Knelpunten in het management van acute pijn bij kinderen

Knelpunten in het management van acute pijn bij kinderen Knelpunten in het management van acute pijn bij kinderen

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30 nederlands tijdschrift voor anesthesiologie mei '10 | Figuur 2. Flowchart postoperatieve pijnbestrijding na sternotomie, geïntroduceerd in MUMC+ De flowchart begint op de Medium Care (MC). (De eerste 6-24 uur bevindt de patiënt zich op de Intensive Care, alwaar paracetamol wordt gegeven en opiaten via een continue perfusor worden toegediend.) Het beleid op de MC staat op de linker kant van de kaart. Een dag later gaan ze naar de afdeling alwaar de rechter kant van de flowchart in werking treedt. Tijdens de nameting bleek dat de pijnbestrijding door dit protocol in kwaliteit is verbeterd gerandomiseerde studie dat parasternaalblokkade middels een eenmalige injectie ropivacaine leidt tot adequate pijnbestrijding van de sternale wond, een significant verminderde vraag naar postoperatieve analgetica binnen de eerste 24 uur van zowel opiaten als paracetamol in vergelijking met placebo [29]. Een sterk gelijkende techniek is een wondkatheter. Wondinfiltratie wordt reeds toegepast bij verschillende orthopedische en abdominale operaties als adjuvante pijnbestrijding. In cardiothoracale chirurgie is deze methode en betrekkelijk nieuwe verschijning. McDonald combineerde parasternaal blokkade met wondinfiltratie middels levobupivacaine, wat resulteerde in een verminderd gebruik van morfine in de eerste vier uur na operatie [30]. Ook wondinfiltratie zonder parasternaal blokkade levert in verschillende studies vergelijkbare positieve resultaten op [31]. Er zijn ook studies die minder positief zijn over wondinfiltratie. In een studie van Magnano vindt geen verbetering van postoperatieve pijnbestrijding na wondinfiltratie met 0.5% bupivacaine. Protocoleren De kwaliteit van postoperatieve pijnbestrijding na sternotomie is in het MUMC+ geëvalueerd. Daaruit bleek dat deze onvoldoende is, ondanks het bestaan van een algemeen postoperatief pijnprotocol. Dit protocol vermeldt tevens het gebruikt van NSAIDs, die we om genoemde redenen niet willen voorschrijven. Uit de evaluatie bleek ook dat ondanks de pijn slechts 30% van alle patiënten de voorgeschreven analgetica ontvingen. De redenering hiervoor was verschillend. Vaak was het gewoon angst voor de bijwerkingen van de medicijnen. Daarom hebben we, specifiek voor de patiënten na sternotomie, een pijnprotocol ontwikkeld (figuur 2). In een periode van 3 maanden bleek dit protocol tot een verbetering van de situatie te leiden. De lange termijn effecten zouden nog worden bekeken. Conclusie Het gebruik van systemische analgetica met opiaten en paracetamol bij postoperatieve pijnbestrijding na cardiothoracale chirurgie blijft, al of niet in combinatie met locale anesthetica, de standaardbehandeling. Protocollering van de therapie heeft zeker baat bij het bereiken van effectieve pijnbestrijding en verlaagt misschien de kans op ontwikkeling van chronische pijn. Thoracale epidurale anesthesie zou een plaats kunnen innemen in de cardiothoracale chirurgie. Over andere regionale technieken is een positieve uitkomst nog niet met zekerheid te zeggen, gezien de geringe ervaringen. De studies die er zijn verschillen sterk in de hoeveelheid van het gebruikte anestheticum en precieze toedieningswijze. Hier is zeker meer onderzoek voor nodig om tot een uitspraak te komen.

