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Der Schmerz

, Volume 25, Issue 3, pp 256–265 | Cite as

Postoperative Schmerzmessung bei speziellen Patientengruppen

Teil II: Das kognitiv beeinträchtigte Kind
  • B. Messerer
  • J. Meschik
  • A. Gutmann
  • M. Vittinghoff
  • A. Sandner-KieslingEmail author
Übersichten

Zusammenfassung

Die postoperative Schmerzerfassung bei Kindern mit intellektueller Beeinträchtigung fordert Ärzte und Pflege gleichermaßen heraus.

Kinder mit mäßiger bis schwerer intellektueller Einschränkung sind im Allgemeinen nicht in der Lage, Schmerz einzuschätzen und ausreichend zu kommunizieren. Schwierigkeiten in der Schmerzerfassung führen dazu, dass diese Kinder nicht in klinische Studien einbezogen werden und daher Gefahr laufen, schmerztherapeutisch insuffizient behandelt zu bleiben.

Das Sichtbarmachen von Schmerz ist ein besonders wichtiger Schritt in Richtung einer verbesserten Betreuung.

Selbstbeurteilungsskalen spielen bei Kindern mit einer intellektuellen Behinderung nur eine begrenzte Rolle. Hier sind Schmerzerfassungstools gefragt, die das Schmerzverhalten evaluieren. Der r-FLACC, der zuverlässig wie valide ist, berücksichtigt individuelle Verhaltensmuster und ist wegen des geringen Zeitaufwands zu seiner Erfassung für den klinischen Alltag tauglich.

Unsere Aufgabe muss es sein, Schmerzerfassung beim intellektuell eingeschränkten Kind zum Routinevorgehen werden zu lassen. Nur so können wir eine bessere Betreuung dieser sensiblen Patientengruppe sicherstellen.

Schlüsselwörter

Schmerz Schmerzmessung Schmerzbeurteilung Kind Mentale Retardierung 

Postoperative pain assessment in special patient groups

Part II. Children with cognitive impairment

Abstract

Postoperative pain assessment in children with cognitive impairment poses major challenges to healthcare professionals.

Children with moderate to severe cognitive impairment are generally unable to communicate effectively and to self-report the level of pain. Difficulties assessing pain have led to their exclusion from clinical trials and rendered them vulnerable to insufficient treatment of pain.

The realization of pain is a particularly important step forward for a better care of children with cognitive impairment.

Scales based on a child’s own perception of pain and its severity play a limited role in this vulnerable population and pain assessment tools which rely on observing pain behavior are essential. The r-FLACC, which is reliable and valid, includes specific behavioral descriptors and can be used simply and effectively postoperatively in clinical practice. Our task has to be assessing pain as a routine procedure in cognitively impaired children as a keystone for an improved and successful pain management in this very sensitive patient population.

