B. Messerer

Implementation of a standardized pain management in a pediatric surgery unit.

Postoperative pain is still a major complication causing discomfort and significant suffering, especially for children. Therefore, every effort should be made to prevent pain and treat it effectively once it arises. Under-treatment of pediatric pain is often due to a lack of both knowledge about age-specific aspects of physiology and pharmacology and routine pain assessment. Factors for long term success require regularly assessing pain, as routinely as the other vital signs together with documentation of side effects. The fear of side effects mostly prevents the adequate usage of analgesics. Essential is selecting and establishing a simple concept for clinical routine involving a combination of non-pharmacological treatment strategies, non-opioid drugs, opioids and regional anesthesia.

[Quality improvement of postoperative pain management in infants QUIPSI) - A pilot study].

Outcome-focussed benchmarking has been shown to be a successful tool in adult quality improvement of postoperative pain management in adults. We report on feasibility and first results of a similar project in operated children (quality improvement of postoperative pain management in infants, QUIPSI). Our results show that outcomes in postoperative pain management can be measured and compared in routine clinical practice. QUIPSI (Quality Improvement in Postoperative Pain Management in Infants) represents a new tool for outcome evaluation, consisting of standardized data acquisition of outcome and process quality indicators. In the currently starting second phase of the project, a multicenter evaluation will take place in ten medical centres.

Perioperative systemische Schmerztherapie bei Kindern

BACKGROUND Many analgesics used in adult medicine are not licensed for pediatric use. Licensing limitations do not, however, justify that children are deprived of a sufficient pain therapy particularly in perioperative pain therapy. The treatment is principally oriented to the strength of the pain. Due to the degree of pain caused, intramuscular and subcutaneous injections should be avoided generally. NON-OPIOIDS The basis of systemic pain therapy for children are non-opioids and primarily non-steroidal anti-inflammatory drugs (NSAIDs). They should be used prophylactically. The NSAIDs are clearly more effective than paracetamol for acute posttraumatic and postoperative pain and additionally allow economization of opioids. Severe side effects are rare in children but administration should be carefully considered especially in cases of hepatic and renal dysfunction or coagulation disorders. Paracetamol should only be taken in pregnancy and by children when there are appropriate indications because a possible causal connection with bronchial asthma exists. To ensure a safe dosing the age, body weight, duration of therapy, maximum daily dose and dosing intervals must be taken into account. Dipyrone is used in children for treatment of visceral pain and cholic. According to the current state of knowledge the rare but severe side effect of agranulocytosis does not justify a general rejection for short-term perioperative administration. OPIOIDS In cases of insufficient analgesia with non-opioid analgesics, the complementary use of opioids is also appropriate for children of all age groups. They are the medication of choice for episodes of medium to strong pain and are administered in a titrated form oriented to effectiveness. If severe pain is expected to last for more than 24 h, patient-controlled anesthesia should be implemented but requires a comprehensive surveillance by nursing personnel. KETAMINE Ketamine is used as an adjuvant in postoperative pain therapy and is recommended for use in pediatric sedation and analgosedation.

[Pediatric perioperative systemic pain therapy: Austrian interdisciplinary recommendations on pediatric perioperative pain management].

BACKGROUND Many analgesics used in adult medicine are not licensed for pediatric use. Licensing limitations do not, however, justify that children are deprived of a sufficient pain therapy particularly in perioperative pain therapy. The treatment is principally oriented to the strength of the pain. Due to the degree of pain caused, intramuscular and subcutaneous injections should be avoided generally. NON-OPIOIDS The basis of systemic pain therapy for children are non-opioids and primarily non-steroidal anti-inflammatory drugs (NSAIDs). They should be used prophylactically. The NSAIDs are clearly more effective than paracetamol for acute posttraumatic and postoperative pain and additionally allow economization of opioids. Severe side effects are rare in children but administration should be carefully considered especially in cases of hepatic and renal dysfunction or coagulation disorders. Paracetamol should only be taken in pregnancy and by children when there are appropriate indications because a possible causal connection with bronchial asthma exists. To ensure a safe dosing the age, body weight, duration of therapy, maximum daily dose and dosing intervals must be taken into account. Dipyrone is used in children for treatment of visceral pain and cholic. According to the current state of knowledge the rare but severe side effect of agranulocytosis does not justify a general rejection for short-term perioperative administration. OPIOIDS In cases of insufficient analgesia with non-opioid analgesics, the complementary use of opioids is also appropriate for children of all age groups. They are the medication of choice for episodes of medium to strong pain and are administered in a titrated form oriented to effectiveness. If severe pain is expected to last for more than 24 h, patient-controlled anesthesia should be implemented but requires a comprehensive surveillance by nursing personnel. KETAMINE Ketamine is used as an adjuvant in postoperative pain therapy and is recommended for use in pediatric sedation and analgosedation.

