Zusammenfassung
Hintergrund
Das Hauptaugenmerk der Studie galt dem Schmerzniveau bei postoperativer Schmerztherapie mit einer parenteral verabreichten Kombination aus Paracetamol und Ketoprofen im Vergleich zur parenteralen Gabe der jeweiligen Einzelsubstanzen bei Kindern nach Adenotomien und Tonsillektomien. Des Weiteren wurden die Zeit bis zum Verabreichen der „Rescue“-Analgesie, der Propofolbedarf, das „postoperative vomiting“ (POV) und der Entlassungszeitpunkt aus dem Aufwachraum (AWR) erfasst.
Material und Methoden
Zur elektiven Adenotomie, Adenotonsillektomie oder Tonsillotomie erhielten 120 Kinder (3 bis 13 Jahre) randomisiert entweder Ketoprofen (Gruppe 1), Paracetamol (Gruppe 2) oder die Kombination aus beidem (Gruppe 3) nach Anästhesieeinleitung.
Ergebnisse
Während ihres Aufenthalts im AWR brauchten die Kinder der Kombinationsgruppe signifikant weniger Rescue-Medikation. Die höchsten Schmerz-Scores und die kürzesten Morphinanforderungszeiten wurden nach Paracetamol erfasst. Die allgemeine Erbrechensrate war mit 6,45% sehr niedrig. Der Propofolbedarf und der Zeitraum bis zur Entlassung aus dem AWR unterschieden sich nicht signifikant zwischen den 3 Gruppen.
Schlussfolgerung
In der postoperativen Schmerztherapie bei Kindern ist die i.v.-Kombinationstherapie von Paracetamol und Ketoprofen der i.v.-Gabe von Paracetamol überlegen.
Abstract
Background
The primary aim of this study was to determine whether the combination of i.v. ketoprofen and i.v. paracetamol provides superior postoperative analgesia in children undergoing adenoidectomy or tonsillotomy compared to either drug alone. The secondary goal was to assess the time until rescue analgesia was needed, propofol requirements and the incidence of vomiting and time of discharge from the postanaesthesia recovery unit (PARU).
Methods
This double-blinded study included 120 children (aged 3–13 years) scheduled for elective tonsillectomy, adenoidectomy or adenotonsillectomy. The children were randomly assigned to one of 3 groups of 40 children each, using the sealed envelope method. The children received i.v. ketoprofen 2 mg/kgBW (group 1) or paracetamol 15 mg/kgBW (group 2) or the combination of these 2 drugs (group 3) after induction of anaesthesia. Standardized general anaesthesia consisted of sevoflurane and fentanyl at a dose of 2–3 μg/kgBW. Pain was assessed using a 5-point scoring system based on the Smiley scale. The Smiley scale shows various faces from a laughing face which corresponds to the state of no pain to a very unhappy face which corresponds to the situation of worst pain (1: no pain, 2: mild pain, 3: moderate pain, 4: severe pain, 5: worst pain). Pain was assessed at 30 min, 1 h, 2 h, 3 h and 4 h after arriving in the PACU. If the pain score exceeded 2 an i.v. dose of 0.1 mg/kgBW morphine was administered as rescue analgesia.
Results
During the stay in the PACU the children in the combination group required significantly less supplementary rescue analgesia than children in the ketoprofen and paracetamol groups (17.5% versus 30.8% versus 45%, respectively, χ2 analysis <0.05). Pain scoring was highest after paracetamol, however, this difference was only significant when compared to the group receiving the combination of paracetamol and ketoprofen (U-test p<0.05). Rescue analgesia was administered earliest in group 2 (paracetamol) reaching statistical significance, however, only when compared to group 3 (logrank test p<0.05). Propofol requirements and time to discharge from the PACU did not differ significantly between the 3 groups (χ2 analysis; U-test; p>0.05). The overall incidence of vomiting was very low in this study with 6.4% (9/139). Significantly more children in the paracetamol group compared to ketoprofen group and combination group suffered from vomiting (17.5% versus 2.6% versus 2.5%; χ2 analysis; p<0.05). The time to discharge from PACU did not differ significantly between the 3 groups (U-test: p>0.05).
Conclusion
The combination of i.v. paracetamol and i.v. ketoprofen provides superior postoperative analgesia compared to the single use of paracetamol.