mei '10 nederlands tijdschrift voor anesthesiologie 31 | referenties 1. Peters M.L., Sommer M., De Rijke J.M. Kessels F. Somatic and Psychologic Predictors of Long-term Unfavourable Outcome After Surgical Intervention, Ann Surg. 2007;245(3):487-494. 2. Herlitz J., Bradrup G., Caidahl K., Haglid M. Symptoms of chest pain and dyspnea and factors associated with chest pain and dyspnoea 10 years after coronary artery byass grafting. Am Heart J. 2008;156(3):580-587. 3. Diby M., Romand J., Frick S., Heidegger . Waldere B. Reducing pain in patients undergoing cardiac surgery after implementation of a quality improvement pain treatment program J Crit Care. 2008;23(3):359-367. 4. Maddali M., Kurian E., Fahr J. Extubation time, hemodynamic stability and postoperative pain control in patients undergoing coronary artery bypass surgery: an evaluation of fentanyl, remifentanil, and nonsteroidal anti-inflammatory drugs with propofol for perioperative management J. of Clin Anesthesia 2006;18:605-610. 5. Dhawan N., Das S., Kiran U. Effect of rectal diclofenac in reducing postoperative pain and rescue analgesia requirement after cardiac surgery, Pain practice;2009;9(5):385-393. 6. Nussmeier N., Whelton A., Brown M, Langford R, Hoeft A, Parlow J. Complications of the COX-2 inhibitors parecoxib and valdecoxib after cardiac surgery, NEJM 2005;352(11)1081-1091. 7. Ballantyne J., Carr D., Chalmers T., Dear K., Angelillo I., Mosteller F. Postoperative patient – controlled analgesia ; meta-analysis of initial randomized control trials, J Clin Anesth. 1993;5(3):182-193. 8. Walder B., Achafer M., Henzi I., Tramer M. Efficacy and safety of patient- controlled opioid analgesia for acute postoperative pain. A quantitative systematic review, Acta Anaesthesiol Scand. 2001;45(7):795-804. 9. Turan A., White P., Karamanlioglu B., Mernis D., Tasdogan M., Parmukcu Z., Yavuz E. Gabapentin: an alternative to the cyclooxygenase-2 inhibitors for perioperative management, Anesth analg 2006;102:175-181. 10. Bell R., Dahl J., Moore R., Kalso E. Perioperative ketamine for acute postoperative pain Cochrane Database Syst. Rev. 2006;25(1):CD004603. 11. Müllenheim J., Rulands R., Wietschorke T., Frassdorf J., Preckel B., Schlack W. Later preconditioning is blocked by racemic ketamine, but not by S(+)-ketamine Anesth Analg. 2001;93(2):265-270. 12. Leone S., Di Cianni S., Casati A., Fanelli G. Pharmacology, toxicology, and clinical use of new ling acting local anesthetics ropivacaine and levobupivacaine Acta Biomed. 2008 ;79(2):92-105. 13. Chaney M. Intrathecal and epidural anesthesia and analgesia for cardiac surgery. Anesth Analg. 2006;102(1):45-64. 14. Barrington M., Kluger R., Watson R., Scott D., Harris K. Epirdural anesthesia for coronary artery bypass surgery compared with general anesthesia alone does not reduce biochemical markers of myocardial damage Anesth Analg. 2005;100(4):921-928. 15. Kozian A., Schilling T., Hachenberg T. Non-analgetic effects of thoracic epidural anaesthesia Curr Opin Anaesthesiol. 2005;18(1):29-34. 16. Liu S. , Block B., Wu C. Effects of perioperative central neuaxial analgesia on outcome after coronary artery bypass surgery: a meta analysis Anesthesiology 2004;101(1):153-161. 17. Liem T., Booij L., Gielen M., Hasenbos M. Coronary artery bypass grafting using two different anesthetic techniques: part 1: Hemodynamic results, J Cardiothorac Vasc Anesth. 1992;6(2):148-155. 18. Alvarez J., Hernandez B., Atanassoff P. Hihg thoracic epidural anesthesia and coronary disease in surgical and non-surgical patients Curr Opin Anaesthesiol. 2005;18(5):501-506. 19. Lagunilla J., Garcia-bengochea J., Fernandez A, Alvarez J., Rubio J., Veiras S. High thoracic epidural block increases myocardial oxygen availability in coronary surgery patients Acta Anaesthesiol Scand. 2006;50(7):780-786. 20. Scott N. , Turfrey D., Ray D., Nzewi O., Suttcliffe N., Lal A., Norrie J., Nagels W., Ramayya G. A prospective randomized study of the potential benefits of thoracic epidural anesthesia and analgesia in patients undergoing coronary artery bypass grafting Anesth Analg. 2001;93(3):528-535. 21. Hansdottir V., Phillip J., Olsen M., Eduard C., Houltz E., Ricksten S. Thoracic epidural versus intravenous patient-controlled analgesia after cardiac surgery: a randomized controlled trial on length of stay and patient-perceived quality of recovery Anesthesiology. 2006;104(1):142-151. 22. Lundstrom L., Nygard E., Hviid L., Pedersen F., Ravn J., Aldershvile J., Rosenberg J. The effect of thoracic epidural analgesia on the occurrence of late postoperative hypoxemia in patients undergoing elective coronary pypass surgery: a randomized controlled trial Chest. 2005;128(3):1564-1570. 23. Catala E., Casas J., Unzueta M., Diaz X., Aliaga L. Villar Landeira J. Continuous infusion is superior to bolus doses with thoracic paravertebral blocks after thoracotomies J Cardiothorac Vasc Anesth. 1996;10(5):586- 588. 24. Davies R., Myles P., Graham J. A comparison of the analgesic afficacy and side-effects of paravertebral vs epidural blockade for thoracotomy – a systematic review and metaanalysis of randomized trials Br J Anaesth. 2006;96(4):418-426. 25. Navlet M., Garutti I., Olmedilla L., Perez-pena J., San Joaquin M., Martinez- Ragues G., Gomez-Caro L. Paravertebral ropivacaine, 0.3% and bupivacaine, 0.25% provide similar pain relief after thoracotomy J Cardiothorac Vasc Anesth. 2006;20(5):644-647. 26. Hura G., Knapik P., Misiolek H., Krakus A., Karpe J. Sensory blockade after thoracic paravertebral injection of ropivacaine or bupivacaine Eur J Anaesthesiol. 2006;23(8):658-664. 27. Canto M., Sanchez M., Casas M., Bateller M. Bilateral paravertebral blockeade for conventional cardiac surgery Anaesthesia. 2003;58(4):365- 370. 28. Dhole S., Mehta Y., Saxena H., Juneja R., Trehan N. Comparison of continuous thoracic epidural and paraverebral blocks for postoperative analgesia after minimally invasive direct coronary artery bypass surgery. J Cardiothorac Vasc Anesth. 2001;15(3):288-292. 29. Barr A., Tutngi E., Almeida A. Parasternal intercostal block with ropivacaine for pain management after cardiac surgery: a doubleblind, randomized, controlled trial. J Cardiothorac Vasc Anesth. 2007;21(4):547-553. 30. McDonald S., Jacobsohn E., Kopacz D., Desphande S., Helman J., Saliinas F., Hall R. Parasternal block and local anesthetic infiltration with levobupivaciane after cardiac surgery with desflurane : the effect on postoperative pain, pulmonary function, and tracheal extubation times. Anesth Analg. 2005;100(1):25-32. 31. Kocabas S., Yedicocuklu D., Yuksel E., Uysallar E., Askar F., Infiltration of the sternotomy wound and mediastinal tubes sites with 0.25% levobupivacaine as adjunctive treatment for postoperative pain after cardiac surgery. Eur J Anaesthesiol. 2008;25(10):842-849.

