Konzepte zur Schmerzreduktion in der neonatalen Intensivtherapie

Zusammenfassung

Prolongierte Schmerzen beeinflussen bei frühgeborenen Kindern unter neonataler Intensivtherapie das Verhalten und die physiologische Regulation. Aus unzureichender Schmerzbehandlung resultieren erhöhte Morbidität und Mortalität. Langfristige Konsequenzen von Schmerz und Stress für die spätere Entwicklung sind unklar, jedoch werden neurologische und verhaltensbezogene Spätfolgen diskutiert. Zur Objektivierung kindlicher Schmerzreaktionen stehen eine Anzahl von psychometrischen Konstrukten (Schmerzskalen) zur Verfügung, auf deren Grundlage die Notwendigkeit einer Behandlung überprüft werden kann. Typische Indikationsgruppen für eine Therapie sind schmerzhafte interventionelle Prozeduren, eine Analgosedierung unter Beatmungstherapie sowie die Unterdrückung von Stressantwort auf chirurgische Maßnahmen. Nichtmedikamentöse Ansätze zur Reduzierung von Schmerz und Stress beziehen sich auf das Verhalten des Kindes, unterstützende Maßnahmen durch das Personal und die Optimierung der Umgebungsbedingungen. Für die analgetische Pharmakotherapie stehen bei leichten Schmerzen Acetaminophen, bei moderaten und schweren Schmerzen hauptsächlich die Opioide Fentanyl und Morphin zur Verfügung. Unter weniger schmerzhaften Bedingungen kann eine ausschließliche oder zusätzliche Sedierung die physiologische Stabilität des Kindes verbessern. Individuelle Behandlung, engmaschige klinische Überwachung und Dosisanpassung entsprechend einer standardisierten Schmerzbeurteilung sind erforderlich. Die aktuelle Datenlage ermöglicht auch bei sehr unreifen Frühgeborenen eine effektive Schmerzreduktion. Es bestehen jedoch eine Reihe von Unklarheiten über frühkindliche Schmerz- und Stressreaktionen, so dass in jedem Fall eine sorgfältige Nutzen-Risiko-Abwägung erforderlich ist.

Abstract

Prolonged pain influences behaviour and physiological regulation in preterm infants undergoing intensive care. Insufficient pain treatment results in increased morbidity and mortality. Long-term consequences of stress and pain yet are not clear, but associations with neurobehavioral and developmental sequelae are discussed. A number of psychometric constructs (pain scales) are available to identify pain indicators. These pain scales represent the basis to consider treatment strategies. Mainindications are painful interventional procedures, analgesia during mechanical ventilation and the reduction of pain following surgery. Supporting approaches to reduce pain and stress relate to infant’s behaviour, care of the professionals and improvement of „infant’s world”. Pharmacologic interventions are practicable with acetaminophen in mild pain and with opioid drugs (fentanyl and morphine) in moderate and severe pain. A pure or complementary sedative agend can provide physiological stability in settings in which there are less acutely painful stimuli. After standard pain evaluation it is necessary to individualize treatment, to monitor clinical situation and to adjust dosage. Actual knowledge allows an effective reduction of pain even in very premature infants. Because of lack of clarity about early development of pain and stress reactivity at the time it is necessary to estimate benefits against potential risks of therapy.

Schlüsselwörter

Frühgeborenes - Schmerz - Stress - Analgesie - Sedierung

Key words

Premature infant - pain - stress - analgesia - sedation

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