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
Literatur
- 1
Aasboe V, Raeder J C, Groegaard B.
Betamethasone reduces postoperative pain and nausea after ambulatory surgery.
Anesth Analg.
1998;
87
319-323
- 2
Allan C Y, Jacqueline P A, Shubhda J H.
Caudal epidural block versus other methods of postoperative pain relief for circumcision
in boys.
Cochrane Database Syst Rev.
2003;
2
CD003005
- 3
Anderson B, Kanagasundaram S, Woollard G.
Analgesic efficacy of paracetamol in children using tonsillectomy as a pain model.
Anaesth Intensive Care.
1996;
24
669-673
- 4
Anderson B J, Ralph C J, Stewart A W, Barber C, Holford N H.
The dose-effect relationship for morphine and vomiting after day-stay tonsillectomy
in children.
Anaesth Intensive Care.
2000;
28
155-160
- 5
Bacon A K.
An alternative block for post circumcision analgesia.
Anaesth Intensive Care.
1977;
5
63-64
- 6
Bean-Lijewski J D.
Glossopharyngeal nerve block for pain relief after pediatric tonsillectomy: retrospective
analysis and two cases of life-threatening upper airway obstruction from an interrupted
trial.
Anesth Analg.
1997;
84
1232-1238
- 7
Bisgaard T, Klarskov B, Kehlet H, Rosenberg J.
Preoperative dexamethasone improves surgical outcome after laparoscopic cholecystectomy:
a randomized double-blind placebo-controlled trial.
Ann Surg.
2003;
238
661-662
- 8
Broadman L M, Hannallah R S, Belman A B, Elder P T, Ruttimann U, Epstein B S.
Post-circumcision analgesia - a prospective evaluation of subcutaneous ring block
of the penis.
Anesthesiology.
1987;
67
399-402
- 9
Brown K A, Laferrière A, Moss I R.
Recurrent hypoxemia in young children with obstructive sleep apnea is associated with
reduced opioid requirement for analgesia.
Anesthesiology.
2004;
100
806-810
- 10
Brown R E , Wilhoit R D, Samuel M P.
Excessively high plasma bupivacaine concentrations after tonsillar bed and adenoidal
injection of 0.25 % bupivacaine.
Paediatr Anaesth.
1993;
3
287-290
- 11
Büttner W, Finke W, Hilleke M, Reckert S, Vsianska L, Brambrink A.
Entwicklung eines Fremdbeobachtungsbogens zur Beurteilung des postoperativen Schmerzes
bei Säuglingen.
Anästhesiol Intensivmed Notfallmed Schmerzther.
1998;
33
353-361
- 12
Carr M M, Williams J G, Carmichael L, Nasser J G.
Effect of steroids on posttonsillectomy pain in adults.
Arch Otolaryngol Head Neck Surg.
1999;
125
1361-1364
- 13
Chambers F A, Lee J, Smith J, Casey W.
Post-circumcision analgesia: comparison of topical analgesia with dorsal nerve block
using the midline and lateral approaches.
Br J Anaesth.
1994;
73
637-639
- 14
Choy W Y, Irwin M G, Hui T W, Lim H H, Chan K L.
EMLA cream versus dorsal penile nerve block for postcircumcision analgesia in children.
Anesth Analg.
2003;
96
396-398
- 15
Clergue F, Auroy Y, Péquignot F, Jougla E, Lienhart A, Laxenaire M C.
French survey of anesthesia in 1996.
Anesthesiology.
1991;
91
1509-1520
- 16
Dalens B, Vanneuville G, Dechelotte P.
Penile block via the subpubic space in 100 children.
Anesth Analg.
1989;
69
41-45
- 17
Eberhart L H, Morin A M, Georgieff M.
Dexamethason zur Prophylaxe von Übelkeit und Erbrechen in der postoperativen Phase.
Eine Metaanalyse kontrollierter randomisierter Studien.
Anaesthesist.
2000;
49
713-720
- 18
Elhakim M, Ali N M, Rashed I, Riad M K, Refat M.
Dexamethasone reduces postoperative vomiting and pain after pediatric tonsillectomy.
Can J Anaesth.
