Perioperative Anwendung von Metamizol und anderen Nichtopioidanalgetika bei Kindern

Zusammenfassung

Hintergrund

Nichtsteroidale Antiphlogistika (NSAID, „nonsteroidal anti-inflammatory drugs“), Paracetamol und Metamizol werden täglich zur Akutschmerztherapie bei Kindern eingesetzt. Die Datenlage zum Stellenwert von Metamizol in der klinischen Praxis ist unzureichend.

Ziel der Arbeit

Überblick zur aktuell praktizierten Anwendung von Nichtopioidanalgetika perioperativ bei Kindern sowie zu beobachteten Nebenwirkungen und zur Aufklärung bei der Therapie mit Metamizol.

Methodik

Mitglieder der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin und der Deutschen Schmerzgesellschaft erhielten einen Online-Fragebogen.

Ergebnisse

Von den 2284 antwortenden Umfrageteilnehmern gaben 1476 an, regelmäßig Kinder perioperativ zu versorgen. NSAID wurden von 83,9 %, Metamizol von 68,6 % und Paracetamol von 67,5 % der Teilnehmer eingesetzt. Intraoperativ wurde Metamizol bevorzugt, postoperativ wurden die 3 Nichtopioidanalgetika etwa gleich häufig verwendet. Bei starken Schmerzen kombinierten 49,3 % Metamizol mit einem anderen Nichtopioidanalgetikum, 14,8 % verabreichten es als einziges Nichtopioidanalgetikum. Vollständig auf Metamizol verzichteten 23,2 % der Umfrageteilnehmer. Die meist gewählte Einzeldosis lag bei 8–15 mg/kgKG: über 16 mg/kgKG dosierten 26 %. Zeitlich befristet wurde Metamizol von 20,2 % der Teilnehmer eingesetzt. Fälle einer Agranulozytose wurden von 2 Teilnehmern beschrieben (0,14 %). Blutbildkontrollen zum Monitoring der Metamizoltherapie und eine Aufklärung der Eltern über potenzielle Risiken einer Metamizolmedikation wurden selten durchgeführt.

Diskussion

Die Umfrage bestätigt die häufige perioperative Anwendung von Metamizol bei Kindern. Intraoperativ war Metamizol das bevorzugte Nichtopioidanalgetikum. Das Monitoring der Metamizoltherapie und die Patienteninformation sollten verbessert werden.

Abstract

Background

Nonopioid analgesics are frequently used for perioperative pain management in children. In many countries, the nonopioid metamizole (dipyrone) is administered as an alternative to paracetamol and traditional NSAIDs (nonsteroidal anti-inflammatory drugs), such as ibuprofen and diclofenac; however, concerns over possible life-threatening adverse events (agranulocytosis) have prompted a debate over the use of metamizole.

Objective

To investigate current practice and use of nonopioid analgesics, particularly of metamizole in children younger than 14 years, in the perioperative setting. Furthermore, metamizole-related side effects, safety and approaches used to inform patients were addressed.

Methods

A link to an online questionnaire on the perioperative use of nonopioid analgesics in children, with a specific focus on dipyrone, was sent by e‑mail to members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and to members of the German Pain Society.

Results

A total of 2284 anesthesiologists filled out the questionnaire. Of these, 1476 were involved in the perioperative care of children younger than 14 years. The majority of respondents worked in German hospitals (90.5%) but Austria, Switzerland and the Netherlands were also among the countries represented. Of the respondents, 99.1% reported using nonopioid analgesics in the perioperative setting. The NSAID, metamizole, paracetamol and COX-2 inhibitors were administered by 83.9%, 68.6%, 67.5% and 2% of the respondents, respectively. Intravenous metamizole was the preferred nonopioid analgesic during surgical procedures, but following surgery, NSAID, metamizole and paracetamol were given with the same frequency by anesthesiologists. Of the respondents, 49.3% reported using metamizole in combination with another nonopioid analgesic in cases of severe pain, 14.8% used it as the sole nonopioid analgesic, and 23.2% never used it at all. Nearly half of the respondents administered metamizole i.v. in doses of 15 mg/kg body weight or lower, whereas 26% administered doses of at least 16 mg/kg up to more than 20 mg/kg. Of the physicians, 298 (20.2%) restricted the duration of metamizole use, varying between one single administration (4.7%), administration for 1 day (27.5%), or for 1–2 weeks (29.2%). Of the anesthesiologists, 65.6% reported no metamizole-related adverse effects. Allergic reactions/anaphylaxis and a drop in blood pressure requiring intervention were observed by 3–4% of the respondents. No change in blood cell counts within the last 2 years was reported by 73.1% of the respondents, whereas 17 anesthesiologists (1.3%) had observed children with altered blood cell counts, with 2 (0.14%) reporting agranulocytosis. In most cases these were incidental findings. No severe sequelae or deaths were reported. Few respondents (5.5%) performed routine blood cell counts to monitor metamizole therapy. Furthermore, only a minority always (3.5%) or sometimes (6.1%) informed a child’s parents of possible side effects of treatment with metamizole.

Conclusion

The survey confirmed that metamizole is frequently used in children in the perioperative setting. Intravenous metamizole is the preferred nonopioid analgesic administered intraoperatively for pain prophylaxis. Clinical symptoms of agranulocytosis should be monitored and patients should be better informed about metamizole-related side effects.