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Der Schmerz

, Volume 28, Issue 1, pp 43–64 | Cite as

Perioperative systemische Schmerztherapie bei Kindern

Österreichische interdisziplinäre Handlungsempfehlungen zum perioperativen Schmerzmanagement bei Kindern
  • B. MessererEmail author
  • G. Grögl
  • W. Stromer
  • W. Jaksch
Schwerpunkt

Zusammenfassung

Allgemeines

Viele Analgetika aus der Erwachsenenmedizin sind für Kinder nicht zugelassen. Zulassungseinschränkungen rechtfertigen speziell in der perioperativen Schmerztherapie dennoch nicht, dass Kindern eine suffiziente Schmerztherapie vorenthalten wird. Die Behandlung orientiert sich grundsätzlich an der Stärke der Schmerzen. Auf i.m.- und s.c.-Injektionen ist aufgrund der Schmerzhaftigkeit generell zu verzichten.

Nichtopioide

Basis der systemischen Schmerztherapie bei Kindern sind Nichtopioide, zuvorderst nichtsteroidale Antirheumatika (NSAR). Sie sollten prophylaktisch angewendet werden. NSAR sind bei akuten posttraumatischen und postoperativen Schmerzen deutlich wirksamer als Paracetamol. Zudem ermöglichen sie eine Einsparung von Opioiden. Schwere Nebenwirkungen sind bei Kindern selten, der Einsatz sollte aber u. a. bei einer Leber- und Nierendysfunktion oder Gerinnungsstörung wohlüberlegt sein. Paracetamol sollte in der Schwangerschaft und bei Kindern nur bei entsprechender Indikation eingesetzt werden, da möglicherweise ein kausaler Zusammenhang mit dem Auftreten von Asthma bronchiale besteht. Für eine sichere Dosierung müssen Alter, Körpergewicht, Dauer der Therapie, Tageshöchstdosis und Dosierungsintervalle berücksichtigt werden. Metamizol wird bei Kindern zur Behandlung von viszeralen Schmerzen und von Koliken eingesetzt. Die Agranulozytose als seltene, aber schwerwiegende Nebenwirkung rechtfertigt nach aktuellem Wissensstand keine generelle Ablehnung des kurzfristigen, perioperativen Einsatzes.

Opioide

Bei unzureichender Analgesie durch Nichtopioidanalgetika werden auch bei Kindern in allen Altersgruppen ergänzend Opioide eingesetzt. Sie sind die Medikamente der Wahl bei mittleren bis starken Schmerzen. In Orientierung an der Wirkung werden sie titrierend appliziert. Ist mit starken Schmerzen über mehr als 24 h zu rechnen, sollte die patientenkontrollierte Analgesie Anwendung finden. Diese erfordert eine umfassende Überwachung durch das Pflegepersonal.

S-(+)-Ketamin

S-(+)-Ketamin ist in der postoperativen Schmerztherapie als Adjuvans anzusehen. Es wird für den Einsatz bei pädiatrischen Sedierungen bzw. Analgosedierungen empfohlen.

Schlüsselwörter

Off-label-Anwendung Paracetamol Metamizol Antirheumatika, nichtsteroidale Opioidanalgetika 

Pediatric perioperative systemic pain therapy

Austrian interdisciplinary recommendations on pediatric perioperative pain management

Abstract

Background

Many analgesics used in adult medicine are not licensed for pediatric use. Licensing limitations do not, however, justify that children are deprived of a sufficient pain therapy particularly in perioperative pain therapy. The treatment is principally oriented to the strength of the pain. Due to the degree of pain caused, intramuscular and subcutaneous injections should be avoided generally.

Non-opioids

The basis of systemic pain therapy for children are non-opioids and primarily non-steroidal anti-inflammatory drugs (NSAIDs). They should be used prophylactically. The NSAIDs are clearly more effective than paracetamol for acute posttraumatic and postoperative pain and additionally allow economization of opioids. Severe side effects are rare in children but administration should be carefully considered especially in cases of hepatic and renal dysfunction or coagulation disorders. Paracetamol should only be taken in pregnancy and by children when there are appropriate indications because a possible causal connection with bronchial asthma exists. To ensure a safe dosing the age, body weight, duration of therapy, maximum daily dose and dosing intervals must be taken into account. Dipyrone is used in children for treatment of visceral pain and cholic. According to the current state of knowledge the rare but severe side effect of agranulocytosis does not justify a general rejection for short-term perioperative administration.

Opioids

In cases of insufficient analgesia with non-opioid analgesics, the complementary use of opioids is also appropriate for children of all age groups. They are the medication of choice for episodes of medium to strong pain and are administered in a titrated form oriented to effectiveness. If severe pain is expected to last for more than 24 h, patient-controlled anesthesia should be implemented but requires a comprehensive surveillance by nursing personnel.

Ketamine

Ketamine is used as an adjuvant in postoperative pain therapy and is recommended for use in pediatric sedation and analgosedation.

Keywords

Off label use Acetaminophen Dipyrone Anti-inflammatory agents, non-steroidal Analgesics, opioid 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt. B. Messerer gibt an, dass kein Interessenkonflikt besteht. G. Grögl hielt in der Vergangenheit bezahlte Vorträge für die Fa. Fresenius-Kabi und Bene und übte eine Beratertätigkeit für die Fa. Grünenthal und MSD aus. W. Stromer: Vorträge für TEVA, Fresenius Kabi, ratiopharm; Beratertätigkeit für Grünenthal und Astellas. W. Jaksch hielt in der Vergangenheit bezahlte Vorträge für die Fa. Grünenthal, MSD, CSC, Pfizer und Rüsch-Teleflex und übte eine Beratertätigkeit für die Fa. Grünenthal aus. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  1. 1.Universitätsklinik für Anästhesiologie und IntensivmedizinMedizinische Universität Graz, LKH-Universitätsklinikum GrazGrazÖsterreich
  2. 2.Abteilung für Anästhesiologie und IntensivmedizinRudolfstiftung WienWienÖsterreich
  3. 3.Abteilung für Anästhesiologie und allgemeine IntensivmedizinLandesklinikum Waldviertel HornHornÖsterreich
  4. 4.Abteilung für Anästhesie, Intensiv- und SchmerzmedizinWilhelminenspital der Stadt WienWienÖsterreich

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