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Postoperative Qualitätsanalyse bei Kindern

Schmerz sowie postoperative Übelkeit und Erbrechen

Pediatric postoperative quality analysis

Pain and postoperative nausea and vomiting

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Zusammenfassung

Hintergrund

Zur Evaluation des postoperativen Behandlungskonzepts beteiligt sich das Kinderspital Luzern am Projekt für Qualitätsanalyse in PONV („postoperative nausea and vomiting“, postoperative Übelkeit und Erbrechen) und Schmerzen bei Kindern (QUIPSi; i: „infants“). Erste Resultate und eine Möglichkeit der postoperativen Qualitätsanalyse bei Kindern werden dargestellt. Dabei waren zentrale Fragen entscheidend: Ist das hausinterne postoperative Behandlungskonzept adäquat genug, und ist QUIPSi ein hilfreiches postoperatives Qualitätsevaluationsprojekt?

Material und Methoden

Innerhalb von 1,5 Jahren wurden 460 Kinder im Alter von 4 bis 17 Jahren bezüglich Schmerzen, Wunsch nach mehr Schmerzmitteln, Schmerzmitteldosis und PONV am 1. postoperativen Tag mithilfe eines standardisierten Fragebogens erfasst.

Ergebnisse

Die teilnehmenden Kinder ließen sich in 5 ambulante Operationsgruppen (Hernie, Knochen, Metallentfernung, Penis, Weichteil) und 9 stationäre (Appendektomie, Knochen, Metallentfernung, Orchidopexie, Kombinationsoperation: Orchidopexie und Hernienoperation oder Zirkumzision, Otoplastik, Tonsillektomie, Trichterbrustoperation, Weichteil) einteilen. Folgende Operationsgruppen gaben insuffizient behandelte Maximalschmerzen (Skala nach Hicks 0–10) und/oder den Wunsch nach mehr Schmerzmitteln an: ambulant versorgte Kinder: Zirkumzision 5,1/19 %, stationär versorgte Kinder: Appendektomie 6,5/43 %, Tonsillektomie 6,4/32 %, Trichterbrustoperation 7,7/33 %, Orchidopexie 4,2/19,4 % und Otoplastik 3,1/22,2 %. Die Ursachen hierfür waren ungenügende postoperative Schmerzmittelverabreichung trotz der maximal verordneten Tagesdosis sowie wahrscheinlich verspätete Verabreichung der Schmerzmittel. Die Inzidenz des PONV fiel bei stationär behandelten Kindern (Übelkeit 14–50 %/Erbrechen 0–37 %) höher aus als bei ambulant versorgten Kindern (Übelkeit 0–29 %/Erbrechen 3–17 %).

Schlussfolgerung

Besonders die Kinder mit dem Wunsch nach mehr Schmerzmitteln sowie einer hohen PONV-Inzidenz der stationären Operationsgruppe bedürfen einer qualitativen Verbesserung des postoperativen Behandlungskonzepts. Durch QUIPSi werden unerkannte Schwächen im postoperativen Behandlungskonzept aufgedeckt; es trägt zu deren Vermeidung bei und ist ein bereicherndes Werkzeug in der Führung eines Klinikbetriebs.

Abstract

Background

For the evaluation of postoperative pain therapy, nausea and vomiting (PONV), the Children’s Hospital in Lucerne acts as a member of the postoperative quality improvement project QUIPSi for children. Initial results and the potential for evaluation of the postoperative pain therapy and PONV are presented here. The central questions are whether the postoperative therapy concept is sufficient and if QUIPSi serves as an ideal tool for postoperative quality improvement?

Methods

Over a period of 1.5 years a total of 460 children aged between 4 to 17 years evaluated their postoperative pain, requirements for more analgesic medicine and the incidence of PONV according to a standardized questionnaire on the first postoperative day. The administration of analgesic medicine was recorded until finishing the questionnaire.

