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1.

Background

Data on practice and quality of postoperative pain treatment by anaesthesiologists after ambulatory surgery are sparse. The current survey enrolled anaesthesiologists in private practice who were responsible for pain therapy after ambulatory surgery. The aim of this investigation was to evaluate the implementation of the German S3 guidelines for acute and postoperative pain therapy in the outpatient setting.

Patients and methods

A total of 2,156?anaesthesiologists in private practice received a postal questionnaire which was limited to those anaesthesiologists who were responsible for postoperative pain therapy. The questionnaire included items such as types of surgery, techniques of anaesthesia and analgesic drugs used for pain management during the immediate postoperative phase and for the treatment at home as well as details of pain measurement.

Results

Out of 116?responses 108 could be analyzed covering a total of 86,616?patients receiving postoperative pain therapy, 80% of the operations were performed using general anaesthesia and local anaesthesia was additionally used in 9% of the institutions. In the perioperative period 66% of the respondents administered non-steroidal-antiinflammatory drugs (NSAIDs), 62% metamizol (dipyrone), 41% paracetamol (acetaminophen) and 73% opioids. After discharge 81% of the responding anaesthesiologists prescribed NSAIDs, 55% metamizol and 47% opioids for pain relief at home. Only 40% of the respondents measured and documented pain intensity. Nearly all respondents (93%) were satisfied with their pain management after outpatient surgery.

Conclusions

Pain therapy after ambulatory surgery significantly varied with respect to the methods, drugs and measures of quality assurance used by anaesthesiologists in private praxis. This survey demonstrated that the national guidelines of acute pain therapy have only been partially implemented.  相似文献   

2.
The aim of the prospective clinical study was to test the feasibility of a dipyrone/tramadol combination for pain therapy after laparoscopic and open obesity surgery. The study group was made up of 29 surgical patients; 14 following a median laparotomy and 15 following a laparoscopic approach. All received a continuous intravenous infusion of dipyrone (metamizol) and tramadol for pain relief.

The surgical procedure (laparotomy or laparoscopy), body mass index, postoperative analgesic requirement and pain intensity (visual analogue scale (VAS 1–10)) were documented.

Following laparotomy, the combination infusion provided effective analgesia. On the first and fourth postoperative days, the pain scores at rest were 1.5 and 2.3 respectively. The pain scores did not increase significantly with movement (2.7 and 2.2 respectively).

Following laparoscopic gastric banding the pain scores were less than 2.0 at rest and with movement on the first postoperative day. On the fourth postoperative day the pain scores at rest and with movement were 0.2.

This feasibility study suggests that a combination of the strong non-opioid dipyrone and the atypical opioid tramadol provides good analgesia following laparotomy and laparoscopic surgery for morbid obesity.  相似文献   


3.
Seven below-knee amputees undergoing prosthetic training had severe pain from neuromas in their stumps. All were unable to bear adequate weight on their amputated side, consequently they walked with unequal step length and obvious limp.

Pre-treatment assessment included pain on a four-point scale, muscle strength, goniometric measurement, ability of performing ambulatory activities on a three-point scale, and measurement of spatial-temporal characteristics of gait from footprints.

In this study, patients were treated daily with an intensity of 0.5 W/cm2 underwater ultrasound at a frequency of 1 MHz from a distance of 1 cm for five minutes in the continuous mode, for a total of ten treatments.

In all patients there was an immediate decrease in pain and reassessment showed improvement in gait parameters and walking. This improvement was statistically significant (p<0.05). This suggests that ultrasound can be considered a valuable modality in the treatment of neuromas.  相似文献   


4.
The specific problems related to postoperative analgesia in patients with substance use disorders (SUD) concerning opioids, alcohol, benzodiazepines, barbiturates (Part I), cocaine, crack, amphetamines, amphetamine-like designer drugs (MDMA, ecstasy), LSD, and marijuana (Part II) are described. Whereas SUD with only one substance rarely occurs, the number of polysubstance abusers is increasing. Patients with SUD may have multiple organic diseases, impaired immune response psychiatric and behavioural abnormalities, and substance-induced disorders (intoxication, withdrawal, delerium, psychotic disorders), often associated with low compliance and craving behaviour.

The perioperative management should be focused on three problems: (1) on the prevention of physical withdrawal symptoms and stressful complications in patients with SUD using CNS-depressants, (2) on the symptomatic treatment of the predominant affective withdrawal symptoms in patients suffering from SUD with CNS-stimulants, and (3) on the effective pain treatment.

The analgesic therapy is often difficult and required for longer periods of time than in other patients. However, the principles of multimodal analgesia are as valid as in non-addicts. To be effective, systemic analgesia with paracetamol, NSAIDs and opioids has to be adapted as usual, but regional analgesia techniques should be preferred for postoperative pain relief.