Postoperative paediatric pain prevalence: A retrospective analysis in a university teaching hospital.

BACKGROUND Overall pain prevalence in paediatric patients is well documented, but relatively little attention has been paid to pain prevalence and intensity on specific postoperative days within the first week following an operation. OBJECTIVES To evaluate reported pain prevalence on the day of surgery and each day during the following week and to analyse pain trajectories. DESIGN Retrospective study. SETTING Single centre university hospital. PARTICIPANTS 815 postoperative children and adolescents (age≤18 years) were included (female: 36%, age 9.8±5.8). Children with ear, nose, throat (e.g. tonsillectomy), eye (e.g. strabismus repair) or dental surgery (e.g. dental extraction) were treated at other departments and therefore were not included in this study. METHODS Retrospective analysis of the overall and clinically relevant (pain score ≥4/10) postoperative pain prevalence in children and adolescents during the first week after surgery. Possible influencing factors (age, sex, body mass index, type of anaesthesia, type of surgery and duration of surgery) on pain trajectories are analysed using mixed model techniques. RESULTS Overall, 36% of 815 analysed children and adolescents suffered from pain ≥4 during their entire hospital stay. Compared to the day of surgery, the number of patients with pain ≥4 was slightly higher on day 1 after surgery (21% vs. 25%, respectively). In self-reported pain intensity rating (done for patients age≥4 years) the type of surgery (p<.001) was the only significant variable influencing pain intensity. In observational pain assessment (age<4 years) pain scores increased with patients age (p=.004). In this patient group, pain intensity ratings did not differ between types of surgery (p=.278). CONCLUSION Type of surgery is an important predictor for self-reported pain intensity ratings in children but not for observational pain assessment in younger children. In younger children observational pain assessment ratings increase with age.

The impact of item order and sex on self-report of pain intensity in children.

OBJECTIVE When questionnaires are used for pain assessment, the order effect must be taken into consideration; that is, whether the answer to a pain item is influenced by answers given to previous items. This study aimed to evaluate possible order effects in children and adolescents when answering pain items. Furthermore, the possible influence of sex on order effects was analyzed. METHOD Three pain items (worst, at movement, and at rest) were given in 6 different orders. Two hundred and 46 postoperative hospitalized children and adolescents (age range of 11-18 years, mean of 14.4 years; female: 41%, duration of surgery range of 2-274 min) participated in this study. Each item order was answered by 40-43 children and adolescents. RESULTS While there were no general order effects, we observed a sex-specific order effect. The position of pain at rest (p = .034) and pain on movement (p = .036) items had different influences on worst pain values in female patients compared to male patients. A sex-specific influence on pain at rest values was only caused by the position of pain on movement items (p = .036). CONCLUSION The fact that male and female pediatric patients are differently influenced by the order of pain items has to be considered in planning a questionnaire. As more specific items (pain on movement) are less influenced by the item order effect, they should be preferred.

