Peter Schmucker

Pain Among Children and Adolescents: Restrictions in Daily Living and Triggering Factors

Objectives. Pain among children and adolescents has been identified as an important public health problem. Most studies evaluating recurrent or chronic pain conditions among children have been limited to descriptions of pain intensity and duration. The effects of pain states and their impact on daily living have rarely been studied. The objective of this study was to investigate the impact of perceived pain on the daily lives and activities of children and adolescents. In addition, we sought to delineate self-perceived triggers of pain among children and adolescents. In this study, we (1) document the 3-month prevalence of painful conditions among children and adolescents, (2) delineate their features (location, intensity, frequency, and duration), (3) describe their consequences (restrictions and health care utilization), and (4) elucidate factors that contribute to the occurrence of pain episodes among young subjects. Methods. The study was conducted in 1 elementary school and 2 secondary schools in the district of Ostholstein, Germany. Children and adolescents, as well as their parents/guardians, were contacted through their school administrators. The teachers distributed an information leaflet, explaining the conduct and aim of the study, to the parents a few days before the official enrollment of the youths in the study. Parents of children in grades 1 to 4 of elementary school were asked to complete the pain questionnaire for their children at home, whereas children from grade 5 upward completed the questionnaire on their own during class, under the supervision of their teachers. The response rate was 80.3%. As previously stated, chronic pain was defined as any prolonged pain that lasted a minimum of 3 months or any pain that recurred throughout a minimal period of 3 months. The children and adolescents were surveyed with the Luebeck Pain-Screening Questionnaire, which was specifically designed for an epidemiologic study of the characteristics and consequences of pain among children and adolescents. The questionnaire evaluates the prevalence of pain in the preceding 3 months. The body area, frequency, intensity, and duration of pain are addressed by the questionnaire. In addition, the questionnaire inquires about the private and public consequences of pain among young subjects. Specifically, the questionnaire aims to delineate the self-perceived factors for the development and maintenance of pain and the impact of these conditions on daily life. Results. Of the 749 children and adolescents, 622 (83%) had experienced pain during the preceding 3 months. A total of 30.8% of the children and adolescents stated that the pain had been present for >6 months. Headache (60.5%), abdominal pain (43.3%), limb pain (33.6%), and back pain (30.2) were the most prevalent pain types among the respondents. Children and adolescents with pain reported that their pain caused the following sequelae: sleep problems (53.6%), inability to pursue hobbies (53.3%), eating problems (51.1%), school absence (48.8%), and inability to meet friends (46.7%). The prevalence of restrictions in daily living attributable to pain increased with age. A total of 50.9% of children and adolescents with pain sought professional help for their conditions, and 51.5% reported the use of pain medications. The prevalence of doctor visits and medication use increased with age. Weather conditions (33%), illness (30.7%), and physical exertion (21.9%) were the most frequent self-perceived triggers for pain noted by the respondents. A total of 30.4% of study participants registered headache as the most bothersome pain, whereas 12.3% cited abdominal pain, 10.7% pain in the extremities, 8.9% back pain, and 3.9% sore throat as being most bothersome. A total of 35.2% of children and adolescents reported pain episodes occurring ≥1 time per week or even more often. Health care utilization because of pain differed among children and adolescents according to the location of pain. Children and adolescents with back pain (56.7%), limb pain (55.0%), and abdominal pain (53.3%) visited a doctor more often than did those with headache (32.5%). In contrast, children and adolescents with headache (59.2%) reported taking medication because of pain more often than did those with back pain (16.4%), limb pain (22.5%), and abdominal pain (38.0%). The prevalence of self-reported medication use and doctor visits because of pain increased significantly with age (χ2 test). The prevalence of self-reported medication use was significantly higher among girls than among boys of the same age, except between the ages of 4 and 9 years (χ2 test). The prevalence of restrictions in daily activities varied among children and adolescents with different pain locations; 51.1% of children and adolescents with abdominal pain and 43.0% with headache but only 19.4% with back pain reported having been absent from school because of pain. The prevalence of restrictions attributable to pain was significantly higher among girls than among boys of the same age, except between the ages of 4 and 9 years (χ2 test). The self-reported triggers for pain varied between girls and boys. Girls stated more often than boys that their pain was triggered by weather conditions (39% vs 25%), illness (eg, common cold or injury) (35.9% vs 23.9%), anger/disputes (20.9% vs 11.9%), family conditions (12.1% vs 5.2%), and sadness (11.9% vs 3.4%). In contrast, boys stated more often than girls that their pain was triggered by physical exertion (28% vs 17.2%). We used a logistic regression model to predict the likelihood of a child paying a visit to the doctor and/or using pain medication. Health care utilization was predicted by increasing age, greater intensity of pain, and longer duration of pain but not by the frequency of pain. We used a logistic regression model to predict restrictions in daily activities. Only the intensity of pain was predictive of the degree of restrictions in daily life attributable to pain; the duration of pain and the frequency of pain episodes had no bearing on the degree to which the daily lives of the children were restricted because of pain. Conclusions. More than two thirds of the respondents reported restrictions in daily living activities attributable to pain. However, 30 to 40% of children and adolescents with pain reported moderate effects of their pain on school attendance, participation in hobbies, maintenance of social contacts, appetite, and sleep, as well as increased utilization of health services because of their pain. Restrictions in daily activities in general and health care utilization because of pain increased with age. Girls ≥10 years of age reported more restrictions in daily living and used more medications for their pain than did boys of the same age. We found gender-specific differences in self-perceived triggers for pain. Pain intensity was the most robust variable for predicting functional impairment in ≥1 areas of daily life. Increasing age of the child and increasing intensity and duration of pain had effects in predicting health care utilization (visiting a doctor and/or taking medication), whereas restrictions in daily activities were predicted only by the intensity of pain. Our results underscore the relevance of pediatric pain for public health policy. Additional studies are necessary and may enhance our knowledge about pediatric pain, to enable parents, teachers, and health care professionals to assist young people with pain management, allowing the young people to intervene positively in their conditions before they become recurrent or persistent.

