Grundriß der Schmerztherapie in der Kinderchirurgie

Summary

Surgical operations are painful and the surgeon can and must be involved in all aspects of pain management. Minimizing pain also reduces the physiologic stress in the patient, improves wound healing, end ensures a more rapid return to normal organ system homeostasis. Physical pain and the body’s response to it begin on the operating table, but the surgeon can prevent or minimize the sources of pain with good surgical technique. Optimal patient positioning taking into account the individual characteristics of the patient and the planned operation should be utilised.

Whenever they can be performed expertly, minimally invasive procedures should be considered. If open operative procedures are necessary, all incisions, exposures and wound closure should be planned to minimize pain and damage to normal surrounding tissue and structures. Even though “asleep” the neonate receives pain from the operative site that augments the stress response if the anesthetic used does not provide sufficient analgesia. An adequate intraoperative relief of pain under anesthesia prevents a high level of this stress response.

Most patients staying in hospital following an operation will require narcotics for pain control. Instead of intramuscular injections, which have been the standard regime for years, we now use closely monitored intravenous narcotic administration. Morphine sulfate is used most frequently and has worked well. Intermittent intravenous morphine sulfate is the most practical method of narcotic administration for patients not expected to require regular high dose narcotics for more than 1–2 days. Close monitoring accompanied by Naloxone at the bedside has been recommended for safety reasons. Continuous infusion of morphine sulfate or fentanyl gives excellent and consistent pain control for the patients with high and prolonged narcotic requirements. For practicality and safety concerns, this method is used in an intensive care setting. Patient-controlled analgesia (PCA) offers a gratifying new option for older children. Typically the PCA pump infuses morphine at a low preset dose with a lock-out time interval (minimum time between two doses) and a limitation of total dosage over a specific time. In our hospital, patients are offered a PCA pump routinely if they understand its use and are aged 10 years or older. Children between 8 and 10 years may use PCA pumps only after individual assessment and patients less than 8 years in more exceptional circumstances.

Continuous epidural narcotic administration can revolutionalize the postoperative care of children undergoing major thoracic or upper abdominal operations. Patients are awake and alert the same day of operation, cooperating fully with instructions to breathe deeply and cough. Epidural narcotics also represent a major improvement over epidural anesthetics such as bupivacaine, the incidence of complications being far less than that with anesthetics. The catheter generally remains in place for 2–3 days after the operation or is removed earlier if fever or complications result. The maximal rate of continuous narcotic fentanyl infusion generally recommended is 1 µg/kg/h.

These patients are always monitored closely, vital signs are taken frequently, including neurostatus assessment at least every 4 h. Pulse oximeters and apnea monitors are generally recommended for the patients. To avoid using potent narcotics (which would require hospitalization) in outpatients, regional blockade has been used increasingly for perioperative pain control, with very good results.