Postoperative analgesia in children - current practice in Germany

Current practice of acute pain management in children-a national follow-up survey in Germany

OBJECTIVES

This study aimed to summarize the current standard practices for acute pain management in children in Germany and the implementation of these procedures. The last survey on acute pain management in children was performed in 1999, highlighting the need for an up to date review.

METHODS

A questionnaire was mailed to German departments of anesthesiology (n = 885), asking for structures and processes of acute pain management in children. Results were compared between hospitals with and without an acute pain service and with and without a pediatric department.

RESULTS

Of the 407 responding hospitals (response rate of 46%), 342 treated children younger than 14 years. These were considered for analysis. Of the 342 hospitals, 42% contained either a general pediatric department or a department of pediatric surgery, and the majority of the responding hospitals had an acute pain service (83%). Pain intensities were measured at least once per shift in 40% of the institutions, and at least once or twice a day in 27%. Of the institutions, 31% did not document pain scores regularly, without any difference between hospitals with or without a pediatric department. Standard operating procedures for acute pain management existed in 68% of the hospitals, with large differences in content and length. Opioids were administered to children in 85% of the hospitals. Nonopioid analgesics were the first choice baseline analgesics in most hospitals. Peripheral regional and epidural analgesia were performed in children in 18% and 8% of the hospitals, respectively (21%/16% with a paediatric department, 16%/1% without; P < 0.001).

CONCLUSION

Current practice of pediatric pain management varied widely and the recommendations of guidelines, like regular pain management, were frequently not met. However, improvements could be observed since 1999, for example, an increase in regular pain measurements (4% vs 67%). Furthermore, pain management in hospitals running a pediatric department had a higher degree of organization, and more sophisticated analgesic techniques.

Developing a pediatric pain service

Pediatric pain services were first established in larger pediatric centers over two decades ago. Children's acute pain was poorly managed at the time owing to misconceptions, safety concerns, and variability in practice. While many larger pediatric centers now have acute pain services, there remains a need for better pain management in facilities and geographic locations with fewer resources. Institutional acknowledgement and desire to change, appropriate staffing, and funding are major obstacles. Better recognition and assessment as well safer and more efficacious treatment of pain are the principal objectives when establishing a pain service. It is important to determine whether the proposed service intends to treat acute, chronic, procedural, and/or cancer and palliative pain as each requires different skills and resources. An ideal and comprehensive pediatric pain service should be equipped to diagnose and treat acute, persistent (chronic), procedural, and cancer/palliative pain. It is not feasible or necessary for every hospital to manage all. Establishing the scope of practice (based on case mix and caseload) in any given hospital will determine which resources are desired. Country-specific standards, local staffing, and fiscal constraints will influence which resources are available.

Efficacy and adverse effects of ketamine as an additive for paediatric caudal anaesthesia: a quantitative systematic review of randomized controlled trials

BACKGROUND

The aim of this quantitative systematic review was to assess the efficacy and adverse effects of ketamine added to caudal local anaesthetics in comparison with local anaesthetics alone in children undergoing urological, lower abdominal, or lower limb surgery.

METHODS

The systematic search, data extraction, critical appraisal, and pooled data analysis were performed according to the PRISMA statement. All randomized controlled trials (RCTs) were included in this meta-analysis and relative risk (RR), mean difference (MD), and the corresponding 95% confidence intervals (CIs) were calculated using the Revman(®) statistical software for dichotomous and continuous outcomes.

RESULTS

Thirteen RCTs (published between 1991 and 2008) including 584 patients met the inclusion criteria. There was a significant longer time to first analgesic requirements in patients receiving ketamine in addition to a local anaesthetic compared with a local anaesthetic alone (MD: 5.60 h; 95% CI: 5.45-5.76; P<0.00001). There was a lower RR for the need of rescue analgesia in children receiving a caudal regional anaesthesia with ketamine in addition to local anaesthetics (RR: 0.71; 95% CI: 0.44-1.15; P=0.16).

CONCLUSIONS

Caudally administered ketamine, in addition to a local anaesthetic, provides prolonged postoperative analgesia with few adverse effects compared with local anaesthetics alone. There is a clear benefit of caudal ketamine, but the uncertainties about neurotoxicity relating to the dose of ketamine, single vs repeated doses and the child's age, still need to be clarified for use in clinical practice.

[Therapy of perioperative pain in pediatric urology]

Difficulties in estimating the kind and intensity of pain as well as uncertainty in drug selection and dosing are often responsible for a suboptimal treatment of pain therapy in the various age groups in childhood. The following article will help to minimize these deficits by contributing full details of safe and effective concepts for perioperative pain therapy in childhood.

Mikrovaskuläre Knochentransplantation im Kindesalter

Apart from the perioperative care in children undergoing microvascular bone transplantation, postoperative pain therapy plays an important role in avoiding the development of chronic pain. Additionally perfusion of the transplant can possibly be improved by sympathicolysis provided by a continuous peripheral nerve block. We report the case of a 7-year-old boy with neurofibromatosis type I who underwent an autologous fibula transplantation due to an aplastic left radius. The perioperative pain management was performed via a preoperatively placed axillary plexus catheter combined with a proximal sciatic nerve catheter. Via both catheters a continuous postoperative infusion of 0.1% ropivacaine (3 ml/h) was performed. Within the first 5 postoperative days complete pain relief at rest could be achieved.

Schmerztherapie bei ambulanten Operationen im Kindesalter

A number of surgical procedures for pediatric patients can be suitably performed in an outpatient setting. The advantages are impressive: reduced costs, lower rate of infection, avoidance of hospitalization with the inherent psychological stress, and timely return of the patients to their familiar home environment. An essential feature of the quality of outpatient surgery is the efficacy of the perioperative pain therapy for which a multimodal approach has proven to be very effective: workflow tailored to children's needs, ambiance appropriate for children, and pharmacological analgesia. In the preliminary counseling session it is imperative that parents and children receive detailed information on procedures (role playing, modeling). Associated unpleasant factors prior to induction of anesthesia should be avoided. The primary element of pharmacological analgesia is regional anesthesia; additional options are paracetamol, nonsteroidal antirheumatic agents (be aware of the highest dosages!), and opioids. When opioids are employed, care should be taken that monitoring standards in the recovery room are not lowered and include pulsoxymetry. Because of the clearly elevated rate of postoperative nausea and vomiting related to perioperative administration of opioids, the lower dosage level should be chosen. This article presents concepts of perioperative analgesia.