2003;
50
392-397
- 19
Gadiyar V, Gallagher T M, Phil M, Taylor R H.
The effect of a combination of rectal diclofenac and caudal bupivacaine on postoperative
analgesia in children.
Anaesthesia.
1995;
50
820-822
- 20
Gersema L, Baker K.
Use of corticosteroids in oral surgery.
J Oral Maxillofac Surg.
1992;
50
270-277
- 21
Hamers J P, Abu-Saad H H.
Children's pain at home following (adeno) tonsillectomy.
Eur J Pain.
2002;
6
213-219
- 22
Henzi I, Walder B, Tramèr M.
Dexamethasone for the prevention of postoperative nausea and vomiting: a quantitative
systematic review.
Anesth Analg.
2000;
90
186-194
- 23
Herschel M, Khoshnood B, Ellman C, Maydew N, Mittendorf R.
Neonatal circumcision. Randomized trial of a sucrose pacifier for pain.
Arch Pediatr Adolesc Med.
1998;
152
279-284
- 24
Holder K J, Peutrell J M, Weir P M.
Regional anaesthesia for circumcision. Subcutaneous ring block of the penis and subpubic
penile block compared.
Eur J Anaesthesiol.
1997;
14
495-498
- 25
Hollis L J, Burton M J, Millar J M.
Perioperative local anaesthesia for reducing pain following tonsillectomy.
Cochrane Database Syst Rev.
2000;
2
CD001874
- 26
Holt R, Rask P, Coulthard K P, Sinclair M, Roberts G, van der Walt J, MacKenzie V,
Rasmussen M.
Tropisetron plus dexamethasone is more effective than tropisetron alone for the prevention
of postoperative nausea and vomiting in children undergoing tonsillectomy.
Paediatr Anaesth.
2000;
10
181-188
- 27
Homer J J, Frewer J D, Swallow J, Semple P.
An audit of post-operative analgesia in children following tonsillectomy.
J Laryngol Otol.
2002;
166
367-370
- 28
Jebeles J A, Reilly J S, Gutierrez J F, Bradley E L , Kissin I.
The effect of pre-incisional infiltration of tonsils with bupivacaine on the pain
following tonsillectomy under general anesthesia.
Pain.
1991;
47
305-308
- 29
Joshi W, Connelly N R, Reuben S S, Wolckenhaar M, Thakkar N.
An evaluation of the safety and efficacy of administering rofecoxib for postoperative
pain management.
Anesth Analg.
2003;
97
35-38
- 30
Jöhr M.
Postoperative Schmerztherapie bei Kindern.
Anaesthesist.
1998;
47
889-899
- 31 Jöhr M. Kinderanästhesie. 5. Auflage. München; Urban & Fischer 2001
- 32
Kehlet H, Dahl J B.
The value of “multimodal” or “balanced analgesia” in postoperative pain treatment.
Anesth Analg.
1993;
77
1048-1056
- 33
Kehlet H, Werner M, Perkins F.
Balanced analgesia: what is it and what are its advantages in postoperative pain?.
Drugs.
1999;
58
793-797
- 34
Lander J, Brady-Fryer B, Metcalfe J B, Nazarali S, Muttitt S.
Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal
circumcision: a randomized controlled trial.
JAMA.
1997;
278
2157-2162
- 35
Marret E, Flahault A, Samama C M, Bonnet F.
Effects of postoperative, nonsteroidal, antiinflammatory drugs on bleeding risk after
tonsillectomy: meta-analysis of randomized, controlled trials.
Anesthesiology.
2003;
98
1497-1502
- 36
Moiniche S, Romsing J, Dahl J, Tramèr M.
Nonsteroidal antiinflammatory drugs and the risk of operative site bleeding after
tonsillectomy: a quantitative systematic review.
Anesth Analg.
2003;
96
68-77
- 37
Moir M S, Bair E, Shinnick P, Messner A.
Acetaminophen versus acetaminophen with codeine after pediatric tonsillectomy.
Laryngoscope.
2000;
110
1824-1827
- 38
Molliex S, Haond P, Baylot D, Prades J M, Navez M, Elkhoury Z, Auboyer C.