mei '10 nederlands tijdschrift voor anesthesiologie 31<br />

|<br />

referenties<br />

1. Peters M.L., Sommer M., De Rijke<br />

J.M. Kessels F. Somatic and Psychologic<br />

Predictors of Long-term<br />

Unfavourable Outcome After<br />

Surgical Intervention, Ann Surg.<br />

2007;245(3):487-494.<br />

2. Herlitz J., Bradrup G., Caidahl<br />

K., Haglid M. Symptoms of chest<br />

pa<strong>in</strong> and dyspnea and factors<br />

associated with chest pa<strong>in</strong> and<br />

dyspnoea 10 years after coronary<br />

artery byass graft<strong>in</strong>g. Am Heart J.<br />

2008;156(3):580-587.<br />

3. Diby M., Romand J., Frick S., Heidegger<br />

. Waldere B. Reduc<strong>in</strong>g pa<strong>in</strong> <strong>in</strong><br />

patients undergo<strong>in</strong>g cardiac surgery<br />

after implementation of a quality improvement<br />

pa<strong>in</strong> treatment program<br />

J Crit Care. 2008;23(3):359-367.<br />

4. Maddali M., Kurian E., Fahr J. Extubation<br />

time, hemodynamic stability<br />

and postoperative pa<strong>in</strong> control <strong>in</strong><br />

patients undergo<strong>in</strong>g coronary artery<br />

bypass surgery: an evaluation of fentanyl,<br />

remifentanil, and nonsteroidal<br />

anti-<strong>in</strong>flammatory drugs with propofol<br />

for perioperative <strong>management</strong><br />

J. of Cl<strong>in</strong> Anesthesia 2006;18:605-610.<br />

5. Dhawan N., Das S., Kiran U. Effect of<br />

rectal diclofenac <strong>in</strong> reduc<strong>in</strong>g postoperative<br />

