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Postoperative Intrathecal Pain Treatment in Children

Hesselgard, Karin LU (2005)
Abstract (Swedish)
Popular Abstract in Swedish

Selektiv dorsal rhizotomi (SDR) är en effektiv operationsmetod som framgångsrikt minskar graden av spasticitet med bestående positiva effekter för barn med spastisk diplegia. Barn som genomgår SDR har svåra smärtor postoperativt, smärtan är relaterad till både den stora kirurgin med blocklaminotomin och nervrots manipulation. För att kunna ge en optimal smärtlindring är smärtskattning en nödvändighet i smärtbehandlingen, smärtskattningen kan vara svår att bedöma hos små barn. Avsikten med avhandlingen är att evaluera och förbättra smärtbehandlingen till barn som genomgår stor ryggkirurgi samt utveckla ett smärtskattningsinstrument för att evaluera postoperativ smärta.



Antalet... (More)
Popular Abstract in Swedish

Selektiv dorsal rhizotomi (SDR) är en effektiv operationsmetod som framgångsrikt minskar graden av spasticitet med bestående positiva effekter för barn med spastisk diplegia. Barn som genomgår SDR har svåra smärtor postoperativt, smärtan är relaterad till både den stora kirurgin med blocklaminotomin och nervrots manipulation. För att kunna ge en optimal smärtlindring är smärtskattning en nödvändighet i smärtbehandlingen, smärtskattningen kan vara svår att bedöma hos små barn. Avsikten med avhandlingen är att evaluera och förbättra smärtbehandlingen till barn som genomgår stor ryggkirurgi samt utveckla ett smärtskattningsinstrument för att evaluera postoperativ smärta.



Antalet centra som utför SDR är okänt. Syftet med studie I var att uppskatta omfattningen av SDR kirurgin, evaluera vilken operations metod som används och kartlägga smärtbehandlingen efter SDR. Ett frågeformulär sändes ut till 59 tänkbara centra. 44 (75%) svarade. 33 centra utgör studiematerialet, 11 centra utför inte längre SDR kirurgi.



I en prospektiv studie (studie II) användes två olika intrathekala (IT) smärtlindrings regimer, kontinuerlig infusion kontra intermittent injektion för att evaluera smärtlindringen och eventuella sidoeffekter. 12 barn, fick antingen intermittent IT morfin, 5 µg/kg x 4 eller en kontinuerlig infusion med bupivacaine, 40 µg/kg//h och morfin 0.6 µg/kg/h. IT kontinuerlig infusion med bupivacaine och morfin var överlägsen som smärtlindring.



För att definiera en optimal dos (studie III) med kontinuerlig IT morfin och bupivacaine som behandling för svåra smärtor jämfördes två olika koncentrationer av morfin 0.4 µg/kg//h och 0.6 µg/kg//h med en fixerad dos av bupivacaine 40 µg/kg/h med avseende till den analgetiska effekten och undersöka om det fanns någon skillnad i sidoeffekter. BOPS användes för att värdera smärtan. Kontinuerlig IT smärtlindring med 0.6 µg/kg//h morfin och 40µg/kg/h bupivacaine utgör en säker och tillfredställande smärtlindring efter stora spinala operationer. Detta styrks ytterligare genom att sidoeffekterna inte skiljer sig mellan grupperna.



För att kunna ge en effektive smärtbehandling till barn ska det finnas rutiner och tydlig dokumentation för att evaluera smärta. Detta kräver reliabla, valida och kliniska känsliga mätverktyg. I studie IV evaluerades reliabiliteten och validiteten av BOPS som en postoperativ smärtskattningsskala till barn 1-7 år. Skalan bedömer tre smärtbeteendevariabler; ansiktsuttryck, verbalisering och kroppsställning. Med BOPS kan sjuksköterskan evaluera och dokumentera smärtan med hög reliabilitet och validitet och därmed förbättra den postoperativa smärtbehandlingen, det enkla bedömningssystemet gör att BOPS är lätt att införa på en postoperativ avdelning. (Less)
Abstract
Selective dorsal rhizotomy (SDR) is an effective operations method that successfully decreased the degree of spasticity with long lasting beneficial effects for children with spastic diplegia. Children undergoing SDR are postoperatively in severe pain, a pain related to both the extensive surgical exposure with multilevel laminotomy and the nerve root manipulation. To give an optimal pain relief, pain measurement is a necessity in pain treatment, but it can be difficult in pre-school children.



A worldwide survey was made (study I) to estimate the extent of SDR surgery, evaluate operation techniques and to clarify different centres pain management after SDR. A questionnaire comprise 8 questions was sent to 59 centres. 44... (More)
Selective dorsal rhizotomy (SDR) is an effective operations method that successfully decreased the degree of spasticity with long lasting beneficial effects for children with spastic diplegia. Children undergoing SDR are postoperatively in severe pain, a pain related to both the extensive surgical exposure with multilevel laminotomy and the nerve root manipulation. To give an optimal pain relief, pain measurement is a necessity in pain treatment, but it can be difficult in pre-school children.



A worldwide survey was made (study I) to estimate the extent of SDR surgery, evaluate operation techniques and to clarify different centres pain management after SDR. A questionnaire comprise 8 questions was sent to 59 centres. 44 (75%) centres responded to the questionnaire. 33 centres constitute the study material.