Keywords

Pain Pain measurement Pain assessment Child Mental retardation 

Notes

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Literatur

  1. 1.
    Weber G, Rojahn J (2009) Intellektuelle Beeinträchtigung. Kapitel 22, Lehrbuch der Verhaltenstherapie Band 3 (Störungen im Kindes- und Jugendalter, Springer Medizin, Heidelberg, S 351–366Google Scholar
  2. 2.
    Luckasson R, Borthwick-Duffy S, Buntinx WHE et al (2002) Mental retardation: Definition, classification and systems of support. 10. Aufl. American Association on Mental Retardation, Washington DCGoogle Scholar
  3. 3.
    Schrojenstein Lantman-De Valk HM van, Metsemakers JF, Haveman MJ, Crebolder HF (2000) Health problems in people with intellectual disability in general practice: a comparative study. Fam Pract 17(5):405–407CrossRefGoogle Scholar
  4. 4.
    Zernikow B (2009) Schmerztherapie bei Kindern, Jugendlichen und jungen Erwachsenen. 4. Aufl. Springer, Berlin Heidelberg New YorkGoogle Scholar
  5. 5.
    Rothenhäusler HB, Täschner KL (2007) Kompendium Praktische Psychiatrie; Intelligenzminderung, Springer, Wien New York, S 463–471Google Scholar
  6. 6.
    Hennequin M, Morin C, Feine JS (2000) Pain expression and stimulus localisation in individuals with Down’s syndrome. Lancet 356(9245):1882–1887PubMedCrossRefGoogle Scholar
  7. 7.
    Breau LM, Camfield CS, McGrath PJ, Finley GA (2004) Risk factors for pain in children with severe cognitive impairements. Dev Med Child Neurol 46(6):364–371PubMedCrossRefGoogle Scholar
  8. 8.
    Lennox NG, Diggens JN, Ugoni AM (1997) The general practice care of people with intellectual disability: barriers and solutions. J Intellect Disabil Res 41(5):380–390PubMedCrossRefGoogle Scholar
  9. 9.
    Biersdorff KK (1991) Pain insensitivity and indifference: alternative explanations for some medical catastrophes. Ment Retard 29(6):359–362PubMedGoogle Scholar
  10. 10.
    Kain ZN, Cicchetti DV, McClain BC (2002) Measurement of pain in children: state-of-the-art considerations Anaesthesiology 96(3):523–526Google Scholar
  11. 11.
    Nolan J, Chalkiadis GA, Low J et al (2000) Anaesthesia and pain management in cerebral palsy. Anaesthesia 55(1):32–41PubMedCrossRefGoogle Scholar
  12. 12.
    Breverik H, Borchgrevink PC, Allen SM et al (2008) Assessment of pain. Br J Anaesth 101(1):17–24CrossRefGoogle Scholar
  13. 13.
    Closs SJ, Barr B, Briggs M et al (2004) A comparison of five pain assessment scales for nursing home residents with varying degrees of cognitive impairment. J Pain Symptom Manage 27(3)196–205Google Scholar
  14. 14.
    Breivik H, Borchgrevink C, Allen SM et al (2008) Assessment of pain. Br J Anaesth 101(1):17–24PubMedCrossRefGoogle Scholar
  15. 15.
    McKearnan KA, Kieckhefer GM, Engel JM et al (2004) Pain in children with cerebral palsy: a review. J Neurosci Nurs 36(5):252–259PubMedCrossRefGoogle Scholar
  16. 16.
    Voepel-Lewis T, Malviya S, Merkel S, Tait AR (2003) Behavioral pain assessment and the Face, Legs, Activity, Cry and Consolability instrument. Expert Rev Pharmacoecon Outcomes Res 3(3):317–325PubMedCrossRefGoogle Scholar
  17. 17.
    Stallard P, Williams L, Lenton S, Velleman R (2001) Pain in cognitively impaired, non-communicating children. Arch Dis Child 85(6):460–462PubMedCrossRefGoogle Scholar
  18. 18.
    Malviya S, Voepel-Lewis T, Tait AR et al (2001) Pain management in children with and without cognitive impairment following spine fusion surgery. Paediatr Anaesth 11(4):453–458PubMedCrossRefGoogle Scholar
  19. 19.
    Breau LM, Finley GA, McGrath PJ, Camfield CS (2002) Validation of the Non-communicating Children’s Pain Checklist-Postoperative Version. Anesthesiology 96(3):528–535PubMedCrossRefGoogle Scholar
