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.     

Epidural and intrathecal administration of alpha 2-adreno-ceptor agonists for postoperative pain relief

Spinal clonidine interacts with pre- and postsynaptic alpha(2)-adrenoceptors on afferent neurons in the superficial dorsal horn of the spinal cord: it causes analgesia by inhibition of the synaptic and electrotonic neurotransmission of nociceptive impulses. Epidural doses higher than 4 microg/kg have an analgesic onset time of less than 30 min, reduce pain by more than 70 %; these effects last for 4-5 h. Epidural clonidine analgesia is accompanied by a reduction in heart rate, cardiac output and blood pressure of approximately 20 % compared with baseline. The haemodynamic side effects mean close supervision is needed during the first hour after epidural application and limit the use of epidural clonidine to patients who are refractory to the analgesic effects of epidural opioid or local anaesthetics. In these patients excellent results can be achieved either with clonidine alone or with a combination of clonidine and an opioid or a local anaesthetic to exploit the additive or supra-additive interactions of these drugs.     

Besondere Aspekte der Schmerztherapie im Kindesalter

Zum Thema Auch wenn sich die Prinzipien der Schmerzbehandlung von Kindern nicht grunds?tzlich von der bei Erwachsenen unterscheidet, gibt es Besonderheiten zu beachten. Diese beziehen sich natürlich nicht nur auf Dosierungen und Applikationsformen, sondern zus?tzlich auch auf Nebenwirkungen, die für das Kindesalter spezifisch sind. Ein weiteres Problem stellt die Abneigung der Eltern gegen eine Behandlung mit Morphium- oder Opioidpr?paraten dar. Unbedingt ist dafür Sorge zu tragen, da? auch Kindern im finalen Stadium maligner Erkrankungen ein angst- und schmerzfreies Sterben nicht vorenthalten wird. Alle Aspekte der Schmerztherapie bei Kindern werden in dieser Arbeit kurz abgehandelt und durch pragmatische Tabellen erg?nzt.     

Präemptive Analgesie mit Ropivacain bei Tonsillektomien im Erwachsenenalter

Aim of investigation: We examined whether a pre-emptive analgesic effect could be achieved with ropivacaine, which has less cardiovascular and central nervous system toxicity than bupivacaine, in adults undergoing tonsillectomy. Methods: The study was carried out in 80 patients in a randomised, double-blind fashion. The patients were randomly assigned to one of four groups. In group I, 3 ml ropivacaine 7,5 mg/ml were injected pre-operatively 5 minutes before the start of OR into each tonsil bed. In group II, 3 ml ropivacaine 7,5 mg/ml were injected post-operatively into each tonsil bed. In group III, 3 ml NaCl were injected pre-operatively 5 minutes before the start of OR into each tonsil bed. In group IV, 3 ml NaCl were injected post-operatively into each tonsil bed. The analgesic effectiveness was measured post-operatively by the use of a visual analogue scale, a numeric rating scale (at rest and during activity) and by measuring the total analgesic comsumption (mefenamic acid) in the first 192 hours. In addition the time of first analgesic request was noted. Vital parameters and side-effects were documented. Results: There was no significant difference between the groups in the time of first analgesic request. Likewise, there was no significant difference in the post-operative cumulative analgesic consumption between the four groups. The post-operative administration of ropivacaine resulted in significantly lower pain scores at certain time points compared with the other groups as measured both with the visual analogue scale and the numeric rating scale (at rest). It must be emphasized, that the pain scores both at rest and with exertion remain high and that the net analgesic consumption (per day) remains constant for the first 8 post-operative days. Conclusions: We could demonstrate no significant pre-emptive analgesic effect with ropivacaine in adults undergoing tonsillectomy in our study. One can, however, recommend the administration of ropivacaine post-operatively after tonsillectomy, since a reduction of pain scores can thereby be achieved. For post-operative analgesia we recommend the combination of a non-opioid analgesic with a weak opioid.     

Postoperative Schmerztherapie bei minimal-invasiver direkter koronararterieller Bypass-Chirurgie (MIDCAB) i.v.-Opioid-PCA versus Interkostalblockaden

Objective. Lately introduced cardiosurgical procedures such as MIDCAB enable an early extubation immediately after surgery. This also requires an adequate anesthesia regime and especially a sufficient postoperative analgesia. Patient controlled analgesia (PCA) and intercostal nerve blockade (ICB) were evaluated for their suitability for postoperative pain relief in patients undergoing a MIDCAB procedure. Material and methods. After approval by the local ethic committee and obtaining written informed consent 43 patients were included in this study. Anesthesia was induced and maintained in a total intravenous standardised manner with propofol, remifentanil, cisatracurium and additionally glyceroltrinitrate, clonidine and esmolol were given as needed. After revascularisation patients were randomly assigned to one of two groups receiving either 7,5 mg piritramid i.v. before extubation and continuing a PCA with 2 mg boli and a 10 min lockout, or an ICB with ropivacaine 1 % (4 times 5 ml). Additionally all patients received 1 g paracetamol rectally before induction of anesthesia and 1 g metamizol i.v. at the end of surgery. A rescue medication of 3.75 mg piritramid i.v. was allowed. A pain score (NRS 0–10), the Aldrete score (AS 0–12) and oxygen saturation were obtained 1, 4, and 8 h after extubation. Results. The ICB group showed a significantly greater pain reduction in the first (5.8 ± 1.8 vs. 7.3 ± 1.9; P<0.02) and fourth h (3.6 ± 1.3 vs. 4.6 ± 1.4; P<0.02), respectively. Transfer to an intermediate care ward one hr after extubation was achieved more often in the ICB group according to the AS (ICB 9.6 ± 1.5 vs. PCA 8.9 ± 1.2; P<0.05), too. There was no difference with respect to the oxygen saturation. The additional piritramid demand was 9.3 mg in the ICP group and 5 mg in the PCA group in the first 8 hours postoperative. Conclusion. ICB gives a better pain relief in the early postoperative phase after MIDCAB procedures compared to a PCA. Both regimes are adequate in order to provide a sufficient pain relief and help to avoid prolonged postoperative mechanical ventilation. These will enable an early transfer of patients to an intermediate care station and save ICU capacity.     

