Postoperative On-Demand Analgesie mit Pentazocin (Fortral)

Zusammenfassung Das Verfahren der On-Demand Analgesie (intravenöse Selbstapplikation von Analgetica) wurde im Rahmen der postoperativen Schmerztherapie bei 40 ASA I-III Patienten nach elektiven Eingriffen erprobt. Bei Bedarf konnten über einen Handdruckknopf Einzelboli von Pentazocin (8 mg) bis zu einer Stundenmaximaldosis von 60 mg angefordert werden, die von einer Mikroprozessor-kontrollierten Infusionspumpe (On-Demand Analgesia Computer, ODAC) geliefert wurden. Zwischen zwei gültigen Anfragen lag eine Geräte-Refraktärzeit von jeweils einer Minute. Zur Vermeidung von Katheterverstopfungen wurden kleine Pentazocinmengen (1 mg/h) unabhängig vom jeweiligen Bedarf kontinuierlich infundiert. Die Behandlungsdauer betrug 20,3 ± 5,9 h (Mittelwert, St. Abw.); bei einer mittleren Anforderungshäufigkeit von 20,0 ± 12,7 Demands pro Patient ergab sich ein Pentazocinverbrauch von 135,6 ± 81,4 g/kg/h. Die Selbstapplikation war durch ausgeprägte inter- und intraindividuelle Variationen gekennzeichnet. Patienten nach abdominalchirurgischen Eingriffen unterschieden sich weder im Pentazocinkonsum noch in der erreichten Schmerzlinderung signifikant von solchen nach orthopädischen Operationen. Zwischen den Geschlechtern ergaben sich ebenfalls keine statistisch signifikanten Unterschiede. Ein eindeutiger Einfluß der Narkosetechnik (Neuroleptanalgesie, Halothan- oder lumbale Spinalanaesthesie) auf die Analgeticaanforderungen ließ sich nicht feststellen. Wirksamkeit und Patientenakzeptanz erschienen ausgezeichnet: 68% der Kranken beurteilten die Effektivität der On-Demand-Analgesie als besser als die einer früher erlebten konventionellen Schmerztherapie. Ins Gewicht fallende Nebenwirkungen wurden nicht beobachtet; am häufigsten waren Übelkeit, Erbrechen oder Schwitzen zu verzeichnen.

---

Patient-controlled analgesia with pentazocine for the treatment of postoperative pain

Summary Patient-controlled analgesia (PCA, intravenous self-application of narcotics) was studied during the early postoperative period. Subjects were 40 ASA I-III patients recovering from elective major and minor surgery (each 20 having undergone abdominal or orthopaedic operations). Pentazocine bolusses of each 8 mg were available via a hand-button whenever the patients felt pain relief necessary, and delivered by a microprocessor-controlled injection pump (On-Demand Analgesia Computer, ODAC). Hourly maximum dose was set to 60 mg with a pump refractory time of 1 min between valid demands. A continuous low-dose pentazocine infusion (1 mg/h) was additionally administered in order to prevent catheter obstruction. Duration of the PCA period was 20.3 ± 5.9 h (mean, standard deviation). During this time, 20.0 ± 12.7 demands per patient were recorded resulting in mean pentazocine consumption of 135.6±81.4 g/kg/h. Self-administration was characterized by considerable intra- and interindividual variability. There were no statistically significant differences with regard of pentazocine consumption or pain relief between abdominal and orthopaedic patients, nor could any be demonstrated between the sexes. Similarly, no clear differences were found after various anaesthetic techniques (neuroleptanalgesia, halothane or spinal anaesthesia). Over-all efficacy and patient acceptance proved to be excellent. Effectiveness of PCA was judged superior by about 68% of patients when compared with previously experienced conventional postoperative analgesia. Side effects (nausea, emesis, sweating) occurred in about 10–18 % but were usually of minor intensity. Circulatory or respiratory problems were not observed during the PCA period. Patient-controlled analgesia is discussed as a promising concept for the treatment of acute pain and clinical pain research.

     

52. Postoperative Analgesie mit der kontinuierlichen Eniduralanalgesie und mit Dolantin

Zusammenfassung Bei 16 Patienten wurde die Häufigkeit von akuten Blutdruckkrisen nach Unterbrechung der kontinuierlichen Epiduralanalgesie und dem Auftreten von Schmerzen untersucht. Jeder 3. Patient reagierte mit einer schmerzbedingten Drucksteigerung in der A. radialis (+ 30%) und in der A. pulmonalis (+ 40%). Sie konnten durch Analgeticagabe allein nicht beherrscht werden. Die Verabreichung von Antihypertensiva (Alphablocker) oder die Wiederherstellung der Epiduralanalgesie wird dann notwendig.     