  20. 20.
    Lenton S, Stallard P, Lewis M, Mastroyannopoulou K (2001) Prevalence and morbidity associated with non-malignant, life-threatening conditions in childhood. Child Care Health Dev 27(5):389–398PubMedCrossRefGoogle Scholar
  21. 21.
    Schoeffel D, Crasser HR, Bach M et al (2008) Risk assessment in pain therapy. Schmerz 22(5):594–603PubMedCrossRefGoogle Scholar
  22. 22.
    Rawal N, Berggren L (1994) Organization of acute pain services: a low cost model. Pain 57(1):117–123PubMedCrossRefGoogle Scholar
  23. 23.
    Franck LS, Greenberg CS, Stevens B (2000) Pain assessment in infants and children. Pediatr Clin North Am 47(3):487–512PubMedCrossRefGoogle Scholar
  24. 24.
    Treadwell MJ, Franck LS, Vichinsky E (2002) Using quality improvement strategies to enhance paediatric pain assessment. Int J Qual Health Care 14(1):39–47PubMedCrossRefGoogle Scholar
  25. 25.
    Ghai B, Makkar JK, Wig J (2008) Postoperative pain assessment in preverbal children and children with cognitive impairment. Paediatr Anaesth 18 (6):462–477PubMedCrossRefGoogle Scholar
  26. 26.
    Voepel-Lewis T, Malviya S, Tait AR et al (2008) A comparison of the clinical utility of pain assessment tools for children with cognitive impairment. Anaesth Analg 106(1):72–78CrossRefGoogle Scholar
  27. 27.
    Malviya S, Voepel-Lewis T, Burke C et al (2006) The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment. Paediatr Anaesth 16(3):258–265PubMedCrossRefGoogle Scholar
  28. 28.
    Reiter-Theil S, Graf-Baumann T, Kutzer K et al (2008) Ethik-Charta der Deutschen Gesellschaft zum Studium des Schmerzes (DGSS). Schmerz 22:191–206PubMedCrossRefGoogle Scholar
  29. 29.
    Taylor EM, Boyer K, Campbell FA (2008) Pain in hospitalized children: a prospective crosssectional survey of pain prevalence, intensity, assessment and management in a Canadian pediatric teaching hospital. Pain Res Manag 13(1):25–32PubMedGoogle Scholar
  30. 30.
    Burbridge M, Brady S, Davis J (1999) Legal issues: consent and guardianship. In: Lennox N, Diggens J (Hrsg.) Management Guidelines: People with developmental and intellectual disabilities. Therapeutic Guidelines Limited, MelbourneGoogle Scholar
  31. 31.
    Guisiano B, Jimeno MT, Collignon P, Chau Y (1995) Utilization of neural network in the elaboration of an evaluation scale for pain in cerebral palsy. Methods Inf Med 34(5):498–502Google Scholar
  32. 32.
    McGrath PA (1987) An assessment of children’s pain: a review of behavioural, physiological and direct scaling techniques. Pain 31(2):147–176PubMedCrossRefGoogle Scholar
  33. 33.
    McGrath PJ, Rosmus C, Canfield C et al (1998) Behaviours caregivers use to determine pain in non-verbal, cognitively impaired individuals. Dev Med Child Neurol 40(5):340–343PubMedGoogle Scholar
  34. 34.
    Krulewitch H, London MR, Skakel VJ et al (2000) Assessment of pain in cognitively impaired older adults: a comparison of pain assessment tools and their use by nonprofessional caregivers. J Am Geriatr Soc 48(12):1607–1611PubMedGoogle Scholar
  35. 35.
    Franurik D, Koh JL, Harrison RD et al (1998) Pain assessment in children with cognitive impairment. An exploration of self-report skills. Clin Nurs Res 7(2):103–119; discussion 120–124CrossRefGoogle Scholar
  36. 36.
    Stallard P, Williams L, Velleman R et al (2002) The development and evaluation of the pain indicator for communicatively impaired children (PICIC). Pain 98(1–2):145–149Google Scholar
  37. 37.
    Soussignan R, Schaal B, Schmit G, Nadel J (1995) Facial responsiveness to odours in normal and pervasively developmentally disordered children. Chem Senses 20(1):47–59PubMedCrossRefGoogle Scholar
