[Pain therapy for children and adolescents with hemophilia : Recommendations by an expert panel]. / Schmerztherapie bei Kindern und Jugendlichen mit Hämophilie : Handlungsempfehlungen einer Expertengruppe.

BACKGROUND: Children and adolescents with severe hemophilia commonly suffer from acute and chronic pain as a consequence of hemophilia-related bleeding. Intervention-related pain also plays a major role. Despite its high prevalence in this patient group, hemophilia-related pain is not always adequately addressed and sufficiently treated. OBJECTIVES: This paper discusses how to improve pain management for children and adolescents (0-18 years) with hemophilia and which specific features in this population should influence decisions in pain management. MATERIALS AND METHODS: An expert panel discussed challenges in pain treatment in children and adolescents with hemophilia. Recommendations are based on evidence and clinical experience. RESULT: Pain management in children with hemophilia needs improvement. Children with hemophilia are at risk of developing chronic pain and of suffering traumatization due to insufficient pain management. Pain therapy can be challenging in these children as both their age and the underlying disease limit the options in particular in pain medication. The expert panel developed recommendations to improve pain management in children with hemophilia.

Correction to: S(+)-ketamine : Current trends in emergency and intensive caremedicine.

Correction to: Wien Klin Wochenschr 2017 https://doi.org/10.1007/s00508-017-1299-3 The article S(+)-ketamine Current trends in emergency and intensive caremedicine, written by Helmut Trimmel, Raimund Helbok, Thomas Staudinger, Wolfgang Jaksch, Brigitte Messerer, Herbert Schöchl and Rudolf Likar, was ….

[Pain care in Austrian health care centers: Questionnaire study on the current status of Austrian pain clinics]. / Schmerztherapeutische Versorgung österreichischer Gesundheitszentren: Fragebogenstudie zum Istzustand österreichischer Schmerzambulanzen.

BACKGROUND: Pain clinics provide interdisciplinary therapy to treat chronic pain patients and to increase the return-to-work rate. In recent years and due to increased economic pressure in health care, a change in the management of pain in Austrian health care centers has been observed. For the analysis of the current situation, two surveys addressing all Austrian pain clinics were performed. MATERIALS AND METHODS: In total, 133 heads of Austrian Anesthesia Departments were interviewed online and personally. The data from the first interview were confirmed by an additional telephone survey that was performed by one anesthetist per Austrian state (n = 9). RESULTS: Currently, 44 Austrian pain clinics are active. During the last 5 years, 9 pain clinics closed. Adding the current active pain clinics together, they represent a total of 17.5 full-time-operated clinics. The most common reasons for closing the pain clinics were lack of personnel (47%), lack of time resources (26%), lack of space resources (11%), and financial difficulties (11%). A reduction of >50% of operating hours during the last 3 years was reported by 9 hospitals. The reasons for not running a pain clinic were lack of personnel (36%), lack of time (25%) and department too small (16%). Estimates between actual and required clinics indicate that 49.5 full-time-operating pain clinics are lacking in Austria, resulting in 74% of the Austrian chronic pain patients not receiving interdisciplinary pain management. CONCLUSION: Our survey confirmed the closure of 9 pain clinics during the last 5 years due to lack of personnel and time. Pain clinics appear to provide the simplest economic saving potential. This development is a major concern. Although running a pain clinic seems to be expensive at the first sight, it reduces pain, sick leave, complications, and potential legal issues against health care centers, while simultaneously increasing the hospital's competitiveness. Our results show that 74% of Austrian chronic pain patients do not have access to an interdisciplinary pain clinic. Because of plans to further economize resources, Austria may lose its ability to provide state-of-the-art pain therapy and management.

[Austrian interdisciplinary recommendations on pediatric perioperative pain management: background, aims, methods and key messages]. / Österreichische interdisziplinäre Handlungsempfehlungen zum perioperativen Schmerzmanagement bei Kindern : Hintergrund, Ziel, Methodik und Kernaussagen.

