Background: Fever and hypothermia have been observed in septic patients. Their influence on prognosis is subject to ongoing debates. Methods: We did a secondary analysis of a large clinical dataset from a quality improvement trial. A binary logistic regression model was calculated to assess the association of the thermal response with outcome and a multinomial regression model to assess factors associated with fever or hypothermia. Results: With 6542 analyzable cases we observed a bimodal temperature response characterized by fever or hypothermia, normothermia was rare. Hypothermia and high fever were both associated with higher lactate values. Hypothermia was associated with higher mortality, but this association was reduced after adjustment for other risk factors. Age, community-acquired sepsis, lower BMI and lower outside temperatures were associated with hypothermia while bacteremia and higher procalcitonin values were associated with high fever. Conclusions: Septic patients show either a hypothermic or a fever response. Whether hypothermia is a maladaptive response, as indicated by the higher mortality in hypothermic patients, or an adaptive response in patients with limited metabolic reserves under colder environmental conditions, remains an open question. Trial registration The original trial whose dataset was analyzed was registered at ClinicalTrials.gov (NCT01187134) on August 23, 2010, the first patient was included on July 1, 2011.

Anesthesiology and Pain Medicine

Although tonsillectomy is one of the most frequent and painful surgeries, the association between baseline and process parameters and postoperative pain are not fully understood. A multicentre prospective cohort study using a web-based registry enrolled 1,527 women and 1,008 men aged 4 to 85 years from 52 German hospitals between 2006 and 2015. Maximal pain (MP) score the first day after surgery on a numeric rating scale (NRS) from 0 (no pain) to 10 (MP) was the main outcome parameter. The mean maximal pain score was 5.8±2.2 (median 6). Multivariable analysis revealed that female gender (Odds ratio [OR] = 1.33; 95% confidence interval [CI] = 1.12 to 1.56; p = 0.001), age <20 years (OR = 1.56; CI = 1.27 to 1.91; p<0.0001), no pain counselling (OR = 1.78; CI = 1.370 to 2.316; p<0.001), chronic pain (OR = 1.34; CI = 1.107 to 1.64; p = 0.004), and receiving opioids in recovery room (OR = 1.89; CI = 1.55 to 2.325; p<0.001) or on ward (OR = 1.79; CI = 1.42 to 2.27; p<0.001) were independently associated with higher experienced maximal postoperative pain (greater the median of 6). The effect of age on pain was not linear. Maximal pain increased in underage patients to a peak at the age of 18 to 20 years. From the age of ≥20 years on, maximal pain after tonsillectomy continuously decreased. Even after adjustment to all statistically important baseline and process parameters, there was substantial variability of maximal pain between hospitals with a heterogeneity variance of 0.31. Many patients seem to receive insufficient or ineffective analgesia after tonsillectomy. Further research should address if populations at risk of higher postoperative pain such as females, younger patients or those with preexisting pain might profit from a special pain management protocol. Beyond classical demographical and process parameters the large variability between different hospitals is striking and indicates the existence of other unknown factors influencing postoperative pain after tonsillectomy.

Background: Patient-reported outcome measures (PROMs) are essential instruments for assessing postsurgical pain-related outcomes from the patient’s perspective. The concept of minimal clinically important difference (MCID) aims to identify the smallest change in PROMs that is meaningful to patients. In this multicenter study, data were used to calculate MCIDs for several PROMs assessing pain intensity and physical function after surgery and to perform a sensitivity analysis. Methods: Data from 2,661 patients undergoing sternotomy, total knee arthroplasty, breast surgery, or surgery related to endometriosis, recruited from 18 centers in 10 European countries, were included in the analysis. Eight PROMs were collected on days 1 and 3 after surgery, assessing pain intensity (at rest, average, worst, during movement, during physiotherapy) and physical function (in bed, during movement, during physiotherapy). MCIDs were calculated using a combination of distribution-based (30% of SD, standard error of the measurement) and anchor-based (calculating the absolute change between day 1 and day 3 for patients reporting “minimal improvement” or “minimal worsening” on 7-point global and specific impression of change scales) methods. Results: The MCID estimates for pain intensity ranged from 1.2 (at rest) to 1.6 (during activity), while physical function was consistent between 1.5 (in bed) and 1.6 (during physiotherapy) on an 11-point scale. Sensitivity analyses revealed no significant difference in MCID estimates between symptom improvement and worsening for all PROMs. However, baseline pain influenced MCID estimates, with higher baseline pain leading to patients reporting higher changes as meaningful ( e.g. , for pain at rest, MCID mild pain 1.0, MCID severe pain 2.1). Conclusions: The authors found differences between MCID estimates for eight PROMs related to pain intensity and physical function. Baseline values appear to have a significant impact on what patients consider to be a minimal relevant change, which should be addressed in future studies.

Postsurgical outcome measures are crucial to define the efficacy of perioperative pain management; however, it is unclear which are most appropriate. We conducted a prospective study aiming to assess sensitivity-to-change of patient-reported outcome measures assessing the core outcome set of domains pain intensity (at rest/during activity), physical function, adverse events, and self-efficacy. Patient-reported outcome measures were assessed preoperatively, on day 1 (d1), d3, and d7 after four surgical procedures (total knee replacement, breast surgery, endometriosis-related surgery, and sternotomy). Primary outcomes were sensitivity-to-change of patient-reported outcome measures analysed by correlating their changes (d1-d3) with patients' global impression of change and patients' specific impression of change items as anchor criteria. Secondary outcomes included identification of baseline and patient characteristic variables explaining variance in change for each of the scales and descriptive analysis of various patient-reported outcome measures from different domains and after different surgeries. Of 3322 patients included (18 hospitals, 10 countries), data from 2661 patients were analysed. All patient-reported outcome measures improved on average over time; the median calculated sensitivity-to-change for all patient-reported outcome measures (overall surgeries) was 0.22 (range: 0.07-0.31, scale: 0-10); all changes were independent of baseline data or patient characteristics and similar between different procedures. Pain-related patient-reported outcome measures have low to moderate sensitivity-to-change; those showing higher sensitivity-to-change from the same domain should be considered for inclusion in a core outcome set of patient-reported outcome measures to assess the effectiveness and efficacy of perioperative pain management.