Effect of pre- vs. postoperative tonsillar infiltration with local anesthetics on
postoperative pain after tonsillectomy.
Acta Anaesthesiol Scand.
1996;
40
1210-1215
- 39
Nordahl S H, Albrektsen G, Guttormsen A B, Pedersen I L, Breidablikk H J.
Effect of bupivacaine on pain after tonsillectomy: a randomized clinical trial.
Acta Otolaryngol.
1999;
119
369-376
- 40
Orntoft S, Longreen A, Moiniche S, Dhal J B.
A comparison of pre- and postoperative tonsillar infiltration with bupivacaine on
pain after tonsillectomy. A pre-emptive effect?.
Anaesthesia.
1994;
49
151-154
- 41
Schmidt A, Bjorkman S, Akeson J.
Preoperative rectal diclofenac versus paracetamol for tonsillectomy: effects on pain
and blood loss.
Acta Anaesthesiol Scand.
2001;
45
48-52
- 42
Schuepfer G, Jöhr M.
Generating a learning curve for penile block in neonates, infants and children: An
empirical evaluation of technical skills in novice and experienced anesthetists.
Pediatr Anesth.
2004;
14
574-578
- 43
Soh C R, Ng S B, Lim S L.
Dorsal penile nerve block.
Paediatr Anaesth.
2003;
13
329-333
- 44
Steward D L, Weldge J A, Myer C M.
Steroids for improving recovery following tonsillectomy in children.
Cochrane Database Syst Rev.
2003;
1
CD003997
- 45
Stewart R, Bill R, Ullah R, McConaghy P, Hall S J.
Dexamethasone reduces pain after tonsillectomy in adults.
Clin Otolaryngol.
2002;
21
321-326
- 46
Strub K A, Tschopp K, Frei F, Kern C, Erb T.
Zur lokalen Infiltration von Epinephrin und Bupivacain vor Tonsillektomie.
HNO.
1996;
44
672-676
- 47
Stuart J C, MacGregor F B, Cairns C S, Chandrachud H R.
Peritonsillar infiltration with bupivacaine for paediatric tonsillectomy.
Anaesth Intensive Care.
1994;
22
679-682
- 48
Swallow J, Briggs M, Semple P.
Pain at home: children's experience of tonsillectomy.
J Child Health Care.
2000;
4
93-98
- 49
Taddio A, Ohlsson A, Einarson T R, Stevens B, Koren G.
A systematic review of lidocaine-prilocaine cream (EMLA) in the treatment of acute
pain in neonates.
Pediatrics.
1998;
101
E1
- 50
Taddio A, Ohlsson K, Ohlsson A.
Lidocaine-prilocaine cream for analgesia during circumcision in newborn boys.
Cochrane Database Syst Rev.
2000;
2
CD000496
- 51
Taddio A, Stevens B, Craig K, Rastogi P, Ben-David S, Shennan A, Mulligan P, Koren G.
Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision.
N Engl J Med.
1997;
336
1197-1201
- 52
Weksler N, Nash M, Rozentsveig V, Schwartz J A, Schily M, Gurman G M.
Vocal cord paralysis as a consequence of peritonsillar infiltration with bupivacaine.
Acta Anaesthesiol Scand.
2001;
45
1042-1044
- 53
Wilson K, Lakheeram I, Morielli A, Brouillette R, Brown K.
Can assessment for obstructive sleep apnea help predict postadenotonsillectomy respiratory
complications?.
Anesthesiology.
2002;
96
313-322
- 54
Wolf A R.
Tears at bedtime: a pitfall of extending paediatric day-case surgery without extending
analgesia.
Br J Anaesth.
1999;
82
319-320
- 55
Wong A K, Bissonnette B, Braude B M, Macdonald R M, St. Louis PJ, Fear DW.
Post-tonsillectomy infiltration with bupivacaine reduces immediate postoperative pain
in children.
Can J Anaesth.
1995;
42
770-774
Dr. Martin Jöhr
Institut für Anästhesie · Kantonsspital
CH-6000 Luzern 16 · Schweiz ·
Email: joehrmartin@bluewin.ch