These recommendations were originally commissioned by the"Österreichische Gesellschaft für Anästhesiologie, Reanimation und Intensivmedizin" (ÖGARI, Austrian Society for Anesthesiology, Resuscitation and Intensive Care Medicine). Against this background, Austrian experts from the disciplines anesthesiology, pain management, pediatrics and the "Berufsverband Kinderkrankenpflege" (Professional Association of Pediatric Nursing) have with legal support developed evidence-based and consensus recommendations for the clinical practice. The recommendations include key messages which cover the most important recommendations for the individual topics. The complete recommendations on pediatric perioperative pain management consist of seven separate articles which each deal with special sub-topics with comments on and explanations of the key messages. The target groups of the recommendations are all medical personnel of the individual disciplines involved in the treatment of perioperative and posttraumatic pain for neonates, infants and children up to 18 years old.

[Organization of pediatric pain management: Austrian interdisciplinary recommendations for pediatric perioperative pain management]. / Organisation des Schmerzmanagements bei Kindern : Österreichische interdisziplinäre Handlungsempfehlungen zum perioperativen Schmerzmanagement bei Kindern.

BACKGROUND: Postoperative pain management is still in need of vast improvement, especially for children. The aim of this article is to demonstrate which structures and processes must be optimized to ultimately improve patient satisfaction and safety. RESPONSIBILITIES: Basic prerequisites are among others personnel continuity and good cooperation in a multiprofessional team. A clear assignment of responsibilities is also of essential importance. PATIENT HISTORY AND INFORMED CONSENT: On admission every patient should be questioned on the currently existing pain. Patients or the parents must be informed about the pain therapy in a comprehensible manner. Possible complications, chances of success, advantages and disadvantages of the planned procedure and alternative forms of treatment must be discussed. IMPLEMENTATION: The implementation needs a great deal of consideration. The introduction of clearly defined pathways and thorough schooling contribute more to successful pain management than the establishment of pain measurement or the use of special techniques alone. EVALUATION AND DOCUMENTATION: Because pain intensity can only be described indirectly it is difficult to assess in children. Assessment is made by another person until children are 5 years old. The gold standard in pain measurement is, however, self-estimation using appropriate scales which is possible for older children. The routinely carried out representation of pain values and prompt documentation of all pain therapeutic measures are indispensible for the control and optimization of pain therapy. QUALITY OF RESULTS: Whether improvements in acute pediatric pain therapy will actually be achieved can only be realized by standardized compilation and analysis of the quality of therapy. For this purpose QUIPSInfant was developed.

[Pharmacodynamic and pharmacokinetic characteristics of pain therapy in neonates: Austrian interdisciplinary recommendations on pediatric perioperative pain management]. / Pharmakodynamische und pharmakokinetische Besonderheiten der Schmerztherapie bei Neugeborenen : Österreichische interdisziplinäre Handlungsempfehlungen zum perioperativen Schmerzmanagement bei Kindern.

The false assumption that neonates are less sensitive to pain than adults led to a long delay in the introduction of a reasonable pain therapy for children. Even if the basic principles of the development, transmission and perception of pain in premature infants and neonates are not completely understood, the results of studies have clearly shown that pain can be perceived from 22 weeks of gestation onwards. This knowledge results in the necessity to also administer an adequate pain therapy to premature and newly born infants. However, for the use of pharmaceuticals in neonates and infants the pharmacodynamic and pharmacokinetic characteristics must also be considered. The immaturity of the organs liver and kidneys limits the metabolism and also excretion processes. The different physical proportions also modify the dosing of pharmaceuticals. Children in the first year of life differ substantially from adults in physiology, pharmacodynamics and pharmacokinetics. The care of neonates and infants requires specialist knowledge which is described in this article.

[Non-pharmaceutical measures, topical analgesics and oral administration of glucose in pain management: Austrian interdisciplinary recommendations on pediatric perioperative pain management]. / Nichtmedikamentöse Maßnahmen sowie topische Analgetika und orale Zuckerstoffe im Schmerzmanagement : Österreichische interdisziplinäre Handlungsempfehlungen zum perioperativen Schmerzmanagement bei Kindern.