Paracetamol im Kindesalter Aktueller Wissensstand und Hinweise für einen rationalen Einsatz zur postoperativen Analgesie

The administration of paracetamol (in the US known as acetaminophen) to children and infants for postoperative pain after minor surgery is a well established and safe treatment option, if appropriately used. However, if paracetamol is dosed according to traditional recommendations (about 20 mg/kg body weight) frequently a sufficient analgetic effect cannot be achieved immediately after painful interventions. Recently, a higher initial dose (40 mg/kg body weight) was suggested for effective postoperative pain control, which seems especially important for children after ambulatory anesthesia, but may also be associated with certain risks to the patient. Current recommendations also involve appropriate timing and route of administration of paracetamol to be most effective under different clinical circumstances. In contrast, the risk for liver toxicity appears to be very low, if the daily paracetamol dose does not exceed 90 mg/kg body weight in otherwise healthy children, and if specific risk factors of the individual patient are always considered. This review discusses the recent publications on pharmacokinetics and -dynamics, the clinical use and dosing, as well as the risks and benefits of paracetamol for the treatment of postoperative pain in children and infants. Based on this information, specific dosing regimes for the postoperative period are suggested for neonates and infants, as well as for children in different age groups.     

Diagnostische und therapeutische Prozeduren

Zusammenfassung Ziel jeder medikamentösen Sedierung im Rahmen von diagnostischen und therapeutischen Eingriffen muss die sichere und erfolgreiche Therapie von Angst und Schmerzen sein, um damit gute Untersuchungsergebnisse erheben zu können. Die Möglichkeiten zur Sedierung und Analgesie von Kindern für diagnostische oder therapeutische Untersuchungen haben sich durch die Einführung sehr kurz wirksamer, potenter Sedativa und Analgetika deutlich erweitert. Ziel dieser Arbeit ist es, einen aktuellen Überblick über die verfügbaren Möglichkeiten zur kurzzeitigen medikamentösen Sedierung und Analgesie von Kindern sowohl für nichtinvasive als auch invasive Untersuchungen zu geben. Des Weiteren werden die Richtlinien zur Sedierung und Analgesie, die von der American Academy of Pediatrics 1992 sowie der American Society of Anesthesiologists im Jahr 2002 in einer aktualisierten Version publiziert wurden, dargestellt.Ein Erratum zu diesem Beitrag können Sie unter finden.     

Analgesie sub partu

Zusammenfassung Von allen Methoden der Geburtsanalgesie ist die Periduralanästhesie (PDA) bis heute die effektivste, bedarf aber zu ihrem Einsatz einer klaren Indikationsstellung. Vor allem ist die Aufklärung der Gebärenden im Vorfeld, z. B. im Rahmen der Vorsorgeuntersuchung wichtig, die Aufklärung unter der Geburt genügt den juristischen Anforderungen nicht. Die unerwünschte motorische Blockade der PDA kann durch Kombination von Lokalanästhetika mit Opioiden, durch den Einsatz von Ropivacain oder durch die kombinierte spinale und epidurale Anästhesie (CSE) vermieden oder reduziert werden. Durch diese Maßnahmen lässt sich eventuell auch der oft diskutierte Zusammenhang zwischen PDA und instrumenteller Entwicklung des Kindes oder Sectio reduzieren, hierzu kann eine gezielte Absprache zwischen Geburtshelfer und Anästhesist beitragen.Eine Zufriedenheit der Gebärenden kann durch die PDA erreicht werden, jedoch selten durch die PDA allein. So komplex und individuell wie die Geburt sind auch die Möglichkeiten, eine vertrauensvolle, schmerzarme Atmosphäre zu schaffen. Trotz aller Verfeinerungen von Anästhesietechniken ist es das Wichtigste, Angst zu mindern und Vertrauen zu schaffen. Hier ist das persönliche Engagement von Hebamme, Geburtshelfer und Anästhesist gefragt.     

47. Anaesthesie und Schmerzbekämpfung unter Katastrophenbedingungen

Zusammenfassung Katastrophenbedingungen beinhalten für die Anaesthesie die teilweise Abkehr von gebräuchlichen Standardverfahren und den Rückgriff auf technisch und personell unaufwendige Basisverfahren. Zur Analgesie kommen neben Analgetica-Antipyretica die Lokalanaesthetica, Opiate und Ketamine in Frage. Zur Anaesthesie ist Ketamine wegen seiner günstigen Eigenschaften als Monoanaestheticum bei Spontanatmung oder in Kombination mit Muskelrelaxantien bei Luftbeatmung einsetzbar. Das Verfahren ist durch Psychopharmaka, Opiate oder andere Anaesthetica ergänzbar.