pa<strong>in</strong> and rescue analgesia<br />

requirement after cardiac surgery,<br />

Pa<strong>in</strong> practice;2009;9(5):385-393.<br />

6. Nussmeier N., Whelton A., Brown<br />

M, Langford R, Hoeft A, Parlow<br />

J. Complications of the COX-2<br />

<strong>in</strong>hibitors parecoxib and valdecoxib<br />

after cardiac surgery, NEJM<br />

2005;352(11)1081-1091.<br />

7. Ballantyne J., Carr D., Chalmers T.,<br />

Dear K., Angelillo I., Mosteller F.<br />

Postoperative patient – controlled<br />

analgesia ; meta-analysis of <strong>in</strong>itial<br />

randomized control trials, J Cl<strong>in</strong><br />

Anesth. 1993;5(3):182-193.<br />

8. Walder B., Achafer M., Henzi I.,<br />

Tramer M. Efficacy and safety of patient-<br />

controlled opioid analgesia for<br />

<strong>acute</strong> postoperative pa<strong>in</strong>. A quantitative<br />

systematic review, Acta Anaesthesiol<br />

Scand. 2001;45(7):795-804.<br />

9. Turan A., White P., Karamanlioglu<br />

B., Mernis D., Tasdogan M., Parmukcu<br />

Z., Yavuz E. Gabapent<strong>in</strong>: an<br />

alternative to the cyclooxygenase-2<br />

<strong>in</strong>hibitors for perioperative <strong>management</strong>,<br />

Anesth analg 2006;102:175-181.<br />

10. Bell R., Dahl J., Moore R., Kalso E.<br />

Perioperative ketam<strong>in</strong>e for <strong>acute</strong> postoperative<br />

pa<strong>in</strong> Cochrane Database<br />

Syst. Rev. 2006;25(1):CD004603.<br />

11. Müllenheim J., Rulands R., Wietschorke<br />

T., Frassdorf J., Preckel B.,<br />

Schlack W. Later precondition<strong>in</strong>g is<br />

blocked by racemic ketam<strong>in</strong>e, but<br />

not by S(+)-ketam<strong>in</strong>e Anesth Analg.<br />

2001;93(2):265-270.<br />

12. Leone S., Di Cianni S., Casati A.,<br />

Fanelli G. Pharmacology, toxicology,<br />

and cl<strong>in</strong>ical use of new l<strong>in</strong>g act<strong>in</strong>g<br />

local anest<strong>het</strong>ics ropivaca<strong>in</strong>e and<br />

levobupivaca<strong>in</strong>e Acta Biomed. 2008<br />

;79(2):92-105.<br />

13. Chaney M. Intrathecal and epidural<br />

anesthesia and analgesia for<br />

cardiac surgery. Anesth Analg.<br />

2006;102(1):45-64.<br />

14. Barr<strong>in</strong>gton M., Kluger R., Watson<br />

R., Scott D., Harris K. Epirdural<br />

anesthesia for coronary artery bypass<br />

surgery compared with general anesthesia<br />

alone does not reduce biochemical<br />

markers of myocardial damage<br />

Anesth Analg. 2005;100(4):921-928.<br />

15. Kozian A., Schill<strong>in</strong>g T., Hachenberg<br />

T. Non-analgetic effects of thoracic<br />

epidural anaesthesia Curr Op<strong>in</strong><br />

Anaesthesiol. 2005;18(1):29-34.<br />

16. Liu S. , Block B., Wu C. Effects<br />

of perioperative central neuaxial<br />

analgesia on outcome after coronary<br />

artery bypass surgery: a meta analysis<br />

Anesthesiology 2004;101(1):153-161.<br />

17. Liem T., Booij L., Gielen M., Hasenbos<br />

M. Coronary artery bypass<br />

graft<strong>in</strong>g us<strong>in</strong>g two different anest<strong>het</strong>ic<br />

