Postoperative Schmerztherapie nach ambulanten Operationen

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.     

Cancer pain management in an oncological ward in a comprehensive cancer center with an established palliative care unit

Background

This survey was performed to draw information on pain prevalence, intensity, and management from a sample of patients who were admitted to an oncologic center where a palliative care unit (PCU) has been established for 13 years.

Methods

Cross-sectional survey in an oncological department performed 1 day per month for six consecutive months.

Results

Of the 385 patients, 69.1, 19.2, 8.6, and 3.1 % had no pain, mild, moderate, and severe pain, respectively. Inpatients and patients with a low Karnofsky score showed higher levels of pain intensity (p?<?0.0005). One hundred twenty-eight patients with pain or receiving analgesics were analyzed for pain management index (PMI). Only a minority of patients had negative PMI score, which was statistically associated with inpatient admission (p?=?0.011). Fifty of these 128 patients had breakthrough pain (BTP), and all of them were receiving some medication for BTP.

Conclusion

It is likely that the presence of PCU team providing consultation, advices, and cultural pressure, other than offering admissions for difficult cases had a positive impact on the use of analgesics, as compared with previous similar surveys performed in oncological setting, where a PCU was unavailable. This information confirms the need of the presence of a PCU in a high volume oncological department.     

Bewertung der operativen Weisheitszahnentfernung durch sedierte und nicht sedierte Patienten

Methods

A total of 426 patients ranging in age from 11 to 61 years (mean 20.8 years) participated, 335 of whom preferred Midazolam sedation (0.1 mg/kg) while 91 voted for local anaesthesia only. During the operation an impacted lower third molar was removed by osteotomy, and in 80% of these cases the upper third molar on the same side was also removed. A questionnaire on the operation, the follow-up period, postoperative pain and use of analgesics was distributed before the event.

Results

Women and younger patients preferred conscious sedation. Surgery was described as significantly less distressing by the sedated group (diagram 1), whereas there was no difference in views of the follow-up period or postoperative pain. Patients in the Midazolam group took more analgesics on postoperative days 1–3. Nonsedated men tended to evaluate surgery as more distressing than women in the same group, while there were no sex differences in the Midazolam group.

Conclusion

Following the evaluation of surgery as more “pleasant” by sedated patients, it might be expected that this would contribute to a similar experience of the follow-up period. In this study, however no such connection was found. It is possible that preoperative self-selection of the patients (more sensitive and cautious persons preferred conscious sedation) might be responsible for these results.     

Withholding and withdrawing life-sustaining treatment: a comparative study of the ethical reasoning of physicians and the general public

Background

Our objective was to investigate whether a consensus exists between the general public and health care providers regarding the reasoning and values at stake on the subject of life-sustaining treatment.

Methods

A postal questionnaire was sent to a random sample of members of the adult population (n = 989) and to a random sample of intensive care doctors and neurosurgeons (n = 410) practicing in Sweden in 2004. The questionnaire was based on a case involving a severely ill patient and presented arguments for and against withholding and withdrawing treatment, and providing treatment that might hasten death.

Results

Approximately 70% of the physicians and 51% of the general public responded. A majority of doctors (82.3%) stated that they would withhold treatment, whereas a minority of the general public (40.2%) would do so; the arguments forwarded (for instance, belief that the first task of health care is to save life) and considerations regarding quality of life differed significantly between the two groups. Most physicians (94.1%) and members of the general public (77.7%) were prepared to withdraw treatment, and most (95.1% of physicians and 82% of members of the general public) agreed that sedation should be provided.

Conclusion

There are indeed considerable differences in how physicians and the general public assess and reason in critical care situations, but the more hopelessly ill the patient became the more the groups' assessments tended to converge, although they prioritized different arguments. In order to avoid unnecessary dispute and miscommunication, it is important that health care providers be aware of the public's views, expectations, and preferences.     

Preoperative pain treatment in acute abdomen in Osogbo,Nigeria: a randomized double-blind placebo-controlled study

Background

Withholding analgesics in acute abdomen for fear of masking clinical features and impairing diagnosis and decision-making is still being practiced despite recent evidence to the contrary. This study assesses the effect of preoperative analgesia on clinical findings, clinical diagnosis, and decision-making in patients with non-trauma acute abdomen.

Method

This is a randomized, double-blind, placebo-controlled study using Tramal, a brand of tramadol, at the ED of LAUTECH Teaching Hospital Osogbo, Nigeria. Ninety-five patients between 18–60 years received Tramal (n?=?46) or placebo (n?=?49). The pain score, clinical findings, provisional diagnosis, and treatment plan were noted before and 15–20 min after administration of the analgesic or placebo. The final diagnosis arrived at after adequate investigation or operation was considered the gold standard. The pain scores, diagnosis, treatment plan, and decision between the two groups were compared. Statistical analysis was by SPSS 16. Results were considered statistically significant at p?<?0.05.

