RESUMEN
Pain management in paediatric neurosurgery must be a daily concern for surgeons and anaesthetists. Pain assessment in infants and small children is difficult to perform because of limitations associated with these patients. The association of safe and effective analgesics allows good pain relief together with good safety conditions. However, neuropathic pain, which may occur following neurosurgical procedures, will require further studies.
Asunto(s)
Procedimientos Neuroquirúrgicos , Dolor Postoperatorio/tratamiento farmacológico , Analgésicos/uso terapéutico , Niño , Humanos , Dimensión del DolorRESUMEN
OBJECTIVE: Using a weighted combination of the Revised Trauma Score (RTS), the Injury Severity Score (ISS), the type of injury (blunt or penetrating) and patient age, the TRISS method is used to calculate the probability of survival (ps) in trauma patients. The goal of this study was to compare the ability of the American Major Trauma Outcome Study (MTOS) norm for adult blunt trauma patients (ADULT) and the specific norm for paediatric patients (PED) to estimate the ps of injured children using TRISS methodology. DESIGN: Retrospective analysis using a paediatric trauma patient database. SETTING: A French level 1 paediatric trauma centre. PATIENTS: Four hundred seven consecutive paediatric blunt trauma patients, treated over a 3-year period. MEASUREMENTS: The observed and expected survivals were compared, using the M, W and Z scores, with both ADULT and PED. The W score is the number of survivors more or less than expected from the MTOS predictions for 100 patients. A Z score, which measures the significance of W, between -1.96 and +1.96, indicates no significant difference between observed and expected survivors. A value of M less than 0.88 indicates a disparity in the severity match between the study group and the MTOS group. We calculated the standardised W score (Ws), which represents the W score that would have been observed if the case mix of severity was identical to that of the MTOS group. Accordingly, a standardised Z score (Zs) was also calculated. In addition, we calculated the area under the receiver operating curve (aROC) using both norms, while calibration was also assessed by calculation of the Hosmer-Lemeshow goodness-of-fit tests. RESULTS: Using PED, the number of actual survivors (n = 364) was not significantly different from the MTOS (n = 358). The value of M, 0.65, indicated a disparity in the severity match between the study group and the MTOS group, due to a higher proportion of patients with lower ps (TRISS < 0.95, 52 vs 27%). We was +1.06% (95% confidence interval -0.34 to 2.08) and Zs was 1.48, indicating no significant difference from the MTOS. Using ADULT, the number of observed survivors (n = 364) was significantly higher than that expected (n = 354), with a W score of +2.70% (Z = +1.98, p < 0.05). There was a disparity in the severity match (M = 0.67) between the study group and the MTOS group, due to a higher proportion of patients with lower ps. Ws was +1.32% (95% confidence interval -0.12 to 2.37) and Zs = +1.79 (NS), indicating no significant difference from the MTOS. The Hosmer-Lemeshow statistics indicated that ADULT (Cg = 7.24, p = 0.51; Hg = 4.45, p = 0.81) and PED (Cg = 6.08, p = 0.64; Hg = 3.55, p = 0.90) provided sufficient goodness-of-fit. There was no significant difference in the aROC of the TRISS between the two norms (0.935 +/- 0.050 vs 0.936 +/- 0.050; NS). CONCLUSION: Both adult and paediatric norms were equally good predictors of the probability of survival of injured children, provided that Ws and Zs are used when there is a disparity in the severity match between the study group and the MTOS group.
Asunto(s)
Hospitales Pediátricos/estadística & datos numéricos , Puntaje de Gravedad del Traumatismo , Centros Traumatológicos/estadística & datos numéricos , Índices de Gravedad del Trauma , Heridas no Penetrantes/clasificación , Heridas no Penetrantes/mortalidad , Adolescente , Adulto , Factores de Edad , Niño , Preescolar , Femenino , Francia , Humanos , Lactante , Masculino , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Estudios Retrospectivos , Análisis de SupervivenciaRESUMEN
A postal survey of the use of cuffed or uncuffed tracheal tubes for tracheal intubation in children and infants was performed to investigate the criteria used for deciding the choice of tube and the manner of inflating the cuff in the case of use of a cuffed tracheal tube (CTT). From 200 questionnaires despatched, replies were received from 130 paediatric anaesthesiologists (response rate 65%). In paediatric practice, the CTT was routinely used by 25% of respondents for more than 80% of their patients, while more than 37% of respondents use them in less than 20% of the cases. The three main criteria used for inflating a cuff were: (i) the presence of a leak, (ii) the type of surgery associated with the presence of a leak and (iii) the patient's age associated with the type of surgery and the presence of a leak. These criteria were specified, respectively, by 32%, 24% and 18% of the respondents. The cuff was inflated in response to a leak in 18% of the cases and as a response to a pressure manometer in 15% of the cases. Few paediatric anaesthesiologists use a cuffed tracheal tube routinely for tracheal intubation in children, and fewer actually use a pressure monitoring device, while it is suggested that the cuff pressure should be monitored in case of CTT.
Asunto(s)
Intubación Intratraqueal/instrumentación , Niño , Recolección de Datos , Francia , Humanos , Intubación Intratraqueal/estadística & datos numéricos , Enfermeras Anestesistas , Encuestas y CuestionariosRESUMEN
Population approaches are appealing methods for detecting then assessing drug-drug interactions mainly because they can cope with sparse data and quantify the interindividual pharmacokinetic (PK) and pharmacodynamic (PD) variability. Unfortunately these methods sometime fail to detect interactions expected on biochemical and/or pharmacological basis and the reasons of these false negatives are somewhat unclear. The aim of this paper is firstly to propose a strategy to detect and assess PD drug-drug interactions when performing the analysis with a nonparametric population approach, then to evaluate the influence of some design variates (i.e., number of subjects, individual measurements) and of the PD interindividual variability level on the performances of the suggested strategy. Two interacting drugs A and B are considered, the drug B being supposed to exhibit by itself a pharmacological action of no interest in this work but increasing the A effect. Concentrations of A and B after concomitant administration are simulated as well as the effect under various combinations of design variates and PD variability levels in the context of a controlled trial. Replications of simulated data are then analyzed by the NPML method, the concentration of the drug B being included as a covariate. In a first step, no model relating the latter to each PD parameter is specified and the NPML results are then proceeded graphically, and also by examining the expected reductions of variance and entropy of the estimated PD parameter distribution provided by the covariate. In a further step, a simple second stage model suggested by the graphic approach is introduced, the fixed effect and its associated variance are estimated and a statistical test is then performed to compare this fixed effect to a given value. The performances of our strategy are also compared to those of a non-population-based approach method commonly used for detecting interactions. Our results illustrate the relevance of our strategy in a case where the concentration of one of the two drugs can be included as a covariate and show that an existing interaction can be detected more often than with a usual approach. The prominent role of the interindividual PD variability level and of the two controlled factors is also shown.