Schmerztherapeutische Versorgung österreichischer Gesundheitszentren

BACKGROUND Pain clinics provide interdisciplinary therapy to treat chronic pain patients and to increase the return-to-work rate. In recent years and due to increased economic pressure in health care, a change in the management of pain in Austrian health care centers has been observed. For the analysis of the current situation, two surveys addressing all Austrian pain clinics were performed. MATERIALS AND METHODS In total, 133 heads of Austrian Anesthesia Departments were interviewed online and personally. The data from the first interview were confirmed by an additional telephone survey that was performed by one anesthetist per Austrian state (n = 9). RESULTS Currently, 44 Austrian pain clinics are active. During the last 5 years, 9 pain clinics closed. Adding the current active pain clinics together, they represent a total of 17.5 full-time-operated clinics. The most common reasons for closing the pain clinics were lack of personnel (47%), lack of time resources (26%), lack of space resources (11%), and financial difficulties (11%). A reduction of >50% of operating hours during the last 3 years was reported by 9 hospitals. The reasons for not running a pain clinic were lack of personnel (36%), lack of time (25%) and department too small (16%). Estimates between actual and required clinics indicate that 49.5 full-time-operating pain clinics are lacking in Austria, resulting in 74% of the Austrian chronic pain patients not receiving interdisciplinary pain management. CONCLUSION Our survey confirmed the closure of 9 pain clinics during the last 5 years due to lack of personnel and time. Pain clinics appear to provide the simplest economic saving potential. This development is a major concern. Although running a pain clinic seems to be expensive at the first sight, it reduces pain, sick leave, complications, and potential legal issues against health care centers, while simultaneously increasing the hospitals competitiveness. Our results show that 74% of Austrian chronic pain patients do not have access to an interdisciplinary pain clinic. Because of plans to further economize resources, Austria may lose its ability to provide state-of-the-art pain therapy and management.

Regionalanästhesiologische Verfahren im Kindesalter

Regional anesthesia should be used for children whenever possible and is an essential element of a multimodal pain management. The prerequisites for a safe and effective procedure are detailed knowledge of the anatomical, physiological and pharmacological differences in childhood, the use of age-appropriate equipment and rapid recognition and treatment of possible complications. Extensive experience in pediatric as well as regional anesthesia is essential. The rule for selection of the ideal regional anesthesia procedure for each individual patient is: as central as necessary and as peripheral as possible. A risk-benefit assessment must always be carried out. Very specialized techniques, such as thoracic and lumbar epidural anesthesia in childhood must be reserved for specialist pediatric anesthesia centers because experience is necessary which can only be acquired and maintained from a large number of cases. Technically simple procedures, such as caudal anesthesia, penis root block and wound infiltration are, however, also very effective. Even if the evidence is still lacking, ultrasound-guided placement of regional anesthesia is nowadays the method of choice for children. The use will lead to an increased level of acceptance and user-friendliness of the procedure in childhood. This article presents recommendations which demonstrate those points that must be generally observed when carrying out regional anesthesia in children. An overview of the regional anesthesia procedure in children is given.ZusammenfassungEine Regionalanästhesie sollte bei Kindern wann immer möglich zum Einsatz kommen. Sie ist als wesentliches Element eines multimodalen Schmerzmanagements anzusehen. Voraussetzung für die sichere und effektive Anwendung sind die genaue Kenntnis der anatomischen, physiologischen und pharmakologischen Unterschiede im Kindesalter, der Einsatz eines altersgerechten Equipments und das rasche Erkennen und Behandeln möglicher Komplikationen. Essenziell ist eine ausreichende Erfahrung sowohl in der Kinder- als auch in der Regionalanästhesie. Bei der Auswahl des für den jeweiligen Patienten idealen Regionalanästhesieverfahrens gilt der Leitsatz: „So zentral wie nötig, so peripher wie möglich.“ Eine Nutzen-Risiko-Abschätzung hat immer zu erfolgen. Sehr spezielle Techniken wie die thorakale und lumbale Epiduralanästhesie im Kindesalter müssen kinderanästhesiologischen Zentren vorbehalten bleiben, da Erfahrung erforderlich ist, die nur mit einer großen Fallzahl erworben und erhalten werden kann. Sehr wirkungsvoll sind aber bereits technisch einfache Verfahren wie die Kaudalanästhesie, der Peniswurzelblock und die Wundinfiltration. Auch wenn die Evidenz nach wie vor fehlt, stellt die ultraschallgesteuerte Anlage der Regionalanästhesie beim Kind heute die Methode der Wahl dar. Der Einsatz wird zu einer erhöhten Akzeptanz und Anwenderfreundlichkeit der Verfahren im Kindesalter führen. Mit der vorliegenden Handlungsempfehlung soll aufgezeigt werden, was bei der Durchführung einer Regionalanästhesie im Kindesalter allgemein beachtet werden muss. Es wird auch ein Überblick über die Verfahren der Regionalanästhesie bei Kindern gegeben.AbstractRegional anesthesia should be used for children whenever possible and is an essential element of a multimodal pain management. The prerequisites for a safe and effective procedure are detailed knowledge of the anatomical, physiological and pharmacological differences in childhood, the use of age-appropriate equipment and rapid recognition and treatment of possible complications. Extensive experience in pediatric as well as regional anesthesia is essential. The rule for selection of the ideal regional anesthesia procedure for each individual patient is: as central as necessary and as peripheral as possible. A risk-benefit assessment must always be carried out. Very specialized techniques, such as thoracic and lumbar epidural anesthesia in childhood must be reserved for specialist pediatric anesthesia centers because experience is necessary which can only be acquired and maintained from a large number of cases. Technically simple procedures, such as caudal anesthesia, penis root block and wound infiltration are, however, also very effective. Even if the evidence is still lacking, ultrasound-guided placement of regional anesthesia is nowadays the method of choice for children. The use will lead to an increased level of acceptance and user-friendliness of the procedure in childhood. This article presents recommendations which demonstrate those points that must be generally observed when carrying out regional anesthesia in children. An overview of the regional anesthesia procedure in children is given.