  38. 38.
    Prkachin KM (2009) Assessing pain by facial expression: facial expression as nexus. Pain Res Manag 14(1):53–58PubMedGoogle Scholar
  39. 39.
    Stallard P, Williams L, Velleman R et al (2002) Brief report: behaviors identified by caregivers to detect pain in noncommunicating children. J Pediatr Psychol 27(2):209–214PubMedCrossRefGoogle Scholar
  40. 40.
    Terstegen C, Koot HM, Boer JB de, Tibboel D (2003) Measuring pain in children with cognitive impairment: pain response to surgical procedures. Pain 103(1–2):187–198Google Scholar
  41. 41.
    Kleinknecht M (2007) Reliability and validity of the german language version of the „NCCPC-R“. Pflege 20(2):93–102PubMedCrossRefGoogle Scholar
  42. 42.
    Franurik D, Koh JL, Schmitz ML et al (1999) Children with cognitive impairment: parent report of pain and coping. J Dev Behav Pediatr 20(4):228–234CrossRefGoogle Scholar
  43. 43.
    Abu-Saad HH (2000) Challenge of pain in the cognitively impaired. Lancet 356(9245):1867–1868PubMedCrossRefGoogle Scholar
  44. 44.
    Voepel-Lewis T, Malviya S, Tait AR (2005) Validity of parent ratings as proxy measures of pain in children with cognitive impairment. Pain Manag Nurs 6(4):168–174PubMedCrossRefGoogle Scholar
  45. 45.
    Voepel-Lewis T, Merkel S, Tait AR et al (2002) The reliability and validity of the Face, Legs, Activity, Cry, Consolability observational tool as a measure of pain in children with cognitive impairment. Anesth Analg 95(5):1224–1229PubMedCrossRefGoogle Scholar
  46. 46.
    Hamers JP, Abu-Saad HH, den Hout MA van et al (1996) The influence of children’s vocal expressions, age, medical diagnosis and information obtained from parents on nurses‘ pain assessments and decisions regarding interventions. Pain 65(1):53–61PubMedCrossRefGoogle Scholar
  47. 47.
    Voepel-Lewis T, Merkel S, Tait AR (2003) Behavioral pain assessment and the Face, Legs, Acvtivity, Cry and Consolability instrument. Expert Rev Pharmacoecon Outcomes Res 3(3):317–325PubMedCrossRefGoogle Scholar
  48. 48.
    Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S (1997) The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 23(3):293–297PubMedGoogle Scholar
  49. 49.
    Breau LM, McGrath PJ, Camfield C et al (2000) Preliminary validation of an observational pain checklist for persons with cognitive impairments and inability to communicate verbally. Dev Med Child Neurol 42(9):609–616PubMedCrossRefGoogle Scholar
  50. 50.
    Büttner W, Finke W, Hilleke M et al (1998) Entwicklung eines Fremdbeobachtungsbogens zur Beurteilung des postoperativen Schmerzes bei Säuglingen. Anasthesiol Intensivmed Notfallmed Schmerzther 33:353–361PubMedCrossRefGoogle Scholar
  51. 51.
    Hicks CL, Baeyer CL von, Spafford PA et al (2001) The faces pain scale-revised: toward a common metric in pediatric pain measurement. Pain 93(2):173–183PubMedCrossRefGoogle Scholar
  52. 52.
    Zaslansky R, Glasser S, Golobov A et al (2006) A Hebrew version of the FLACC scale: measurement of pain in non-verbal children. Harefuah 145(9):648–651,703,704PubMedGoogle Scholar
  53. 53.
    Celsia GG (1997) Persistent vegetative state: clinical and ethical issues. Theor Med 18(3):221–236CrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • B. Messerer
    • 1
  • J. Meschik
    • 1
  • A. Gutmann
    • 1
  • M. Vittinghoff
    • 1
  • A. Sandner-Kiesling
    • 1
    Email author
  1. 1.Univ. Klinik für Anästhesiologie und IntensivmedizinMedizinische Universität GrazGrazAustria

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