriminating power was low and insufficient in all models tested (0.56-0.65). Furthermore, the predicted incidences of the scores correlated only vaguely with the actual incidences observed. CONCLUSION: Specialized scores for children are required. These might use the history of PV, strabismus surgery, duration of anaesthesia > or =45 min, age > or =5 yr and administration of postoperative opioids as independent risk factors.

Synthesis and biological evaluation of novel piperidine carboxamide derived calpain inhibitors.

Calpain inhibitors which are derived from piperidine carboxamides in the P2 region were prepared and evaluated for mu-calpain inhibition. In particular, the keto amides 11f and 11j have Ki of 30 and 9 nM and display a more than 100-fold selectivity over the closely related cysteine protease cathepsin B. Furthermore, these compounds inhibit NMDA induced convulsions in mice indicating that calpain inhibition in brain results in some anticonvulsive properties.

LU 73068, a new non-NMDA and glycine/NMDA receptor antagonist: pharmacological characterization and comparison with NBQX and L-701,324 in the kindling model of epilepsy.

The aim of this study was to assess whether a drug which combines an antagonistic action at both NMDA and non-NMDA receptors offers advantages for treatment of epileptic seizures compared to drugs which antagonize only one of these ionotropic glutamate receptors. The novel glutamate receptor antagonist LU 73068 (4,5-dihydro-1-methyl-4-oxo-7-trifluoromethylimidazo[1,2a]quinoxal ine-2-carbonic acid) binds with high affinity to both the glycine site of the NMDA receptor (Ki 185 nM) and to the AMPA receptor (Ki 158 nM). Furthermore, binding experiments with recombinant kainate receptor subunits showed that LU 73068 binds to several of these subunits, particularly to rGluR7 (Ki 104 nM) and rGluR5 (Ki 271 nM). In comparison, the prototype non-NMDA receptor antagonist NBQX (2,3-dihydroxy-6-nitro-7-sulphamoyl-benzo[f]quinoxaline) binds with high affinity to AMPA receptors only. Both NBQX and LU 73068 were about equieffective after i.p. injection in mice to block lethal convulsions induced by AMPA or NMDA. In the rat amygdala kindling model of temporal lobe epilepsy, LU 73068 dose-dependently increased the focal seizure threshold (afterdischarge threshold, ADT). When rats were stimulated with a current 20% above the individual control ADT, LU 73068 completely blocked seizures with an ED50 of 4.9 mg kg(-1). Up to 20 mg kg(-1), only moderate adverse effects, e.g. slight ataxia, were observed. NBQX, 10 mg kg(-1), and the glycine/NMDA site antagonist L-701,324 (7-chloro-4-hydroxy-3-(3-phenoxy)phenyl-quinoline-2(1H)one), 2.5 or 5 mg kg(-1), exerted no anticonvulsant effects in kindled rats when administered alone, but combined treatment with both drugs resulted in a significant ADT increase. The data indicate that combination of glycine/NMDA and non-NMDA receptor antagonism in a single drug is an effective means of developing a potent and effective anticonvulsant agent.

A cross-validated multifactorial index of perioperative risks in adults undergoing anaesthesia for non-cardiac surgery. Analysis of perioperative events in 26907 anaesthetic procedures.

OBJECTIVE: To develop a severity index of anaesthetic risk that predicts relevant perioperative adverse events in adults. DESIGN: Prospective cross-sectional study. SETTING: Department of anaesthesiology at one university hospital. PATIENTS: 26907 consecutive anaesthetic procedures in patients over 15 years of age and a complete preoperative evaluation. Patients undergoing cardiac and obstetric surgery were excluded. MEASUREMENTS AND MAIN RESULTS: Demographic data, preoperative health status, type of anaesthesia, operative procedures, and perioperative incidents (standardised on a national basis) were acquired by means of a computerised anaesthetic record system. Occurrence of at least one perioperative event with impact on postanaesthetic care was computed by a multivariate logistic regression model against 17 variables with different characteristics representing possible risk factors. Fourteen variables proved to be independent risk factors. The weighting of the variables was expressed in scores which added up to form a simple index for each patient. Patients without major risk factors (0-10 points) had a 0.3% risk of suffering from a relevant incident. Patients with more than 60 points had a 28.6% risk. The results were well demonstrated by cross-validation. CONCLUSIONS: The index seems to reflect the risk of relevant perioperative incidents. It can be used for audit purposes. In daily routine, the index could focus our attention on patients with increased perioperative risk. However, it is limited in detecting particular constellations of factors which interact on each other with regard to perioperative risk.