Postoperative Schmerztherapie nach radikaler Prostatektomie mit oder ohne epiduraler Analgesie

Epidural analgesia for postoperative pain treatment is favored, for example, within the scope of so-called fast-track surgery, especially abdominal surgery. To improve pain care for our urological patients, we examined the quality of postoperative pain therapy with and without epidural analgesia after radical prostatectomy. After the investigation was approved by the local ethics committee, patients were questioned in detail about the pain they experienced for 7 days after radical prostatectomy. For all 7 postoperative observation days, significantly less pain was measured for patients receiving epidural analgesia compared with patients without epidural analgesia. This could be shown for the average and strongest pain intensity at rest as well as for pain during mobilization. Patients with epidural analgesia were discharged, on average, 1 day earlier. After radical prostatectomy, postoperative pain therapy with epidural analgesia seems to offer advantages with regard to the quality of analgesia and the average length of hospital stay.     

Patienten-kontrollierte Analgesie mit Clonidin und Piritramid

Following parenteral administration, clonidine has analgesic effects at both cerebral and spinal levels. Patient-controlled analgesia (PCA) makes it possible to determine equipotent dosages of analgesics by relating analgesic consumption per time to the levels of analgesia obtained in comparable patient populations. Therefore, we studied the equipotency ratios of clonidine and piritramide and the incidence of undesired side effects in the treatment of postoperative pain in patients undergoing maxillo-facial surgery. Methods. After approval of the local ethics committee and informed consent 40 patients (age >18 year, ASA I–III) were studied. Following randomization, the patients each received a PCA device containing either clonidine (bolus 30?μg), or piritramide (bolus 1.5?mg) for treatment of postoperative pain (lockout interval 5?min in both groups). During the postoperative period, pain was determined using a visual analogue scale, while analgesic consumption, sedation, haemodynamic parameters, respiration rate, and the occurrence of undesired side effects were documented additionally. Results. The groups had comparable distributions of biometric data, duration of anaesthesia, and ASA classification. Pain level decreased significantly (P<0.0001) in both groups during the first 2?h of PCA. Mean arterial pressure and heart rate were lower (P<0.05) in the clonidine group 4 and 6?h after PCA onset, while the degree of sedation after 2 (P<0.01) and 6 (P<0.05) h was higher than in the piritramide group. Nausea and vomiting were more frequent (P<0.05) in the piritramide group. Both groups showed a wide interpatient variation in analgesic requirement. The equipotency ratio clonidine/piritramid was 1:63.7. Conclusion. Intravenous clonidine is a potent analgesic and is suitable or the treatment of postoperative pain following maxillo-facial surgery. The analgesic potency of 150?μg clonidine i.v. was equivalent to that of 9.56?mg piritramide i.v. Nausea and vomiting occurred more rarely in the clonidine group, while deeper sedation was observed more frequently than in the piritramide group. Owing to the wide interindividual variation of analgesic consumption, clonidine dosages have to be adjusted to the actual requirements.     

Postoperative Analgesie bei Kindern nach Hernioplastie Wundinstillation mit verschiedenen Konzentrationen von Bupivacain: eine Pilotstudie

Wound instillation seems to be an easy and preferable way to achieve postoperative analgesia in pediatric hernioplasty. This prospective, randomized and double-blinded pilot-study was initiated to gain preliminary information in order to define the appropriate concentration of local anaesthetic for efficient posthernioplastic analgesia. METHOD: 29 children aged 3.1 to 13.7 (5.25 (3.8-8.2) years were randomly assigned to receive either 0.2 ml/kg bupivacaine 0.125% (n = 10), bupivacaine 0.25% (n = 10) or bupivacaine 0.5% (n = 9). The local anesthetic (LA) was instillated intraoperatively before wound closure above the external oblique muscle and below Scarpa's fascia. After entering the post-anesthetic care unit (PACU) pain was assessed by a trained nurse using the linear analogue pain scale (LAPS) in intervals of 15 min. Patients were observed in the PACU for 30-60 min. Pain was further evaluated for 5.5(3-6) h in the ward every hour. In day-only patients the parents were contacted 24 h postoperatively to obtain additional information. RESULTS: From the beginning of the observation period the 0.5% group tended to have less pain than the others in the PACU. The 0.125% and 0.25% group required earlier supplementary analgetics. In addition, the 0.5% group needed once (1/9) supplementary analgesics; the 0.25% group five times (5/10) and the 0.125% group six times (6/10). None of these results is statistically significant, though they appear to be clinically relevant. DISCUSSION: Wound instillation with 0.2 ml of bupivacaine 0.5% seems to be easy to perform, safe and efficient in controlling posthernioplastic pain. Because of the small numbers of patients included however, no statistically significant differences were observed between the groups. Neither in the LAPS on arrival and observation at the PACU nor in the need for supplementary analgesics. Despite lacking significance the clinical impression suggests a difference to be validated by larger studies. Our data implies that wound instillation with 0.2 ml/kg bupivacaine 0.5% should be regarded for routine usage.     