The laryngeal tube: a new simple airway device.

T he face mask, laryngeal mask, and the Combitube (Tyco Healthcare/Sheridan, Argyle, NY) are devices commonly used to ventilate the lungs of nonintubated patients (1,2), but some disadvantages may result in inadvertent ventilation-associated complications. For example, the face mask is associated with large dead space ventilation, leakage, and gastric inflation (3). In contrast, the laryngeal mask is an alternative airway adjunct that is simple to use, resulting in both minimal dead space ventilation and gastric inflation (4,5). Nevertheless, a possible limiting feature of the laryngeal mask may be the risk of aspirating gastric contents (6) because fiberoptic studies have found 6%–9% visualization of the esophagus (7,8). Although the Combitube was developed as an alternative to endotracheal intubation to secure the airway in an emergency setting, its complex structure requires extensive instruction and training to ensure correct placement within an acceptable time (9). The purpose of this study was to assess whether the newly developed Laryngeal Tube (VBM Medizintechnik GmbH, Sulz, Germany), somewhat a single-lumen, shortened Combitube, can provide sufficient ventilation and adequate oxygenation in patients undergoing routine induction of anesthesia.

A Comparison of the Laryngeal Tube with the Laryngeal Mask Airway During Routine Surgical Procedures

The laryngeal mask airway (LMA; Laryngeal Mask Company, Henley-on-Thames, UK) is an established airway device, whereas the laryngeal tube (LT) is relatively new and therefore not as well investigated. Therefore, the purpose of the present prospective, randomized, controlled trial was to compare the LT with the LMA in routine clinical practice. In 50 patients undergoing general anesthesia for minor routine surgery, standardized anesthesia was induced and maintained with alfentanil and propofol. Patients were randomized to controlled ventilation (fraction of inspired oxygen = 0.4; fraction of inspired nitrous oxide = 0.6; tidal volume = 7 mL/kg; respiratory rate = 10 breaths/min) with the LT (n = 25) or the LMA (n = 25). Oxygen saturation was recorded before the induction of anesthesia and after the administration of oxygen. After 2 and 10 min of ventilation with the LT or LMA, oxygen saturation, end-expiratory carbon dioxide, expiratory tidal volume, and peak airway pressure were recorded. Capillary blood gas samples were taken before the induction of anesthesia and after 10 min of ventilation. Time of insertion and airway leak pressure of each device were measured. The time of insertion was comparable with both devices (LT versus LMA, median 21 s versus 19 s;P = not significant). Blood gas samples and ventilation variables revealed sufficient ventilation and oxygenation with either device (P = not significant). Peak airway pressure (LT, 17 ± 3 cm H2O; LMA, 15 ± 3 cm H2O) and airway leak pressure (LT, 36 ± 3 cm H2O; LMA, 22 ± 3 cm H2O) were significantly (P < 0.05) higher when using the LT compared with the LMA. In conclusion, using the LT and LMA resulted in comparable ventilation and oxygenation variables in this model of ASA physical status I and II patients undergoing routine surgical procedures. The newly developed LT may be a simple alternative device to secure the airway.