Non-pharmaceutical procedures are increasingly being used in pediatric pain therapy in addition to pharmaceutical procedures and have a supporting function. This article describes the non-pharmaceutical procedures which have an influence on perioperative and posttraumatic pain in children and adolescents. Prerequisites for every adequate pain therapy are affection, imparting a feeling of security, distraction and the creation of a child-oriented environment. Topical analgesics are indicated for application to intact skin for surface anesthesia. For a safe use consideration must be given to the duration of application, the dose and the maximum area of skin treated in an age-dependent manner. For simple but painful procedures in premature infants, neonates and infants, pain can be effectively reduced by the oral administration of glucose. The positive effect is guaranteed particularly for the use in a once only pain stimulation. Non-nutritive sucking, swaddling, facilitated tucking and kangaroo mother care, for example can be used as supportive measures during slightly painful procedures. There is insufficient evidence for a pain reducing effect in older infants and small children. Physical therapeutic procedures can be used as accompanying measures for acute pain and are individually adapted. However, the limited amount of currently available data is insufficient to make a critical scientific assessment of the individual measures. The effects can, however, be observed in the daily routine practice. Psychological methods can facilitate coping with pain. In situations with mental and psychiatric comorbidities or psychosocial impairment, a psychologist should be consulted. Acupuncture and hypnosis are also a meaningful addition within the framework of multimodal pain therapy.

[Pediatric perioperative systemic pain therapy: Austrian interdisciplinary recommendations on pediatric perioperative pain management]. / Perioperative systemische Schmerztherapie bei Kindern : Österreichische interdisziplinäre Handlungsempfehlungen zum perioperativen Schmerzmanagement bei Kindern.

BACKGROUND: Many analgesics used in adult medicine are not licensed for pediatric use. Licensing limitations do not, however, justify that children are deprived of a sufficient pain therapy particularly in perioperative pain therapy. The treatment is principally oriented to the strength of the pain. Due to the degree of pain caused, intramuscular and subcutaneous injections should be avoided generally. NON-OPIOIDS: The basis of systemic pain therapy for children are non-opioids and primarily non-steroidal anti-inflammatory drugs (NSAIDs). They should be used prophylactically. The NSAIDs are clearly more effective than paracetamol for acute posttraumatic and postoperative pain and additionally allow economization of opioids. Severe side effects are rare in children but administration should be carefully considered especially in cases of hepatic and renal dysfunction or coagulation disorders. Paracetamol should only be taken in pregnancy and by children when there are appropriate indications because a possible causal connection with bronchial asthma exists. To ensure a safe dosing the age, body weight, duration of therapy, maximum daily dose and dosing intervals must be taken into account. Dipyrone is used in children for treatment of visceral pain and cholic. According to the current state of knowledge the rare but severe side effect of agranulocytosis does not justify a general rejection for short-term perioperative administration. OPIOIDS: In cases of insufficient analgesia with non-opioid analgesics, the complementary use of opioids is also appropriate for children of all age groups. They are the medication of choice for episodes of medium to strong pain and are administered in a titrated form oriented to effectiveness. If severe pain is expected to last for more than 24 h, patient-controlled anesthesia should be implemented but requires a comprehensive surveillance by nursing personnel. KETAMINE: Ketamine is used as an adjuvant in postoperative pain therapy and is recommended for use in pediatric sedation and analgosedation.

[Regional anesthesia procedures in childhood: Austrian interdisciplinary recommendations on pediatric perioperative pain management]. / Regionalanästhesiologische Verfahren im Kindesalter : Österreichische interdisziplinäre Handlungsempfehlungen zum perioperativen Schmerzmanagement bei Kindern.

Regional anesthesia should be used for children whenever possible and is an essential element of a multimodal pain management. The prerequisites for a safe and effective procedure are detailed knowledge of the anatomical, physiological and pharmacological differences in childhood, the use of age-appropriate equipment and rapid recognition and treatment of possible complications. Extensive experience in pediatric as well as regional anesthesia is essential. The rule for selection of the ideal regional anesthesia procedure for each individual patient is: as central as necessary and as peripheral as possible. A risk-benefit assessment must always be carried out. Very specialized techniques, such as thoracic and lumbar epidural anesthesia in childhood must be reserved for specialist pediatric anesthesia centers because experience is necessary which can only be acquired and maintained from a large number of cases. Technically simple procedures, such as caudal anesthesia, penis root block and wound infiltration are, however, also very effective. Even if the evidence is still lacking, ultrasound-guided placement of regional anesthesia is nowadays the method of choice for children. The use will lead to an increased level of acceptance and user-friendliness of the procedure in childhood. This article presents recommendations which demonstrate those points that must be generally observed when carrying out regional anesthesia in children. An overview of the regional anesthesia procedure in children is given.