Literatur
American Academy of Otolaryngology Head, Neck Surgery (2006) ENT health information, tonsils and adenoids. http://www.entnet.org/HealthInformation/tonsilsAdenoids.cfm
Kotiniemi LH, Ryhanen PT, Valanne J et al (1997) Postoperative symptoms at home following day-surgery in children: a multicentre survey of 551 children. Anaesthesia 52:963–969
Romsing J, Ostergaard D, Drozdiewicz D et al (2000) Diclofenac or acetaminophen for analgesia in pediatric tonsillectomy outpatients. Acta Anaesthesiol Scand 44:291–295
Hiller A, Meretoja O, Korpela R et al (2006) The analgesic efficacy of acetaminophen, ketoprofen, or their combination for pediatric surgical patients having soft tissue or orthopedic procedures. Anesth Analg 102:1365–1371
Rømsing J, Møiniche S, Dahl JB (2002) Rectal and parenteral paracetamol, and paracetamol in combination with NSAIDs, for postoperative analgesia. Br J Anaesth 88(2):215–226
Ong CK, Seymour RA, Lirk P et al (2010) Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg 110(4):1170–1179
Pothmann R (1988) Klinische Schmerzmessung. In: Pothmann R (Hrsg) Chronische Schmerzen im Kindesalter. Diagnose und Therapie. Hippokrates, Stuttgart, S 31
Pothmann R, Goepel R (1985) Comparison of the visual analog scale (VAS) and a smiley analog scale (SAS) for the evaluation of pain in children. In: Fields HL, Dubner R, Cervero F (Hrsg) Advances in pain research and therapy vol. 9. Raven, New York
Denecke H, Hünseler C (2000) Assessment and measurement of pain. Schmerz 14(5):302–308
Aono J, Ueda W, Mamiya K et al (1997) Greater incidence of delirium during recovery from sevoflurane anesthesia in preschool boys. Anesthesiology 87(6):1298–300
Weldon BC, Bell M, Craddock T (2004) The effect of caudal analgesia on emergency agitation in children after sevoflurene versus halothane anesthesia. Anesth Analg 98(2):321–326
Steward DJ (1975) A simplified scoring system for the post-operative recovery room. Can J Anesth 22:111–113
Viitanen H, Tuominen N, Vääräniemi H et al (2003) Analgesic efficacy of rectal acetaminophen and ibuprofen alone or in combination for paediatric day-case adenoidectomy. Br J Anaesth 91(3):363–367
Riad W, Moussa A (2007) Pre-operative analgesia with rectal diclofenac and/or paracetamol in children undergoing inguinal hernia repair. Anaesthesia 62(12):1241–1245
Anderson BJ (2008) Paracetamol (Acetaminophen): mechanisms of action. Pediatr Anesth:915–921
Koppert W, Wehrfritz A, Körber N et al (2004) The cyclooxygenase isozyme inhibitors parecoxib and paracetamol reduce central hyperalgesia in humans. Pain 108(1–2):148–153
Luthy CL, Collart L, Dayer P (1993) The rate of administration influences the analgesic effects of paracetamol. Clin Pharm Ther 2:171
Montgomery CJ, McCormack JP, Reichert CC et al (1995) Plasma concentrations after high-dose (45 mg/kg) rectal acetaminophen in children. Can J Anaesth 42:982–986
Ameer B, Divoll M, Abernethy DR et al (1983) Absolute and relative bioavailability of oral acetaminophen preparations. J Pharm Sci 72:955–958
Holmer Pettersson P, Jakobsson J, Owall A (2006) Plasma concentrations following repeated rectal or intravenous administration of paracetamol after heart surgery. Acta Anaesthesiol Scand 50:673–677
Kumpulainen E, Kokki H, Halonen T et al (2007) Paracetamol (acetaminophen) penetrates readily into the cerebrospinal fluid of children after intravenous administration. Pediatrics 119(4):766–771
Bolton CM, Myles PS, Nolan T et al (2006) Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: a systematic review and meta-analysis. Br J Anaesth (5):593–604
Kim MS, Coté CJ, Cristoloveanu C et al (2007) There is no dose-escalation response to dexamethasone (0.0625–1.0 mg/kg) in pediatric tonsillectomy or adenotonsillectomy patients for preventing vomiting, reducing pain, shortening time to first liquid intake, or the incidence of voice change. Anesth Analg 104(5):1052–1058
Tong J (2006) Risk factors for postoperative nausea and vomiting. Anesth Analg 102:1884–1898
Pickering G, Loriot MA, Libert F et al (2006) Analgesic effect of acetaminophen in humans: first evidence of a central serotonergic mechanism. Clin Pharmacol Ther 79(4):371–378
Beringer RM, Thompson JP, Parry S et al (2011) Intravenous paracetamol overdose: two case reports and a change to national treatment guidelines. Arch Dis Child 96:307–308
Beasley R, Clayton T, Crane J et al (2008) Association between paracetamol use in infancy and childhood, and risk of asthma, rhinoconjunctivitis, and eczema in children aged 6–7 years: analysis from phase three of the ISAAC programme Lancet 372(9643):1039–1048
Giest J, StraußJ, Jöhr M et al (2009) Paracetamol für die perioperative Schmerztherapie im Kindesalter – Ende einer Ära? Stellungnahme des Wissenschaftlichen Arbeitskreises Kinderanästhesie der DGAI Anaesth Intensivmed 50:57–59
Cardwell M, Siviter G (2010) Non-steroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Anaesthesia Group. Cochrane Database Syst Rev:11
Anderson BJ, Ralph CJ, Stewart AW et al (2000) The dose – effect relationship for morphine and vomiting after day-stay tonsillectomy in children. Anaesth Intensive Care 28:155–160
Mather SJ, Peutrell JM (1995) Postoperative morphine requirements, nausea and vomiting following anaesthesia for tonsillectomy. Comparison of intravenous morphine and non-opioid analgesic techniques. Paediatr Anaesth 5:185–188
Watters CH, Patterson CC, Mathews HM et al (1988) Diclofenac sodium for post-tonsillectomy pain in children. Anaesthesia 43:641–643
Bone ME, Fell D (1988) A comparison of rectal diclofenac with intramuscular papaveretum or placebo for pain relief following tonsillectomy. Anaesthesia 43:277–280
Howard R, Carter B, Curry J et al; Association of Paediatric Anaesthetists of Great Britain and Ireland (2008) Good practice in postoperative and procedural pain management. Background. Paediatr Anaesth 18(Suppl 1):1–3
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Platzer, M., Likar, R., Stettner, H. et al. Tonsillotomien und Adenotomien im Kindesalter. Anaesthesist 60, 625–632 (2011). https://doi.org/10.1007/s00101-011-1855-6
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DOI: https://doi.org/10.1007/s00101-011-1855-6