Airway management during cardiopulmonary resuscitation--a comparative study of bag-valve-mask, laryngeal mask airway and combitube in a bench model.

Gastric inflation and subsequent regurgitation are a potential risk of ventilation during cardiopulmonary resuscitation (CPR). In respect of recent investigations, principal respiratory components such as respiratory system compliance, resistance and lower esophageal sphincter pressure were adapted according to CPR situations. The purpose of our study was to assess lung ventilation and gastric inflation when performing ventilation with bag-valve-mask, laryngeal mask airway, and combitube in a bench model simulating an unintubated cardiac arrest patient. Twenty-one student nurses, without any experience in basic life support measures, ventilated the bench model with all three devices. Mean ( +/- S.D.) gastric inflation with the laryngeal mask airway (seven cases) was significantly lower than with the bag-valve-mask (0.6 +/- 0.8 vs 3.0 +/- 2.11 min(-1), P < 0.01). There was no gastric inflation when ventilation was performed with the combitube. Only seven of 21 volunteers exceeded 1-min lung volumes of > 5 1 when using the bag-valve-mask, whereas mean (+/-S.D.) 1-min lung volumes with both laryngeal mask airway and combitube were significantly higher (laryngeal mask airway 15.0+/-6.61, combitube 16.6 +/- 6.81 vs bag-valve-mask 4.8 +/- 2.71, P < 0.01). The time for insertion was significantly faster with both bag-valve-mask and laryngeal mask airway compared with the combitube (median: bag valve mask 22 s, laryngeal mask airway 37 s vs combitube 70 s, P < 0.01). This may tip the scales towards using the laryngeal mask airway during basic life support airway management. In conclusion, our data suggests that both laryngeal mask airway and combitube may be appropriate alternatives for airway management in the first few minutes of CPR.

Smaller tidal volumes with room-air are not sufficient to ensure adequate oxygenation during bag–valve–mask ventilation☆

The European Resuscitation Council has recommended decreasing tidal volume during basic life support ventilation from 800 to 1200 ml, as recommended by the American Heart Association, to 500 ml in order to minimise stomach inflation. However, if oxygen is not available at the scene of an emergency, and small tidal volumes are given during basic life support ventilation with a paediatric self-inflatable bag and room-air (21% oxygen), insufficient oxygenation and/or inadequate ventilation may result. When apnoea occurred after induction of anaesthesia, 40 patients were randomly allocated to room-air ventilation with either an adult (maximum volume, 1500 ml) or paediatric (maximum volume, 700 ml) self-inflatable bag for 5 min before intubation. When using an adult (n=20) versus paediatric (n=20) self-inflatable bag, mean +/-SEM tidal volumes and tidal volumes per kilogram were significantly (P<0.0001) larger (719+/-22 vs. 455+/-23 ml and 10.5+/-0.4 vs. 6.2+/-0.4 ml kg(-1), respectively). Compared with an adult self-inflatable bag, bag-valve-mask ventilation with room-air using a paediatric self-inflatable bag resulted in significantly (P<0.01) lower paO(2) values (73+/-4 vs. 87+/-4 mmHg), but comparable carbon dioxide elimination (40+/-2 vs. 37+/-1 mmHg; NS). In conclusion, our results indicate that smaller tidal volumes of approximately 6 ml kg(-1) ( approximately 500 ml) given with a paediatric self-inflatable bag and room-air maintain adequate carbon dioxide elimination, but do not result in sufficient oxygenation during bag-valve-mask ventilation. Thus, if small (6 ml kg(-1)) tidal volumes are being used during bag-valve-mask ventilation, additional oxygen is necessary. Accordingly, when additional oxygen during bag-valve-mask ventilation is not available, only large tidal volumes of approximately 11 ml kg(-1) were able to maintain both sufficient oxygenation and carbon dioxide elimination.