Intra- und postoperative Analgesie mit Kaudalkatheter bei einem Kind mit Schwartz-Jampel-Syndrom

The Schwartz-Jampel syndrome, also known as myotonia chondrodystrophica, is a rare autosomal recessive disorder characterized by bone dysplasia, growth retardation and generalized myotonia. Laryngoscopy and intubation may be difficult because of micrognathia and limited mouth opening due to myotonia of the masseter muscles. As regional anaesthesia reduces myotonic contractions and avoids administration of opioids causing respiratory depression, it appears to be the ideal method for postoperative analgesia. We report on a 5-year-old girl who underwent osteotomy of both hips and received intraoperative and postoperative analgesia via a caudal catheter. Excellent analgesia without myoclonic episodes could be achieved by continuous infusion of ropivacaine.     

Analgesie durch intraartikuläres Morphin nach Kniegelenksarthroskopien? Eine doppelblinde,randomisierte Studie mit patientenkontrollierter Analgesie*

Previous studies investigating the peripheral action of locally instilled morphine after arthroscopic knee surgery found evidence for an analgesic effect. Follow-up studies have lead to conflicting results.We used patient-controlled analgesia (PCA) to test the analgesic potency of intraarticular morphine. Methods. Patients undergoing arthroscopic knee surgery under general anaesthesia received, after written informed consent and in double-blind and randomised manner, 1?mg morphine diluted in 10?ml saline either intraarticularly or intravenously at the end of the surgical procedure. A control injection of 10?ml saline was given at the other site. The pain intensity on a visual analogue scale (VAS) and the cumulative morphine consumption were recorded at 1, 2, 3, 4, 6, 8 and 24?h after the end of general anaesthesia. Statistics: Wilcoxon rank sum test with P<0.05. Results. A total of 59?patients were included in the study; 29 received morphine intraarticularly (verum group), 30 intravenously (control group). There was no difference in gender, age, duration of arthroscopy or anaesthesia. There were more than 60% diagnostic arthroscopies in both groups; other types of surgery were comparable, with the exception of cruciate band repair procedures only in the control group. We found no difference in morphine consumption or pain intensity between the two groups throughout the study period. Median overall consumption of morphine after 24?h was 14?mg in the verum group and 15?mg in the control group, with wide interindividual variation. Pain intensities were remarkably low. The peak pain intensity of both groups was found at 1?h postoperatively, with median 16/100 on the VAS in both groups. Blinding was robust. Conclusion. We found no reduction in postoperative morphine supplementation after 1?mg morphine intraarticularly compared to 1?mg intravenously given at the end of knee arthroscopies. There were also no differences in pain intensities on a VAS. We conclude that titration of postoperative pain with a morphine-filled PCA pump was unable to show a difference in analgesic potency between intraarticular and intravenous morphine.     

Postoperative Schmerztherapie mit Hydromorphon und Metamizol Eine prospektiv randomisierte Untersuchung im Rahmen der intravenösen patientenkontrollierten Analgesie (PCA)

Most potent opioid analgesics available in Germany have been investigated for use in postoperative patient-controlled analgesia (PCA). To conclude an older comparative series, it was the aim of the present study to define analgesic potency, side effects and patient acceptance of hydromorphone and its interaction with the non-opioid analgesic metamizole. A total of 120 patients recovering from elective abdominal or orthopaedic surgery, performed under standardised general anaesthesia, were randomised into 3 double-blind treatment groups to receive intravenous PCA demand doses of hydromorphone 283 micrograms (low dose, LD), 566 micrograms (high dose, HD) or a combination of hydromorphone 283 micrograms and metamizole 50 mg (low dose hydromorphone + metamizole, LM). Demand-independent low-dose background infusions were added to deliver hydromorphone at 67.9 micrograms/h in all groups, with additional metamizole at 12 mg/h in group LM. Lockout times were set to 2 min. After an average observation time of 24.5 +/- 2.6 h (mean, SD) since start of PCA, cumulative PCA hydromorphone doses in groups LD, HD and LM were 7.8 +/- 3.3, 12.1 +/- 4.8 and 7.5 +/- 2.0 mg, respectively, with the well known large inter-individual variability in all groups. Although hydromorphone consumption was significantly higher in group HD, self-reported pain intensities (VAS, retrospective pain scores) were quite comparable between the groups. Low dose, PCA bolus-linked metamizole did not significantly reduce hydromorphone consumption nor improve patient acceptance. Side-effects were typical for potent postoperative opioids, but never required special treatment; haemodynamic or respiratory complications were not observed in any patient. It can be concluded by comparison with other PCA opioid investigations performed under the same study protocol that hydromorphone is about 3-4 times as potent an analgesic as morphine under the conditions of intravenous postoperative PCA. Due to a favourable patient acceptance, hydromorphone can be recommended as a suitable alternative to other opioids for the treatment of postoperative pain.     

