Grundlagen der Tumorschmerztherapie bei Kindern und Jugendlichen
To be successful, any pain therapy must be preceded by a precise pain history and a physical examination, and account must be taken of psychic influences that might be factors in the experience of pain. It is crucial for a positive result of medicamentous pain therapy that the patient and parents receive detailed explanation of the procedures to be applied and of the necessity for preventive treatment, preferably using sustained release preparations given by mouth according to a predetermined time-schedule. The intensity and nature of the pain felt and the effects and side-effects of the therapy must be regularly recorded.
The guideline for medicamentous therapy for tumour pain is the WHO’s graduated schedule, which is also the basis of the design for pain therapy from the Working Group on Pain within the Society for Paediatric Oncology (Konzept zur Schmerztherapie der Arbeitsgruppe Schmerz der Gesellschaft für Pädiatrische Onkologie). The WHO schedule begins with the non-narcotic analgesics that inhibit prostaglandin synthesis for level 1. Preparations of this type often have a very good effect, especially in the case of nociceptor pain (e.g. those arising from bone metastases). Profens (e.g. ibuprofen) and arylacetic acid (e.g. diclofenac) are generally better tolerated than acetylsalicylic acid. Dipyrone is also suitable for use in children from the third month of life onward. It is important to apply a sufficiently high dosage, although when paracetamol is given this should not exceed 90 mg/kg body weight per day, as otherwise there is a danger of toxic liver damage. (The appropriate antidote is acetylcysteine.) If these analgesics do not afford adequate pain relief it is necessary to proceed to stage 2, in which they are combined with weak opioids (e.g. dihydrocodeine or codeine). In stage 3, strong opioids are used instead of weak ones. Preparations suitable for combination with opioids in children are dipyrone (5–15 mg per kg body weight) and paracetamol (10–15 mg per kg body weight), either of which can be given every 4–6 h.
The most important tenet is that the analgesics must be given not “as needed”, but according to a precisely worked out time-schedule designed so that each dose is administered in anticipation of the imminent onset of pain, before the pain is in fact perceived. The preparations of choice are sustained release preparations of drugs that can be given by mouth. If oral administration is no longer possible, portable infusion pumps can be used for continuous administration of opioids by the subcutaneous or the intravenous route.
In some pain syndromes or in the presence of other symptoms associated with the basic tumour illness, it may be that other drugs are also indicated (e.g. neuroleptics, sedatives and hypnotics, tricyclic antidepressants, anticonvulsive agents, spasmolytics); these should be given as adjuvant agents and not on any account as a substitute for opioids.
Various requirements and demands must be fulfilled if tumour pain in children is to be successfully treated: interdisciplinary planning of the therapy, prompt administration and adequate dosage of opioids, preventive therapy for side-effects, consistent documentation of effects and side-effects, and detailed discussion with parents and children.
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