Pharmakodynamische und pharmakokinetische Besonderheiten der Schmerztherapie bei Neugeborenen

The false assumption that neonates are less sensitive to pain than adults led to a long delay in the introduction of a reasonable pain therapy for children. Even if the basic principles of the development, transmission and perception of pain in premature infants and neonates are not completely understood, the results of studies have clearly shown that pain can be perceived from 22 weeks of gestation onwards. This knowledge results in the necessity to also administer an adequate pain therapy to premature and newly born infants. However, for the use of pharmaceuticals in neonates and infants the pharmacodynamic and pharmacokinetic characteristics must also be considered. The immaturity of the organs liver and kidneys limits the metabolism and also excretion processes. The different physical proportions also modify the dosing of pharmaceuticals. Children in the first year of life differ substantially from adults in physiology, pharmacodynamics and pharmacokinetics. The care of neonates and infants requires specialist knowledge which is described in this article.

Nichtmedikamentöse Maßnahmen sowie topische Analgetika und orale Zuckerstoffe im Schmerzmanagement

Non-pharmaceutical procedures are increasingly being used in pediatric pain therapy in addition to pharmaceutical procedures and have a supporting function. This article describes the non-pharmaceutical procedures which have an influence on perioperative and posttraumatic pain in children and adolescents. Prerequisites for every adequate pain therapy are affection, imparting a feeling of security, distraction and the creation of a child-oriented environment. Topical analgesics are indicated for application to intact skin for surface anesthesia. For a safe use consideration must be given to the duration of application, the dose and the maximum area of skin treated in an age-dependent manner. For simple but painful procedures in premature infants, neonates and infants, pain can be effectively reduced by the oral administration of glucose. The positive effect is guaranteed particularly for the use in a once only pain stimulation. Non-nutritive sucking, swaddling, facilitated tucking and kangaroo mother care, for example can be used as supportive measures during slightly painful procedures. There is insufficient evidence for a pain reducing effect in older infants and small children. Physical therapeutic procedures can be used as accompanying measures for acute pain and are individually adapted. However, the limited amount of currently available data is insufficient to make a critical scientific assessment of the individual measures. The effects can, however, be observed in the daily routine practice. Psychological methods can facilitate coping with pain. In situations with mental and psychiatric comorbidities or psychosocial impairment, a psychologist should be consulted. Acupuncture and hypnosis are also a meaningful addition within the framework of multimodal pain therapy.