In a prospective study (study II), two IT different regimes was evaluated, continuous infusion versus inter-mittent, concerning pain killing and possible side effects. Intrathecal continuous infusion of bupivacaine and morphine was superior to intermittent morphine in the pain treatment after selective dorsal rhizotomy operations. To define an optimal dose (study III) of the continuous IT morphine and bupivacaine for severe pain treatment after SDR with regard to the analgesic effect and survey if they differed in side effects, we compared two different concentrations of morphine 0.4 ug/kg/h and 0.6 ug/kg/h in a fixed dose of bupivacaine 40 ug/kg/h. The Behavioural Observational Pain Scale (BOPS) was used to evaluate pain. Continuoues IT pain treatment with 0.6 ug/kg/h morphine and 40 ug/kg/h bupivacaine provides safe and good analgesia after major spinal operations. This is furthered strengthened by the fact that the adverse effect did not differ between the groups and was therefore not a drawback of the high-dose group.



Effective pain management in infants and children starts with routine evaluation of pain and a clear documentation. This requires measurement of pain intensity and pain relief with reliable, valid and clinically sensitive assessment tools. Observation of behaviour can be an acceptable alternative when valid self-report is not possible. We evaluate (study IV) the validity and reliability of BOPS, as a postoperative pain measurement scale for children aged 1 - 7 years. The scale assess three variables of pain behaviours; facial expression, verbalization and body position. With BOPS the nurses can evaluate and document pain with high reliability and validity and thereby improve the postoperative pain treatment in preschool children. The simple scoring system makes BOPS easy to incorporate in a postoperative unit. (Less)
Please use this url to cite or link to this publication:
author
supervisor
opponent
  • docent Olsson, Gunnar L, Inst för kirurgisk vetenskap, Karolinska Institutet i Stockholm
organization
publishing date
type
Thesis
publication status
published
subject
keywords
Pediatri, intensivvård, Pediatrics, Anaesthesiology, intensive care, Anestesiologi, Pain measurement, Intrathecal pain treatment, Children
pages
108 pages
publisher
Department of Clinical Neuroscience, Lund University
defense location
Föreläsningssal F3, Centralblocket, Universitetssjukhuset i Lund.
defense date
2005-11-11 09:15
ISSN
1652-8220
ISBN
91-85439-91-6
language
English
LU publication?
yes
id
b9244fc6-cd0e-482a-8fb1-d8ac0d5572f3 (old id 545555)
date added to LUP
2007-09-20 11:52:39
date last changed
2016-09-19 08:44:59
@phdthesis{b9244fc6-cd0e-482a-8fb1-d8ac0d5572f3,
  abstract     = {Selective dorsal rhizotomy (SDR) is an effective operations method that successfully decreased the degree of spasticity with long lasting beneficial effects for children with spastic diplegia. Children undergoing SDR are postoperatively in severe pain, a pain related to both the extensive surgical exposure with multilevel laminotomy and the nerve root manipulation. To give an optimal pain relief, pain measurement is a necessity in pain treatment, but it can be difficult in pre-school children.<br/><br>
<br/><br>
A worldwide survey was made (study I) to estimate the extent of SDR surgery, evaluate operation techniques and to clarify different centres pain management after SDR. A questionnaire comprise 8 questions was sent to 59 centres. 44 (75%) centres responded to the questionnaire. 33 centres constitute the study material.<br/><br>
<br/><br>
In a prospective study (study II), two IT different regimes was evaluated, continuous infusion versus inter-mittent, concerning pain killing and possible side effects. Intrathecal continuous infusion of bupivacaine and morphine was superior to intermittent morphine in the pain treatment after selective dorsal rhizotomy operations. To define an optimal dose (study III) of the continuous IT morphine and bupivacaine for severe pain treatment after SDR with regard to the analgesic effect and survey if they differed in side effects, we compared two different concentrations of morphine 0.4 ug/kg/h and 0.6 ug/kg/h in a fixed dose of bupivacaine 40 ug/kg/h. The Behavioural Observational Pain Scale (BOPS) was used to evaluate pain. Continuoues IT pain treatment with 0.6 ug/kg/h morphine and 40 ug/kg/h bupivacaine provides safe and good analgesia after major spinal operations. This is furthered strengthened by the fact that the adverse effect did not differ between the groups and was therefore not a drawback of the high-dose group.<br/><br>
<br/><br>
Effective pain management in infants and children starts with routine evaluation of pain and a clear documentation. This requires measurement of pain intensity and pain relief with reliable, valid and clinically sensitive assessment tools. Observation of behaviour can be an acceptable alternative when valid self-report is not possible. We evaluate (study IV) the validity and reliability of BOPS, as a postoperative pain measurement scale for children aged 1 - 7 years. The scale assess three variables of pain behaviours; facial expression, verbalization and body position. With BOPS the nurses can evaluate and document pain with high reliability and validity and thereby improve the postoperative pain treatment in preschool children. The simple scoring system makes BOPS easy to incorporate in a postoperative unit.},
  author       = {Hesselgard, Karin},
  isbn         = {91-85439-91-6},
  issn         = {1652-8220},
  keyword      = {Pediatri,intensivvård,Pediatrics,Anaesthesiology,intensive care,Anestesiologi,Pain measurement,Intrathecal pain treatment,Children},
  language     = {eng},
  pages        = {108},
  publisher    = {Department of Clinical Neuroscience, Lund University},
  school       = {Lund University},
  title        = {Postoperative Intrathecal Pain Treatment in Children},
  year         = {2005},
}