Results

In this study 5 pediatric outpatient operation groups (hernia repair n = 36, bone surgery n = 23, metal removal surgery n = 31, circumcision n = 65 and soft tissue surgery n = 49) and 9 pediatric inpatient operation groups (appendectomy n = 21, bone surgery n = 78, metal removal surgery n = 24, orchidopexy n = 31, combined operation (orchidopexy + hernia repair or circumcision) n = 14, otoplasty n = 9, tonsillectomy n = 41 and pectus excavatum surgery n = 6 and soft tissue surgery n=28) could be classified. All operation groups except the inpatient and outpatient soft tissue surgery groups received regional or infiltration anesthesia. Analgesic medicine was prescribed with the maximum permitted daily dose per kg body weight (paracetamol 100 mg/kgBW, metamizole 80 mg/kgBW, diclofenac 3 mg/kgBW and ibuprofen 40 mg/kgBW; in reserve tramadol 8 mg/kgBW and nalbuphine 2.4 mg/kgBW). The following operation groups complained of persistent pain (scale according to Hicks 0–10) and/or required more pain medicine (%): pediatric outpatients circumcision 5.1/19 %, pediatric inpatients appendectomy 6.5/43 %, tonsillectomy 6.4/32 %, pectus excavatum surgery 7.7/33 %, orchidopexy 4.2/19.4 %, otoplasty 3.1/22.2 %. The reason for the elevated postoperative pain was mainly insufficient administered pain medicine despite the prescription of the maximum daily dose per kg body weight or maybe due to a late administration. Circumcision/appendectomy/tonsillectomy/pectus excavatum surgery/orchidopexy/otoplasty (% of max. daily dose): paracetamol 5/58/99/36/57/37 %, metamizole 0,4/18/8/54/4/4 %, diclofenac 44/45/3/97/51/68 % or ibuprofen 42/1/0/0/0/0 %, tramadol 0,4/0/0/0/0/0 %, nalbuphine 0,4/1/16/0/2/0 %). As the standard inhalative general anesthesia and PONV prophylaxis with tropisetron (body weight: < 20 kg 1 mg, > 20 kg: 2 mg intravenous bolus) was performed. Dexamethasone (0.15–0.5 mg/kgBW, maximum allowed dose 8 mg intravenous bolus) was administered as a back-up drug for PONV. The nausea incidence was higher in the inpatient group (14–50 %) than in the outpatient group (10–29 %). The incidence of vomiting was higher in the inpatient (0–37 %) than in the outpatient group (3–17 %).

Conclusions

The quality analysis showed that especially children with the requirement for more pain medicine and a high PONV incidence (inpatient group) need further improvement in postoperative care. Because of small numbers in some operation groups this qualitative evaluation of the postoperative pain and PONV management only gives an approximate overview. The results of QUIPSi uncovered gaps in the postoperative pain management which will help improve the quality in the postoperative setting. The QUIPSi approach should be integrated as a daily tool into all pediatric surgical departments.

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Abbreviations

AA:

Allgemeinanästhesie

AE:

Appendektomie

CB:

Kaudalblock

EB:

Extremitätenblock (z. B. Plexus axillaris, Femoralis-, Ischiadikus-, Poplitealblock)

EDA:

thorakale Epiduralanästhesie, postoperativ als patientenkontrollierte Epiduralanästhesie (PCEA)

HE:

Hernienoperation

IB:

Ilioinguinalisblock

KN:

Knochenoperation

Komb:

Kombinationsoperation: Orchidopexie + Hernien- oder Penisoperation

LA:

Lokalanästhesie

ME:

Metallentfernung

OE:

obere Extremität

OPE:

Orchidopexie

OPL:

Otoplastik

PB:

Penisblock

PCA:

patientenkontrollierte Analgesie

PE:

Operation am Penis oder Zirkumzision

PONV:

„postoperative nausea and vomiting“ (postoperative Übelkeit und Erbrechen)

QUIPSi:

Qualitätsanalyse in PONV und Schmerzen bei Kindern (QUIPSi; i: „infants“)

RA:

Regionalanästhesie

RB:

Rektusscheidenblock

TAP:

„Transversus-abdominis-plane“-Block

TB:

Trichterbrustoperation nach Nuss

TE:

Tonsillektomie

UE:

untere Extremität

WT:

Weichteiloperation

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Danksagung

Die Autoren danken Frau Dr. Alexandra Bauch (Kinderkardiologin, Erlangen) für die Durchsicht der englischen Zusammenfassung.

Einhaltung der ethischen Richtlinien

Interessenkonflikt. I. Balga, C. Konrad und W. Meissner geben an, dass kein Interessenkonflikt besteht. Das vorliegende Manuskript enthält keine Studien an Menschen oder Tieren.

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Balga, I., Konrad, C. & Meissner, W. Postoperative Qualitätsanalyse bei Kindern. Anaesthesist 62, 707–719 (2013). https://doi.org/10.1007/s00101-013-2211-9

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