Patients enrolled in preoperative maintenance programmes (methadone, buprenorphine) need their daily maintenance dosage as baseline. This baseline therapy does not, however, induce analgesia. Therefore, these patients need additional short-acting opioids which have to be administered at higher dosages than usual (which do not cause respiratory depression due to opioid tolerance). The additional opioid does not increase the risk of relapse into active SUD. On the other hand, regional analgesia in patients who are enrolled in a maintenance programme does not mean withdrawal prophylaxis. These patients have an excellent analgesia, but they need their previously used maintenance opioid to prevent withdrawal. Special considerations will have to be made in patients with naltrexone.

Recovering patients with a history of SUD have both an intensive fear of relapsing into the active SUD as well as fear of suffering from postoperative pain. These patients require an equally effective analgesia as other patients. Depending on the type of surgery and pain intensity they need atypical opioids (eg tramadol) or strong opioids (eg buprenorphine or morphine) as a part of balanced analgesia to the same degree as other patients. Withholding effective analgesic treatment can paradoxically lead to relapses in recovering patients. The common opinion of healthcare providers to withhold strong opioids from recovering patients with SUD is obsolete. However, in order to avoid psychotropic side effects the dosages of opioids, as well as the analgesic efficacy, should be monitored closely.  相似文献   


5.
Appropriate pain therapy prior to diagnosis in patients with acute abdominal pain remains controversial. Several recent studies have demonstrated that pain therapy does not negatively influence either the diagnosis or subsequent treatment of these patients; however, current practice patterns continue to favour withholding pain medication prior to diagnosis and surgical treatment decision. A systematic review of PubMed, Web‐of‐Science and The‐Cochrane‐Library from 1929 to 2011 was carried out using the key words of ‘acute’, ‘abdomen’, ‘pain’, ‘emergency’ as well as different pain drugs in use, revealed 84 papers. The results of the literature review were incorporated into six sections to describe management of acute abdominal pain: (1) Physiology of Pain; (2) Common Aetiologies of Abdominal Pain; (3) Pre‐diagnostic Analgesia; (4) Pain Therapy for Acute Abdominal Pain; (5) Analgesia for Acute Abdominal Pain in Special Patient Populations; and (6) Ethical and Medico‐legal Considerations in Current Analgesia Practices. A comprehensive algorithm for analgesia for acute abdominal pain in the general adult population was developed. A review of the literature of common aetiologies and management of acute abdominal pain in the general adult population and special patient populations seen in the emergency room revealed that intravenous administration of paracetamol, dipyrone or piritramide are currently the analgesics of choice in this clinical setting. Combinations of non‐opioids and opioids should be administered in patients with moderate, severe or extreme pain, adjusting the treatment on the basis of repeated pain assessment, which improves overall pain management.  相似文献   

6.
Dipyrone (metamizol), a non-opioid analgesic, is widely used for acute and chronic pain management. Although not marketed in all countries because of concerns of possible side effects like agranulocytosis, this potent analgesic is frequently used worldwide.

A severe anaphylactic reaction without any cutaneous symptoms was observed after intravenous infusion of dipyrone 1 g. Further symptoms were a short lasting increase in airway pressure and a pronounced generalized oedema. Circulatory arrest required cardiopulmonary resuscitation. Pre-existing β-blockade aggravated poor response to adrenaline. Recovery of the patient was uneventful.

Previous case reports demonstrated that symptoms of allergic reaction after dipyrone might vary considerably. Erythema, bronchospasm and eyelid-/angio-oedema might present alone or in combination. Sole cardiovascular collapse produced by extreme generalized oedema and consecutive hypotension occurred after i.v. administration during anaesthesia. Risk factors for severe dipyrone induced allergy are: allergies/intolerability of dipyrone and other non-opioids and bronchial asthma. However, allergic reaction after previous intake of dipyrone without side effects has been described.  相似文献   


7.
Tortorici V  Nogueira L  Aponte Y  Vanegas H 《Pain》2004,112(1-2):113-120
The analgesic effect of non-steroidal anti-inflammatory drugs (NSAIDs) is partly due to an action upon the periaqueductal gray matter (PAG), which triggers the descending pain control system and thus inhibits nociceptive transmission. This action of NSAIDs engages endogenous opioids at the PAG, the nucleus raphe magnus and the spinal cord. Repeated administration of NSAIDs such as dipyrone (metamizol) and acetylsalicylate thus induces tolerance to these compounds and cross-tolerance to morphine. Since cholecystokinin plays a key role in opioid tolerance, the present study in rats investigated whether PAG cholecystokinin is also responsible for tolerance to PAG-microinjected dipyrone. Microinjection of cholecystokinin (1 ng/0.5 microl) into PAG blocked the antinociceptive effect of a subsequent microinjection of dipyrone (150 microg/0.5 microl) into the same site, as evaluated by the tail flick and hot plate tests. Microinjection of proglumide (0.4 microg/0.5 microl), a non-selective cholecystokinin antagonist, into PAG prevented the development of tolerance to subsequent microinjections of dipyrone, as well as cross-tolerance to microinjection of morphine (5 microg/0.5 microl) into the same site. In rats tolerant to PAG dipyrone, a PAG microinjection of proglumide restored the antinociceptive effect of a subsequent microinjection of dipyrone or morphine. These results suggest that PAG-microinjected dipyrone triggers and/or potentiates local opioidergic circuits leading to descending inhibition of nociception, on the one hand, and to a local antiopioid action by cholecystokinin, on the other. Reiteration of these events would then result in an enhancement of cholecystokinin's antiopioid action and thus tolerance to opioids and dipyrone in the PAG.  相似文献   