Epidemiology of acute renal failure and outcome of haemodiafiltration in intensive care.

OBJECTIVE: To examine the epidemiology of acute renal failure (ARF) and to identify predictors of mortality in patients treated by continuous venovenous haemodiafiltration (CVVHDF). DESIGN: Uncontrolled observational study. SETTING: One intensive care unit (ICU) at a surgical and trauma centre. PATIENTS: A consecutive sample of 3591 ICU treatments. MEASUREMENTS AND RESULTS: Demographic data, indications for ICU admission, severity scores and organ system failure at the beginning of CVVHDF were set against the occurrence of ARF and ICU mortality. 154 (4.3% of ICU patients and 0.6% of the hospital population) developed ARF and were treated with CVVHDF. Higher American Society of Anaesthesiologists (ASA) status and higher Apache II score were associated with ICU incidence of ARF. However, these criteria were not able to predict outcome in ARF. A simplified predictive model was derived using multivariate logistic regression modelling. The mortality rates were 12% with one failing organ system (OSF), 38% with two OSF, 72% with three OSF, 90% with four OSF and 100% with five OSF. The adjusted odds ratio (OR) of death was 7.7 for cardiovascular failure, 6.3 for hepatic failure, 3.6 for respiratory failure, 3.0 for neurologic failure, 5.3 for massive transfusion and 3.7 for age of 60 years or more. CONCLUSION: General measures of severity are not useful in predicting the outcome of ARF. Only the nature and number of dysfunctioning organ systems and massive transfusion at the beginning of CVVHDF and the age of the patients gave a reliable prognosis in this group of patients.

[Combined intravenous administration of diclofenac and apazone for postoperative analgesia A randomized study of 112 patients with access to i. v. on-demand analgesia after minor orthopaedic operations.]. / Kombinierte intravenöse Gabe von Diclofenac und Azapropazon zur postoperativen Analgesie : Eine randomisierte Doppelblindstudie an 112 unfallchirurgischen Patienten mittels der intravenösen On-Demand-Analgesie.

In a double-blind, randomized, placebo-controlled study, 112 patients scheduled for knee-joint arthrotomies or minor orthopaedic operations received 75 mg diclofenac, 600 mg apazone, the combination of 75 mg diclofenac and 600 mg apazone, or placebo (50 ml NaCl 0.9%) as a single i.v. dose immediately after operation. Postoperative pain intensity was measured by a numeric rating scale. All patients were allowed to self-administer piritramide from a PCA (patient-controlled analgesia) pump (Prominjekt, Pharmacia, Sweden) in 2-mg boluses every 5 min during the first 6 h and subsequently every 15 minfor another 18 h after surgery. The patients receiving diclofenac, apazone, or the combination of diclofenac and apazone required a significantly lower cumulated dose of piritramide during the first 24 h after operation than did placebo-treated subjects (38 mg vs 39 mg vs 27 mg vs 67 mg;P<0.05), but there were no significant differences among the former three groups of patients. The incidence of typical side effects of opioids and antipyretic anti-inflammatory analgesics (nausea, vomiting, stomach ache, headache, vertigo) was low, and they were easily controlled in all cases. Postoperative combined application of the nonsteroidal anti-inflammatory analgesics diclofenac and apazone results in a significantly lower opioid requirement (about 60%) after minor orthopaedic surgery. The opioid-sparing effect appears to be superior to that of diclofenac (44%) or apazone (42%) alone, but this was not statistically significant.

Performance characteristics of a novel reusable intermediate-volume low-pressure cuffed endotracheal tube.