Increased mortality in long-term intensive care patients with active cytomegalovirus infection.

Objective:To determine the prevalence and impact on patient outcome of active human cytomegalovirus infections in patients with prolonged treatment in an intensive care unit. Design:Retrospective analysis of stored plasma samples. Setting:Anesthesiological intensive care unit of a university hospital. Patients:All 138 patients treated for at least 14 days (of a total of 4940 patients admitted during the study period). Immunocompromised patients and patients with inconclusive results for cytomegalovirus DNA were excluded. Interventions:None. Measurements and Main Results:Stored plasma samples of patients with prolonged intensive care unit stay were tested for cytomegalovirus DNA. Sixty-four of 255 evaluable samples from 99 immunocompetent patients tested cytomegalovirus DNA-positive with a mean DNA concentration of 8,600 genome equivalents per milliliter. Active cytomegalovirus infection was diagnosed by reproducibly positive results in 35 patients (35%). Only one case had been diagnosed clinically. Patients with and without active cytomegalovirus infection were not significantly different in parameters, such as age, sex, admission category, source of admission, or comorbidities. Even review of specific surgical procedures or the use of a heart-lung–machine showed no significant differences between the groups. The mortality rate in patients with cytomegalovirus infection was significantly increased (28.6% vs. 10.9%, p = 0.048), and surviving patients had a longer intensive care unit stay (32.6 vs. 22.1 days, p <0.001). Conclusions:Active cytomegalovirus infection is a frequent but seldom diagnosed finding in surgical patients with prolonged intensive care unit stay, which is associated with increased mortality and prolonged intensive care unit stay of surviving patients.

Smaller tidal volumes during cardiopulmonary resuscitation: comparison of adult and paediatric self-inflatable bags with three different ventilatory devices

Gastric inflation and subsequent regurgitation of stomach contents is a major hazard of bag-valve-face mask ventilation during the basic life support phase of cardiopulmonary resuscitation (CPR). Recent investigations suggested that use of a paediatric self-inflating bag may reduce stomach inflation while ensuring sufficient lung ventilation. The purpose of our study was to examine whether use of a paediatric self-inflating bag in association with laryngeal mask airway, combitube, and bag-valve-face mask may provide adequate lung ventilation, while reducing the risk of gastric inflation in a bench model simulating the initial phase of CPR. Sixteen intensive care unit registered nurses volunteered for our study. Use of a paediatric versus adult self-inflating bag resulted in a significantly (P < 0.01) lower mean (+/- S.D.) tidal lung volume with both the laryngeal mask airway and combitube (laryngeal mask airway 349 +/- 149 ml versus 725 +/- 266 ml, combitube 389 +/- 113 ml versus 1061 +/- 451 ml). Lung tidal volumes were below the European Resuscitation Council recommendation with both self-inflatable bags in the bag-valve-face mask group (paediatric versus adult self-inflatable bag 256 +/- 77 ml versus 334 +/- 125 ml). Esophageal tidal volumes were significantly (P < 0.05) lower using the paediatric self-inflatable bag in the bag-valve-face mask group; almost no gastric inflation occurred with the laryngeal mask airway, and none with the combitube. In conclusion, use of the paediatric self-inflating bag may reduce gastric inflation, but measured lung tidal volumes are below the European Resuscitation Council recommendation when used with either, the laryngeal mask airway, combitube, or bag-valve-face mask.

Persistent endocrine stress response in patients undergoing cardiac surgery.

