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DOI: 10.1055/s-2004-825882
Schmerztherapie bei Neugeborenen, Säuglingen und Kleinkindern - therapieren wir immer ausreichend?
Pain Treatment in Neonates, Infants and Children - Is the Current Treatment Sufficient?Publication History
Publication Date:
30 August 2004 (online)
Zusammenfassung
Kinder werden vielfach schmerzhaften oder beängstigenden Prozeduren unterworfen, z. B. Blutentnahmen, Verbandwechsel oder dem Entfernen von Drainagen. Das zentrale Problem ist die Frage, ob ein Kind Schmerzen hat oder aus anderen Gründen unglücklich ist. Die regelmäßige Erhebung des Schmerz-Scores und dessen Protokollieren bilden den Grundstein, um Schmerz in einer Abteilung angehen zu können. Für viele klinische Situationen haben wir klare, gut funktionierende Konzepte, wir müssen sie nur anwenden. Fragen und Probleme bleiben jedoch: z. B. die Schmerzevaluation bei sehr kleinen Kindern, die Nebenwirkungen der Opioide, Eingriffe im Bereich der Luftwege oder das Nutzen-Risiko-Verhältnis von gewissen Techniken. Die Schmerztherapie nach Tonsillektomie bringt große Probleme: Der Eingriff bewirkt erhebliche postoperative Schmerzen. Die Infiltration der Tonsillenlogen mit Bupivacain hat die Hoffnungen nicht erfüllt, sie hat keinen prä-emptiven Effekt und nur einen minimalen Effekt auf die postoperativen Schmerzen. Das Analgesiekonzept beruht auf Opioiden, Steroiden und Nichtopiat-Analgetika. Die klassischen nichtsteroidalen Antirheumatika sollen wegen des erhöhten Risikos von Blutungskomplikationen nicht verwendet werden. Die Berichte über COX-2-Hemmer sind viel versprechend. Die Schmerztherapie nach Zirkumzision ist zuverlässig möglich: Die Leitungsblockade mit hohen Konzentrationen eines lang wirkenden Lokalanästhetikums bewirkt zusammen mit einer Dosis eines nichtsteroidalen Antirheumatikums in über ⅔ der Fälle eine ausreichende Analgesie. Der Penisblock ist der Standard für die Zirkumzision, Komplikationen sind selten. Der an sich kleine Eingriff geht aber mit einer erheblichen psychischen Beeinträchtigung einher. Schmerztherapie kann nicht alles Leiden verhindern, das Chirurgie bei Kindern mit sich bringt. Das Konzept, mit einer Kombination von Techniken und Medikamenten - der multimodalen Schmerztherapie - die Schmerzen möglichst zu minimieren, hat sich in vielen klinischen Situationen bewährt. Stete Anstrengungen sind jedoch nötig, um die Schmerztherapie auch in Problemfällen, z. B. bei der Tonsillektomie, zu verbessern.
Abstract
Paediatric patients quite often have to undergo painful or stressful procedures, e. g. blood sampling, dressing of wounds or removal of a drainage. The key problem is to decide if a child has pain or if there are other reasons for crying. Establishing a high standard in an institution requires regular evaluation and documentation of pain scores. For many clinical situations, clear and functioning concepts exist - we just have to use them. Unanswered questions are the evaluation of pain in small children, the side-effects of opioids, surgery involving the airways and the risk-benefit-ratio of certain techniques. Pain therapy after tonsillectomy is still troublesome: relevant postoperative pain occurs. Local infiltration of the tonsillar bed has no pre-emptive effect and only a minimal impact on the postoperative pain. Management relies on opioids, steroids and non-opioids. Non-steroidal anti-inflammatory drugs should not be used because of an increased risk of bleeding. Promising data have been reported on COX-2-blockers, but experience in children is still limited. Pain management after circumcision is relatively easy to perform. A conduction block with a long-acting local anaesthetic combined with one dose of a non-steroidal anti-inflammatory drug provides sufficient analgesia in over ⅔ of patients. Today, penile block is the standard of care and complications only rarely occur. However, despite successful pain prevention, circumcision remains a stressful procedure for the small patients. Pain treatment per se is not sufficient to relieve all the suffering connected with surgery in children. The concept of balanced analgesia is successful under many circumstances, but continuous efforts are needed to improve the management for difficult situations, e. g. tonsillectomy.
Schlüsselwörter
Kinderanästhesie - Säuglinge - Kleinkinder - Kinder - Schmerztherapie - Tonsillektomie - Zirkumzision
Key words
Paediatric anaesthesia - infants - children - pain management - tonsillectomy - circumcision
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Dr. Martin Jöhr
Institut für Anästhesie · Kantonsspital
CH-6000 Luzern 16 · Schweiz ·
Email: joehrmartin@bluewin.ch