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Intrathekale Opioidmedikation zur perioperativen Analgesie bei schwer behinderten Kindern mit Wirbelsäulenoperationen

Intrathecal opioid medication for perioperative analgesia in severely handicapped children undergoing spinal operations

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Zusammenfassung

Hintergrund

An gesunden Kindern konnte gezeigt werden, dass intrathekal verabreichte Opioide eine sichere und effektive perioperative Analgesie bei wirbelsäulenchirurgischen Eingriffen ermöglichen. Das Ziel der vorliegenden Untersuchung ist es, ihre Anwendbarkeit bei schwer- und schwerstbehinderten Kindern für wirbelsäulenchirurgische Eingriffe zu überprüfen.

Methode

Mit Zustimmung der lokalen Ethikkommission wurden Patienten vom Status 3 und 4 der Klassifikation der American Society of Anesthesiologists (ASA), die sich einem wirbelsäulenchirurgischen Eingriff unterziehen mussten, retrospektiv untersucht. Zusätzlich zur Allgemeinanästhesie mit Sevofluran oder i.v.-verabreichtem Propofol erhielten die Patienten vor der Operation 20 µg/kgKG Morphin und 1,5 µg/kgKG Sufentanil intrathekal. Nach Beendigung des Eingriffs wurde eine Nalbuphindauerinfusion gestartet. Der Bedarf an zusätzlichen intra- und postoperativen Analgetika, der Zeitpunkt der Extubation, die postoperativen Schmerz-Scores und die arteriellen Kohlendioxidpartialdruck- (paCO2)-Werte sowie das Auftreten unerwünschter Nebenwirkungen wurden untersucht.

Ergebnisse

Es wurden 28 Patienten im Alter von 2,8 bis 18,5 Jahren (Median 11,6 Jahre) untersucht. Unmittelbar im OP konnten 17 Patienten extubiert werden; bei 11 Patienten entschied man sich zu einer verzögerten Extubation. Bis auf einen Patienten mit postoperativer Massivtransfusion konnten alle innerhalb von 24 h extubiert werden. Eine adäquate postoperative Analgesie mit Schmerz-Scores ≤3 wurde mithilfe der Kombination von intrathekal verabreichten Opioiden mit Nalbuphin postoperativ bei 26 von 28 Patienten (93%) erreicht. Bei 2 Patienten war der Wechsel auf eine i.v.-Morphin-Gabe erforderlich. Postoperative Übelkeit und Erbrechen („postoperative nausea and vomiting“, PONV), Pruritus und leichte Hypoventilation mit paCO2-Werten zwischen 5,2 bis 9,7 kPa (Median 6,3 kPa) waren die beobachteten Nebenwirkungen.

Schlussfolgerung

Der Einsatz intrathekal verabreichter Opioide, ergänzt durch eine postoperative Nalbuphininfusion, erlaubt in den allermeisten Fällen eine frühzeitige Extubation ohne persistierende Atemdepression und ist eine praktikable sowie effektive Methode zur postoperativen Analgesie bei schwer behinderten Kindern nach wirbelsäulenchirurgischen Eingriffen.

Abstract

Purpose of the study

Intrathecal opioids have been shown to be safe and effective for postoperative analgesia in healthy children for spinal surgery. The aim of this study was to evaluate the applicability of intrathecal opioids in severely handicapped children scheduled for spinal surgery.

Methods

With hospital ethical committee approval, patients with physical states III and IV of the ASA classification requiring spinal surgery were retrospectively studied. In addition to inhalational anesthesia with sevoflurane or intravenous anesthesia using propofol, morphine 20 µg/kgBW and sufentanil 1.5 µg/kgBW were administered intrathecally before surgery. After surgery an infusion of nalbuphine was started. Need for additional intraoperative and postoperative analgesics, time of extubation, postoperative pain scores and paCO2 values as well as adverse effects were recorded.

Results

A total of 28 patients aged from 2.8 to 18.5 years (median 11.6 years) were studied. Immediate tracheal extubation in the operating room was possible in 17 patients and for 11 patients delayed extubation was elected. All patients were extubated within 24 h except for 1 patient who received massive postoperative transfusions. In 26 out of 28 patients (93%) the combination of intrathecal opioids with postoperative nalbuphine provided adequate analgesia. Observed side effects were post-operative nausea and vomiting (PONV), pruritus and moderate hypoventilation. In two patients a change to intravenous morphine therapy was necessary.

Conclusion

The use of intrathecal opioids for perioperative pain control from spinal fusion in severely handicapped children is feasible. Intrathecal opioids provide adequate postoperative analgesia and allow early extubation without persisting relevant respiratory compromise in most of these patients.

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  1. Anästhesieabteilung, Universitäts-Kinderkliniken Zürich, Steinwiesstr. 75, 8032, Zürich, Schweiz

    A. Schmitz, B. Salgo, M. Weiss, C.M. Dillier, A. Frotzler & A.C. Gerber

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  1. A. Schmitz
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  2. B. Salgo
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  3. M. Weiss
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  4. C.M. Dillier
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  5. A. Frotzler
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  6. A.C. Gerber
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Correspondence to A. Schmitz.

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Schmitz, A., Salgo, B., Weiss, M. et al. Intrathekale Opioidmedikation zur perioperativen Analgesie bei schwer behinderten Kindern mit Wirbelsäulenoperationen. Anaesthesist 59, 614–620 (2010). https://doi.org/10.1007/s00101-010-1733-7

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  • DOI: https://doi.org/10.1007/s00101-010-1733-7

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