To investigate the endocrine stress response in patients undergoing major surgery with general anesthesia using a balanced technique with sufentanil, isoflurane and midazolam up to the second postoperative day, blood levels of cortisol, epinephrine, norepinephrine, prolactin and growth hormone were determined in 68 males for elective coronary artery bypass grafting (CABG) surgery. Intraoperatively, during extracorporeal circulation none of the measured parameters were significantly increased compared to preoperative values. The endocrine response of patients with perioperative epinephrine medication (n=32) was not significant different to patients that did not receive exogenous epinephrine (n=36). On the evening of the day of surgery, levels of cortisol (3fold), epinephrine (4.7fold), norepinephrine (1.7fold) and growth hormone (16.5fold) were significantly increased. Compared to preoperative values levels of cortisol (3.3fold), growth hormone (5.5fold) and norepinephrine (1.8fold) remained elevated up to the evening of the second postoperative day. In conclusion, the endocrine stress response in patients undergoing CABG-surgery under general anesthesia with sufentanil, midazolam, isoflurane is intraoperatively prevented by anesthesia. Although hemodilution or hormone degradation might be responsible for the lack of an increase in endocrine parameters during CPB, this study indicates that a balanced technique with isoflurane, sufentanil and midazolam is more effective in blocking the endocrine stress response than previously described anesthetic techniques. In the early postoperative period, a sharp increase in cortisol, epinephrine, norepinephrine and growth hormone occurred suggesting that the predominant endocrine stress response begins in the intensive care unit with end of anesthesia. The postoperative elevated levels of cortisol, growth hormone and norepinephrine indicate a persisting stress-response for more than two days after surgical trauma.

Early alterations in the number of circulating lymphocyte subpopulations and enhanced proinflammatory immune response during opioid-based general anesthesia.

The balance between proinflammatory and anti-inflammatory processes is of key importance in the reaction of the body to infection, injury, and surgical trauma. Drugs commonly used in anesthesia and intensive care may modulate immunological reactions by influencing intercellular communication through modification of cytokine response and fluctuation of peripheral immune cells such as natural killer (NK) cells, B cells, and T lymphocyte subpopulations (CD4+ and CD8+ cells). To examine the effects of general anesthesia with the hypnotic agent propofol and the opioid fentanyl, 30 patients undergoing minor elective orthopedic surgery were studied before and 20 min after application of the anesthetic drugs, but before the start of surgery. We found a significant enhancement of TNF-&agr; and IL-1&bgr; release in lipopolysaccharide (LPS)-stimulated whole blood cultures after induction of anesthesia. Similar results were observed with interferon-&ggr; (IFN-&ggr;) in cultures stimulated with phytohemagglutinin (PHA). Conversely, synthesis of the anti-inflammatory cytokine interleukin 10 (IL-10) decreased significantly in LPS-stimulated cultures. During general anesthesia, we found a decrease of circulating lymphocytes, characterized by a significant increase in the percentage of T lymphocytes in favor of CD4+ cells, increased B lymphocytes, and a significant decrease of NK cells. These data suggest that anesthesia with propofol and fentanyl promotes proinflammatory immune responses and influences peripheral lymphocyte composition in patients, which may subsequently affect pathophysiological processes during opioid-based anesthesia.

Postoperative dissociation of blood levels of cortisol and adrenocorticotropin after coronary artery bypass grafting surgery

The regulation of the hypothalamo-pituitary-adrenal (HPA) axis in the operative and perioperative period of major surgical procedures is necessary for successful adaption to surgical stress. We report evidence on an altered response of HPA axis regulation in patients who underwent coronary artery bypass grafting (CABG) surgery. Plasma levels of adrenocorticotropin (ACTH), beta-endorphin, and cortisol were determined with radio-immune assay in 50 males for elective CABG surgery. The patients received general anesthesia using a balanced technique with sufentanil, isoflurane, and midazolam. Pre- and intraoperatively, there was no significant increase in plasma cortisol, ACTH, and beta-endorphin levels. On the evening of surgery, all plasma hormone levels were increased. On the evening of the first and second postoperative day, plasma ACTH and beta-endorphin levels returned to the preoperative baseline values. During the same time interval, plasma cortisol levels were significantly elevated and remained high until the end of the study period (p < 0.001). Our results indicate an altered regulation of the HPA axis in the postoperative period of patients after CABG surgery, as they are compatible with similar results in patients after major abdominal surgery, burned patients, and critically ill patients. Therefore, it is assumed that the finding of a postoperative dissociation between ACTH and cortisol is a result of the severity of perioperative adaptive mechanisms rather than of the specific conditions related to cardiac surgery.