8.
目的:评价塞来昔布在手部手术围手术期的镇痛疗效.方法:将2009年1月至12月收治的60例手部手术患者随机分为观察组和对照组各30例,观察组在术前1h口服塞来昔布400 mg,术后当天口服200mg,术后1~5天,每日两次,每次口服200 mg;对照组予安慰剂,两组术后均不限制使用患者自控镇痛、肌注或口服阿片类药物.比较两组患者的术后视觉模拟( VAS)评分、阿片类药物的用量及术后不良反应的发生率.结果:观察组在术后1~3天的VAS评分明显低于对照组(P<0.05),术后当天和第四、五天两组的VAS评分无明显差异(P>0.05);在术后当天至术后第五天内观察组使用阿片类药物的次数明显少于对照组(P<0.05);两组不良反应的发生率无显著性差异(P>0.05).结论:在手部手术围手术期使用塞来昔布可提高镇痛效果,减少术后阿片类药物的使用,而不增加术后不良反应的发生率.  相似文献   

9.
The aim of this randomised, double-blind study was to determine whether a low-tech patient controlled analgesia (PCA) model with various dose aliquots of piritramid or a combination of tramadol/dipyrone is suitable for use in postoperative pain therapy. By suitable the authors mean (a) whether effective analgesia can be attained; (b) whether patients can understand and appropriately use the PCA pump; and (c) whether good patient acceptance is achieved.The authors studied 82 patients (ASA I–II) aged between 18–70 years. The patients were divided into four subgroups. All patients received a start-up loading dose of the same analgesic which they thereafter received via the PCA pump. The aliquots of drug provided by the PCA pump were always contained in 0.5 ml. This volume, however, contained different amounts of analgesic: piritramid either (1) 1.5 mg (high dose) or (2) 0.75 mg (low dose); (3) tramadol 10 mg with dipyrone 50 mg (high dose mixture); (4) tramadol 5 mg with dipyrone 25 mg (low dose mixture).The results showed that the PCA device is suitable for use in postoperative pain therapy. The rate of side effects was low. In the first 24 hours, the consumption of analgesics was similar in the low dose aliquot and high dose aliquot groups: Group (1) 43.5 mg piritramid; Group (2) 37.2 mg piritramid; Group (3) 267 mg/1335 mg tramadol/dipyrone; Group (4) 256 mg/1275 mg tramadol/dipyrone.Analgesia was effective, as judged by visual analogue scale (VAS) scores of 4 or less. Up to the 12th hour the VAS score was noted to be lower (more effective analgesia) in the tramadol/dipyrone group as compared to the piritramid group.In conclusion, a postoperative PCA regimen using a low-tech PCA device provides effective analgesia with a low rate of side effects and is suitable for use in postoperative patients.  相似文献   

10.
Objective To determine whether dipyrone has an opiate-sparing effect in post-operative pain therapy compared with placebo during patient-controlled morphine therapy (PCA) and to compare the effects on analgesia and respiratory and coagulation parameters.Design Randomized, observer-blind, parallel-group, placebo-controlled study.Setting Surgical intensive care unit of a university hospital.Patients 106 adult patients who were to undergo abdominal or urological surgery under 90-min standardized inhalational anaesthesia were entered and 103 were included in the efficacy analysis (53 on dipyrone, 50 on placbo).Interventions Preprogrammed PCA (0.03 mg morphine/kg per bolus) with either dipyrone (initially 2.0 g i.v. and 1.0 g/2 ml i.v. at 4, 8 and 16 h) or placebo (saline).Measurements and results Cumulative morphine consumption was calculated automatically during PCA. Pain intensity and pain relief and the investigator's global assessments of efficacy and tolerability were recorded on five-point verbal rating scales. Vital signs, standard laboratory parameters, respiratory rate, partial pressure of carbon dioxide (PCO2) and of oxygen, partial thromboplastin time (PTT) and Quick values were recorded. Total consumption of opiates in the dipyrone group (median 31.6 mg) was significantly less (p=0.00015) than in the placebo group (median 50.3 mg), while pain relief (area under the curve) AUC was the same for both PCA+dipyrone (median 4.1) and PCA+placebo (median 3.9). Global assessment of efficacy was good to excellent in more than 90% of cases in both groups. Vital signs, respiratory rate, PCO2, PTT and Quick did not differ between groups. Adverse events were mainly nausea and/or vomiting (dipyrone,n=4; placebo,n=1); 1 patient in the placebo group had bradycardia. Three serious adverse events were unrelated to study medication. In 1 patient, the PCA programme malfunctioned and had to be changed.Conclusions concomitant administration of dipyrone with on-demand morphine (PCA) reduces opiate consumption while maintaining post-operative pain relief with a low incidence of side-effects.Sponsor: Hoechst Marion Roussel, Frankfurt/Main, Germany  相似文献   

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