STUDY OBJECTIVE: To evaluate the performance of the reusable intermediate-volume low-pressure cuffed "Super Safety Yellow" (Willy Rüsch AG, P.O. Box 1620, D-71332 Waiblingen, Germany) endotracheal tube with regard to cuff seal, tube tip position, and incidence of postoperative throat complaints. The "Super Safety Yellow" was compared with the "Super Safety Clear" (W. Rüsch AG), the "lo-pro (Mallinckrodt Laboratories, Cornamady, Athlone County, Ireland), and the "red rubber" (W. Rüsch AG) tubes. METHODS: Two hundred adult patients scheduled for minor surgery under standardized general anaesthesia were allocated to one of these tubes. Past-cuff leakage (indicator; orally instilled 0.2% indigocarmine) as well as intratracheal tube tip position (degree of being centred) were assessed by fibre-optic tracheoscopy. The semi-standardized interviews for the recording of postoperative sore throat were performed in double-blind fashion once a day, starting on the day of operation till p.o. day 3. STATISTICS: chi 2-test; significance: P < 0.05. MAIN RESULTS: A past-cuff leakage was found in three "red rubber" tubes. There were significant differences in tube tip position with the "Super Safety Clear" being best, and the "Super Safety Yellow" being worst centred (P = 0.010). The incidence of postoperative throat complaints showed a nonsignificant tendency in favour of the PVC-tubes. A significant number of such complaints were observed in women (P = 0.0004) and in obese patients (P = 0.011). By contrast, this incidence did not significantly differ with age, tracheal cross-sectional shape, tube tip position, use of atropine, and duration of intubation. CONCLUSION: Although resembling the "red rubber" tube in the incidence of postoperative throat complaints, the "Super Safety Yellow" may be an alternative to the currently used disposable tubes in anaesthesia. Its performance is comparable with regard to cuff seal and intra-cuff pressure. Additionally, it helps in reducing PVC waste and may lessen costs.

Spontaneous reposition of a dislocated arytenoid cartilage.

We report a patient suffering from arytenoid cartilage dislocation after difficult tracheal intubation and the abrupt spontaneous reposition in the course of severe vomiting 1 month after the operation. Predisposing factors for the unusual reposition are discussed.

[A comparison of different endotracheal tubes. Tracheal cuff seal, peak centering and the incidence of postoperative sore throat]. / Vergleich verschiedener Endotrachealtuben. Trachealabdichtung, Spitzenzentrierung und Inzidenz postoperativer Halsbeschwerden.

UNLABELLED: The study objective was to evaluate cuff seal, tube tip position and incidence of postoperative sore throat in three different endotracheal tubes: the reusable Rüsch "red rubber" tube (low-volume, high-pressure cuff) and the disposable Rüsch "Super Safety Clear" and Mallinckrodt "lo-pro" tubes (both high-volume, low-pressure cuffs). METHODS: In a prospective randomized trial, 150 consecutive patients scheduled for minor orthopaedic surgery under standardized general anaesthesia, including standardized cuff pressure control, were allocated to one of the three types of endotracheal tube. Leakage and intratracheal tube tip position were investigated by means of fiberoptic tracheoscopy via the endotracheal tube, preceded by pharyngeal instillation of indigocarmine. The semi-standardized interviews for the recording of postoperative sore throat were performed once a day under double-blind conditions from the day of operation to postoperative day 3. Statistical independence testing was based on the chi 2-test, significance was assumed at P < 0.05. MAIN RESULTS: A past-cuff leakage of the pharyngeally instilled dye was found in three patients with "red rubber" tubes. In all of these cases the tracheal cross section deviated markedly from circular. The tips of the "Super Safety Clear" tubes tended to be better centred (P = 0.099). Bad tip position, however, had little influence on postoperative throat complaints (P = 0.394). The differences in incidence of postoperative throat complaints between the "red rubber" (48.9%), "Super Safety Clear" (35.6%) and "lo-pro" tubes (34.1%) did not reach the 5% level (P = 0.288). Such complaints, however, were significantly more frequent in females and in obese patients who exceeded their Broca weights by more than 25%. By contrast, postoperative throat complaints did not vary statistically significantly by age group, tracheal cross-sectional shape, use of atropine or duration of intubation. CONCLUSION: Despite the economic (usable up to 100 times) and ecological (less PVC waste) advantages of the rubber tube, the disposable tubes with high-volume, low-pressure cuffs tended to be superior regarding cuff seal, tube tip position and incidence of postoperative throat complaints. Nevertheless, the continued use of "red rubber" type reusable tubes may be justified in cases where the tube has to stay in place for only a short time.