Results

Demography and case distribution were similar in both groups. The improvement in pain was greater in the Tramal group (p?=?0.001). The abdominal palpation findings were also better in the Tramal group (p?=?0.02). There were more changes in the diagnosis after use of Tramal (p?=?0.01). There were more changes in the decision in the Tramal group (p?=?0.03). Most of the changes in diagnosis and decision in the Tramal group were for the better.

Conclusion

The preoperative use of Tramal in acute abdomen improved the experience of pain and did not adversely affect the accuracy of the diagnosis or decision-making.

     

Using scenarios to explain life expectancy in advanced cancer: attitudes of people with a cancer experience

Purpose

We sought the attitudes of people with a cancer experience to using best case, worst case, and typical scenarios for survival to explain life expectancy.

Methods

Oncology clinic attendees and Breast Cancer Network Australia (BCNA) members completed a survey describing two formats for explaining life expectancy to a hypothetical patient with advanced cancer—providing either three scenarios for survival or just the median survival time.

Results

Characteristics of the 505 respondents from outpatient clinics (n?=?251) and BCNA (n?=?254) were median age of 58 years, female 74 %, and breast primary 64 %. More respondents agreed that explaining three scenarios (vs. median survival) would make sense (93 vs. 75 %), be helpful (93 vs. 69 %), convey hope (68 vs. 44 %), and reassure (60 vs. 40 %), while fewer respondents agreed that explaining three scenarios (vs. median survival) would upset people (24 vs. 36 %); all p values?<?0.001. Most respondents agreed that each scenario should be presented: best case 89 %, worst case 82 %, and typical 92 %. For information about their own prognosis, 88 % preferred all three scenarios and 5 % a single estimate of the median. Respondents with higher education were more likely to agree that presenting three scenarios would be helpful (95 vs. 90 %, p?=?0.05). Respondents with breast cancer were more likely to agree that explaining three scenarios would upset people (31 vs. 13 %, p?<?0.001).

Conclusions

Most respondents judged presentation of best case, worst case, and typical scenarios preferable and more helpful and reassuring than presentation of just the median survival time when explaining life expectancy to patients with advanced cancer.     

Beschwerden unter Analgetika

Background

Older patients, particularly those with multimorbidity, complain about many symptoms which also occur under analgesics (especially with opiods). The goals of the study were to quantify symptoms and discuss the relationships to analgesics, pain, multimorbidity, function, age and gender.

Patients and methods

On admittance to geriatric hospital, 1700 consecutive inpatients were questioned about symptoms typically of side-effects of analgesics and pain. Additionally medication including analgesics, activities of daily living, orientation, age, gender and morbidity were recorded.

Results

Of the patients, 1,418 (mean age 80.9 years) could answer questions about symptoms. Disturbance of sleep (n=664, 46.8%), pain (n=609, 43.0%), low appetite (551, 37.4%), dizziness (482, 34%), tiredness (331, 19.7%), constipation (236, 16.6%) and problems of urination (213, 12.7%) were indicated most frequently. Univariate analysis showed the well known correlations of analgesics and symptoms to be dependent on dose and substances. However, using a multivariate model, analgesics lost the significance for the symptoms with some exceptions. Pain intensity, duration of pain and gender differences became more important. Vomiting, dry mouth, and problems with urination correlated with low levels of activities of daily living. Increasing morbidity and cognitive deficits were not important for many symptoms.

Conclusions

Our results underline the difficult interpretation of symptoms as a side-effect of analgesic treatment in older patients. Pain and gender differences have to be considered. The recommendation to carefully record symptoms before analgesic treatment is supported by our results.     

Death in emergency departments: a multicenter cross-sectional survey with analysis of withholding and withdrawing life support

Purpose

To describe the characteristics of patients who die in emergency departments and the decisions to withhold or withdraw life support.

Methods

We undertook a 4-month prospective survey in 174 emergency departments in France and Belgium to describe patients who died and the decisions to limit life-support therapies.

Results

Of 2,512 patients enrolled, 92 (3.7%) were excluded prior to analysis because of missing data; 1,196 were men and 1,224 were women (mean age 77.3 ± 15 years). Of patients, 1,970 (81.4%) had chronic underlying diseases, and 1,114 (46%) had a previous functional limitation. Principal acute presenting disorders were cardiovascular, neurological, and respiratory. Life-support therapy was initiated in 1,781 patients (73.6%). Palliative care was undertaken for 1,373 patients (56.7%). A decision to withhold or withdraw life-sustaining treatments was taken for 1,907 patients (78.8%) and mostly concerned patients over 80 years old, with underlying metastatic cancer or previous functional limitation. Decisions were discussed with family or relatives in 58.4% of cases. The decision was made by a single ED physician in 379 cases (19.9%), and by at least two ED physicians in 1,528 cases (80.1%).