Prozedurale Analgesie

The effect of severe pain and its hazardous stress-related cardiocirculatory consequences have been well documented for the perisurgical setting. Independently of surgical intervention however, even short and simple measures (e.g. thorax drain removal, repositioning a limb fracture) and longer diagnostic procedures such as MRI are potentially very painful or stressful to the patient. Though longer diagnostic procedures are frequently supported by systemic medication, short interventions regularly lack this aspect. Specific challenges result from the need to counteract sometimes great changes in pain intensity. Moreover procedural analgesia represents a multidisciplinary measure not restricted to anaesthesiology, as most of these measures are performed without anaesthesia. To avoid endangering the patient, the choice of drugs and patient monitoring have to meet certain professional and technical standards. Competence in respiratory management is of paramount importance. This paper outlines these requirements and serves as an orientation outside the anaesthesiological speciality.     

曲马多硬膜外腔或肌肉注射用于术后镇痛的观察与比较

本文通过４０例硬膜外腔麻醉行中、上腹部手术后硬膜外腔注入曲马多（ＥＴ）与肌肉注射曲马多（ＭＴ）１００ｍｇ的观察比较发现，ＥＴ组舒张压下降有显著性（Ｐ＜０．０５），两组的镇痛效果及副作用的出现相似（Ｐ＞０．０５），镇痛起效时间ＥＴ组快于ＭＴ组（Ｐ＜０．００１），镇痛维持时间ＥＴ组短于ＭＴ组（Ｐ＜０．０５），２４ｈ内重复注药次数的发生率ＥＴ组高于ＭＴ组（Ｐ＜０．０５），且ＥＴ组多数病人有带管不适感。表明曲马多术后镇痛选用ＭＴ法更具优越性     

曲马多硬膜外术后镇痛期间病人脉搏血氧饱和度的变化(与吗啡比较)

作者应用美国Nellcor 250型Oximetor/ECG监测连续8h动态观察和比较曲马多(lmg/kg)与吗啡(0.04mg/kg)在上腹部手术病人(n=24)硬膜外术后镇痛期间脉搏血氧饱和度(Sp O_2)的变化结果表明:两组病人注药后HR、MAP、R、RPP的变化相似(P>0.05);SpO_2从第2h开始、直至第7h两组间有显著或极显著性差异(P<0.05～0.01);其最大降低率T组为1.1%、M组为7.3%说明曲马多硬膜外术后镇痛无呼吸抑制之弊。     

Analgesie beim Kind

Introduction

Children suffer pain due to various causes. Acute pain is usually due to trauma, infectious diseases or following operations, in which pain occurs as a side effect. Chronic pain is usually headache or stomachache. Trauma is the main cause of pain in the particular case of emergency medicine.

Methods

Evaluation of existing literature, with a particular focus on evidence-based recommendations and guidelines.

Results

Acute pain of whatever origin should be treated as soon as possible. If necessary, simple observation or self-evaluation scales can be used to help assess the degree of pain. Children with chronic pain should be treated by specialized teams. The most commonly used analgetics are paracetamol, ibuprofen and morphine. Ibuoprofen appears to be more effective than paracetamol and to have fewer side effects. In emergency medicine, the resources available must be used. The origin of the pain usually requires the administration of opioids or ketamine.     

Analgesie und Sedierung

Patients in intensive care units (ICU) are often in vital danger and subjected to a number of procedures and environmental conditions which are known to cause stress. Both pain and stress can negatively affect patient outcome. In order to minimize these factors, analgesia or sedation is required. However, there is neither an ideal analgesic nor an ideal sedative. The drugs of choice to minimize pain are opioids such as Fentanyl, Sufentanil, and Remifentanil. For sedation, we generally use Propofol or benzodiazepines ?C the latter is most commonly represented by Midazolam in Germany. There are several different systems available for scoring pain level, patient alertness or possible state of delirium.     

硬膜外布比卡因-咪唑安定或/和曲马多用于术后镇痛

目的：观察咪唑安定或／和曲马多在术后镇痛中的作用。方法：分别于硬膜外注入布比卡因（对照组,Ⅰ组,ｎ＝２０）,布比卡因和咪唑安定（Ⅱ组,ｎ＝２５）,布比卡因和曲马多（Ⅲ组,ｎ＝２５）及布比卡因,咪唑安定和曲马多（Ⅳ组,ｎ＝２５）,比较术后镇痛效果,结果：布比卡因－咪唑安定具有罗好的术后镇痛效果。布比卡因加用咪唑安定和曲马多联用可提供更好的术后镇痛作用,并可明显减少阿片类药物用量。加用咪唑安定后主要副