[Postoperative pain assessment in special patient groups: part I: children without cognitive impairment]. / Postoperative Schmerzmessung bei speziellen Patientengruppen: Teil I: Das kognitiv unbeeinträchtigte Kind.

The intensity of pain cannot be measured directly but can only be described subjectively. This obviously complicates the assessment especially in the younger age group. Pain evaluation and documentation are essential for good results in pain therapy. Pain can be measured by pain scales which should fulfill the requirements of practicability, reliability and validity. In neonates and children up to 4 years of age, standardized scales have been developed for observation of their activities. Children in the age group 4-6 years old are able to communicate about pain. At this age self-report scales can be used to assess pain sensations."Quality Improvement in Postoperative Pain Management in Infants" (QUIPSInfant) represents a new tool for pediatric outcome evaluation, consisting of standardized data acquisition of outcome and process quality indicators.

[Postoperative pain assessment in special patient groups: part II. Children with cognitive impairment]. / Postoperative Schmerzmessung bei speziellen Patientengruppen: Teil II: Das kognitiv beeinträchtigte Kind.

Postoperative pain assessment in children with cognitive impairment poses major challenges to healthcare professionals.Children with moderate to severe cognitive impairment are generally unable to communicate effectively and to self-report the level of pain. Difficulties assessing pain have led to their exclusion from clinical trials and rendered them vulnerable to insufficient treatment of pain.The realization of pain is a particularly important step forward for a better care of children with cognitive impairment.Scales based on a child's own perception of pain and its severity play a limited role in this vulnerable population and pain assessment tools which rely on observing pain behavior are essential. The r-FLACC, which is reliable and valid, includes specific behavioral descriptors and can be used simply and effectively postoperatively in clinical practice. Our task has to be assessing pain as a routine procedure in cognitively impaired children as a keystone for an improved and successful pain management in this very sensitive patient population.

Implementation of a standardized pain management in a pediatric surgery unit.

Postoperative pain is still a major complication causing discomfort and significant suffering, especially for children. Therefore, every effort should be made to prevent pain and treat it effectively once it arises. Under-treatment of pediatric pain is often due to a lack of both knowledge about age-specific aspects of physiology and pharmacology and routine pain assessment. Factors for long term success require regularly assessing pain, as routinely as the other vital signs together with documentation of side effects. The fear of side effects mostly prevents the adequate usage of analgesics. Essential is selecting and establishing a simple concept for clinical routine involving a combination of non-pharmacological treatment strategies, non-opioid drugs, opioids and regional anesthesia.

[Endocarditis prophylaxis in children and adolescents : implementation of the current guidelines in the Department of Paediatric Surgery at the Medical University Graz]. / Endokarditisprophylaxe bei Kindern und Jugendlichen : Umsetzung der aktuellen Leitlinien an der Universitätsklinik für Kinderchirurgie in Graz.

The timely administration of endocarditis prophylaxis means an additional stress situation for many children and their parents in an already stressful preoperative period. In addition it causes an increased organizational effort most of all in the day care department. Over many decades the use of prophylactic antibiotics to prevent infective endocarditis was recommended in patients with underlying cardiac conditions undergoing medical procedures which could lead to bacteraemia. However, transient bacteraemia occurs commonly during routine daily activities such as cleaning teeth or chewing. Most cases of endocarditis are not related to a medical procedure. There are currently no randomized and carefully controlled human trials to definitely prove the effectiveness and efficiency of endocarditis prophylaxis. Therefore, the new guidelines recommend the use of antibiotic prophylaxis only for cardiac conditions associated with the highest risk of adverse outcome from endocarditis. In paediatric surgery and paediatric anaesthesiology this applies mainly to patients with congenital heart disease. The implementation of the new guidelines in the Department of Paediatric Surgery at the Medical University Graz is illustrated in the following article.