techniques: part 1: Hemodynamic<br />

results, J Cardiothorac Vasc Anesth.<br />

1992;6(2):148-155.<br />

18. Alvarez J., Hernandez B., Atanassoff<br />

P. Hihg thoracic epidural anesthesia<br />

and coronary disease <strong>in</strong> surgical and<br />

non-surgical patients Curr Op<strong>in</strong><br />

Anaesthesiol. 2005;18(5):501-506.<br />

19. Lagunilla J., Garcia-bengochea J.,<br />

Fernandez A, Alvarez J., Rubio J.,<br />

Veiras S. High thoracic epidural<br />

block <strong>in</strong>creases myocardial oxygen<br />

availability <strong>in</strong> coronary surgery<br />

patients Acta Anaesthesiol Scand.<br />

2006;50(7):780-786.<br />

20. Scott N. , Turfrey D., Ray D.,<br />

Nzewi O., Suttcliffe N., Lal A.,<br />

Norrie J., Nagels W., Ramayya G. A<br />

prospective randomized study of<br />

the potential benefits of thoracic<br />

epidural anesthesia and analgesia<br />

<strong>in</strong> patients undergo<strong>in</strong>g coronary<br />

artery bypass graft<strong>in</strong>g Anesth Analg.<br />

2001;93(3):528-535.<br />

21. Hansdottir V., Phillip J., Olsen M.,<br />

Eduard C., Houltz E., Ricksten<br />

S. Thoracic epidural versus <strong>in</strong>travenous<br />

patient-controlled analgesia<br />

after cardiac surgery: a randomized<br />

controlled trial on length of stay and<br />

patient-perceived quality of recovery<br />

Anesthesiology. 2006;104(1):142-151.<br />

22. Lundstrom L., Nygard E., Hviid<br />

L., Pedersen F., Ravn J., Aldershvile<br />

J., Rosenberg J. The effect of<br />

thoracic epidural analgesia on the<br />

occurrence of late postoperative<br />

hypoxemia <strong>in</strong> patients undergo<strong>in</strong>g<br />

elective coronary pypass surgery: a<br />

randomized controlled trial Chest.<br />

2005;128(3):1564-1570.<br />

23. Catala E., Casas J., Unzueta M., Diaz<br />

X., Aliaga L. Villar Landeira J. Cont<strong>in</strong>uous<br />

<strong>in</strong>fusion is superior to bolus<br />

doses with thoracic paravertebral<br />

blocks after thoracotomies J Cardiothorac<br />

Vasc Anesth. 1996;10(5):586-<br />

588.<br />

24. Davies R., Myles P., Graham J. A<br />

comparison of the analgesic afficacy<br />

and side-effects of paravertebral vs<br />

epidural blockade for thoracotomy<br />

– a systematic review and metaanalysis<br />

of randomized trials Br J<br />

Anaesth. 2006;96(4):418-426.<br />

25. Navlet M., Garutti I., Olmedilla<br />

L., Perez-pena J., San Joaqu<strong>in</strong> M.,<br />

Mart<strong>in</strong>ez- Ragues G., Gomez-Caro<br />

L. Paravertebral ropivaca<strong>in</strong>e, 0.3%<br />

and bupivaca<strong>in</strong>e, 0.25% provide<br />

similar pa<strong>in</strong> relief after thoracotomy<br />

J Cardiothorac Vasc Anesth.<br />

2006;20(5):644-647.<br />

26. Hura G., Knapik P., Misiolek<br />

H., Krakus A., Karpe J. Sensory<br />

blockade after thoracic paravertebral<br />

<strong>in</strong>jection of ropivaca<strong>in</strong>e or<br />

bupivaca<strong>in</strong>e Eur J Anaesthesiol.<br />

2006;23(8):658-664.<br />

27. Canto M., Sanchez M., Casas M.,<br />

Bateller M. Bilateral paravertebral<br />

blockeade for conventional cardiac<br />

surgery Anaesthesia. 2003;58(4):365-<br />

370.<br />

28. Dhole S., Mehta Y., Saxena H.,<br />

Juneja R., Trehan N. Comparison of<br />

cont<strong>in</strong>uous thoracic epidural and<br />

paraverebral blocks for postoperative<br />

analgesia after m<strong>in</strong>imally <strong>in</strong>vasive<br />

direct coronary artery bypass<br />

surgery. J Cardiothorac Vasc Anesth.<br />

2001;15(3):288-292.<br />

29. Barr A., Tutngi E., Almeida A.<br />

Parasternal <strong>in</strong>tercostal block with<br />

ropivaca<strong>in</strong>e for pa<strong>in</strong> <strong>management</strong><br />

after cardiac surgery: a doublebl<strong>in</strong>d,<br />

randomized, controlled<br />

trial. J Cardiothorac Vasc Anesth.<br />

2007;21(4):547-553.<br />

30. McDonald S., Jacobsohn E., Kopacz<br />

D., Desphande S., Helman J., Sali<strong>in</strong>as<br />

F., Hall R. Parasternal block and local<br />

anest<strong>het</strong>ic <strong>in</strong>filtration with levobupivaciane<br />

after cardiac surgery with<br />

desflurane : the effect on postoperative<br />

pa<strong>in</strong>, pulmonary function, and<br />

tracheal extubation times. Anesth<br />

Analg. 2005;100(1):25-32.<br />

31. Kocabas S., Yedicocuklu D., Yuksel<br />

E., Uysallar E., Askar F., Infiltration<br />

of the sternotomy wound and<br />

mediast<strong>in</strong>al tubes sites with 0.25%<br />

levobupivaca<strong>in</strong>e as adjunctive treatment<br />

for postoperative pa<strong>in</strong> after<br />

cardiac surgery. Eur J Anaesthesiol.<br />

2008;25(10):842-849.

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