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Perioperatives Schmerzmanagement bei großen plastisch-rekonstruktiven Eingriffen in der Kinderurologie

Ein Plädoyer für die Periduralanästhesie

Perioperative pain management in major reconstructive surgery in pediatric urology

A plea for continuous epidural anesthesia

Zusammenfassung

Regionale Anästhesieverfahren sind ein essentieller Bestandteil der modernen Kinderanästhesie. In unserer Abteilung ist die kontinuierliche lumbale Periduralanästhesie (PDA) ein etabliertes Verfahren im perioperativen Schmerzmanagement mittlerer und großer Eingriffe am unteren Harntrakt. Ziel der vorliegenden Arbeit war es, die PDA im Säuglings- und Kindesalter hinsichtlich ihrer Effizienz, Sicherheit und möglicher Vorzüge gegenüber der rein systemischen perioperativen Analgesie zu analysieren.

Von 21 Säuglingen, die wegen einer kongenitalen Blasenekstrophie primär plastisch-rekonstruktiv versorgt wurden, erhielten 15 präoperativ eine PDA; 6 Kinder ohne PDA dienten als Vergleichsgruppe. Retrospektiv wurden der perioperative Analgetikabedarf, Intensivpflichtigkeit, Nachbeatmungsdauer, Darmmotilität, der Verbrauch an Anticholinergika sowie PDA-assoziierte Komplikationen zwischen beiden Gruppen verglichen.

Kinder mit kombinierter Allgemeinanästhesie und PDA hatten einen um das 6- bis 10-fache niedrigeren intra- bzw. postoperativen Opiatbedarf, konnten zügiger extubiert (59 vs. 210 min) und früher von der Intensiv- auf die Normalstation verlegt werden (1,1 vs. 1,8 Tage). Der postoperative Verbrauch an Anticholinergika lag um 50% niedriger als bei Kindern ohne PDA. PDA-assoziierte Komplikationen traten nicht auf.

Die lumbale PDA stellt im perioperativen Narkose- und Schmerzmanagement bei mittleren und großen plastisch-rekonstruktiven kinderurologischen Eingriffen im Kindesalter ein analgetisch hocheffektives und sicheres Verfahren dar. Durch den signifikant reduzierten Bedarf an Anästhetika und Analgetika begünstigt die PDA eine zeitnahe Extubation mit allen weiteren Vorteilen der postoperativen Versorgung.

Abstract

Regional analgesia is firmly established in modern pediatric anesthetic practice and its popularity continues to grow. In our department continuous epidural anesthesia (CEA) is a frequently used technique of pain management following major reconstructive procedures of the lower urinary tract. The aim of this study was to investigate the efficacy, safety, and potential benefits of CEA over standard analgesics.

We retrospectively reviewed the records of 21 infants who underwent single-stage bladder exstrophy repair in our department. In 15 children an epidural catheter was placed preoperatively for CEA; 6 patients treated without CEA served as controls. Total doses of narcotics and analgesics, length of intensive care unit (ICU) stay and ventilatory assistance, time to first bowel activity, anticholinergic requirements, and CEA-related side effects were documented and compared for both groups.

Children given epidural anesthesia required six- to tenfold lower doses of morphine intra- and postoperatively compared to those without CEA; ventilatory support upon completion of surgery was remarkably shorter (59 versus 210 min) in the CEA group as well as ICU stay (1.1 versus 1.8 days). The total consumption of anticholinergics was twice as high as in patients without CEA. There were no relevant CEA-related complications.

Being a retrospective audit of practice in our institution with a small number of patients, our results are in line with previously published data on CEA in pediatric patients. CEA has been shown to significantly reduce the need for anesthetics and morphine and allows early extubation with all subsequent advantages for a speedy recovery post surgery. Thus, the technique is to be recommended as a safe and efficacious method for pain management following major reconstructive surgery in pediatric urology. Importantly, this type of anesthesia should be performed only by experienced anesthesiologists in institutions where appropriate equipment, staff, and monitoring are available.

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Correspondence to Dr. P.C. Rubenwolf FEBU MSc.

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Rubenwolf, P., Koller, B., Rübben, I. et al. Perioperatives Schmerzmanagement bei großen plastisch-rekonstruktiven Eingriffen in der Kinderurologie. Urologe 50, 566 (2011). https://doi.org/10.1007/s00120-011-2527-5

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Schlüsselwörter

  • Periduralanästhesie
  • Blasenekstrophie
  • Perioperative Schmerztherapie
  • Plastisch-rekonstruktive Eingriffe
  • Kinderurologie

Keywords

  • Peridural anaesthesia
  • Perioperative pain management
  • Bladder exstrophy
  • Reconstructive surgery
  • Pediatric urology