Conclusions

Death occurring in emergency departments mainly concerned elderly patients with multiple chronic diseases and was frequently preceded by a decision to withdraw and/or withhold life-support therapies. Training of future ED physicians must be aimed at improving the level of care of dying patients, with particular emphasis on collegial decision-taking and institution of palliative care.     

Intranasales Fentanyl zur Therapie akuter Schmerzspitzen bei Karzinompatienten

Background and aim of the study

Despite regular administration of analgesics, a high percentage of patients with chronic malignant pain experience break-through cancer pain or incident pain. Such pain peaks in patients with chronic malignant pain require “rescue” medication in addition to basic analgesia with for example slow-release morphine or buprenorphine. For rescue medication a fast acting and powerful analgesic should be available to the patient. Recent studies have shown that intranasal fentanyl provides rapid onset of pain relief.

Patients and methods

In this open pilot study five patients with chronic cancer pain (age: 42–62 years; weight: 55–80 kg) received demand-adapted intranasal fentanyl titration for treatment of acute breakthrough cancer pain. Intranasal fentanyl doses (0.027 mg) were repeated at 5-min intervals until the patients experienced marked pain relief. Pain intensity was evaluated (0–30 min: 5-min intervals; 30–120 min: 10-min intervals) with the aid of a numerical rating scale (0 = no pain; 100 worst pain possible).

Results and discussion

The patients received 2, 4, 6, 7 or 8 fentanyl boluses (totalling 0.054 mg, 0.108 mg, 0.162 mg, 0.189 mg or 0.216 mg, respectively). Rapid onset and marked reduction of pain intensity was achieved in all five patients. There were no clinically relevant changes in arterial haemoglobin oxygen saturation, heart rate, arterial blood pressure or respiratory rate. All five patients scored the pain relief obtained as good or very good. There were no reports of pain or burning sensations in the nose or other side-effects.     

A prospective,open-label,multicenter study of the clinical efficacy of extended-release hydromorphone in treating cancer pain inadequately controlled by other analgesics

Purpose

The objective of this study was to evaluate whether extended-release hydromorphone (osmotic-controlled release oral delivery system [OROS] hydromorphone) treatment provided pain relief in cancer patients whose pain was inadequately controlled by other analgesics.

Methods

In this prospective, open-label, multicenter trial, patients who have sustained cancer pain with other analgesics were enrolled. After the baseline evaluation (visit 1), OROS hydromorphone was administered. Two evaluations (visits 2 and 3) were made: 29?±?7 and 57?±?7 days later, respectively. The primary end point was the pain intensity difference (PID) at visit 3 relative to visit 1 (expressed as percent PID).

Results

In total, 879 patients were screened and 432 completed all three visits. Of the 874 full analysis set patients, 343 (39.2 %) improved by more than 30 % PID. Of the 432 per-protocol patients, 282 (65.3 %) improved by more than 30 % PID. At visits 2 and 3, the degree of sleep disturbance, the number of awakenings, and the degree of sleep satisfaction were significantly better than at visit 1 (all P?<?0.0001 for both visit 1–visit 2 and visit 1–visit 3). However, this pain relief was not associated with improved quality of life (P?=?0.326 and P?=?0.055 for visit 1–visit 2 and visit 1–visit 3, respectively).

Conclusions

This study suggested that active pain management using the strong opioid OROS hydromorphone was beneficial in the management of cancer pain that was not controlled by other analgesics.     

Spontaneous intraperitoneal hemorrhage as the initial presentation of a gastrointestinal stromal tumor: a case report

Background

Spontaneous hemoperitoneum is rare. The most common etiologies are gynecologic, splenic, and hepatic. Gastrointestinal stromal tumors (GISTs) are commonly associated with intraluminal bleeding, but rarely with spontaneous hemoperitoneum. We report a case of spontaneous hemoperitoneum caused by a gastric GIST.

Case report

A 54-year-old male presented with the acute onset of abdominal pain and a drop in hemoglobin. Subsequent evaluation, including a CT, MRI, and EUS, revealed a 1.2-cm mass along the greater curvature of the stomach and associated hemoperitoneum. The patient was taken electively to the operating room for laparoscopic removal of the mass. Pathology confirmed that it was a GIST.

Conclusion

GIST is a rare clinical entity that infrequently presents with spontaneous hemoperitoneum. Emergent treatment should be guided towards treating the spontaneous hemoperitoneum.     

P?diatrische Schmerztherapie

Background

In order to provide efficient pain treatment clinicians need to know the latest developments in pain management and to implement this knowledge into clinical practice. The knowledge of pediatric nursing staff with regards to pediatric pain management has not yet been investigated. In this study we therefore investigated nurses?? knowledge of pediatric pain management strategies.

Methods

Nursing staff knowledge was analyzed using the German version of the PNKAS-Sr2002. This questionnaire was distributed to 310?pediatric nurses and the response rate was 51.3% (n=159). Analyses of variance (ANOVA) were conducted to examine whether educational level and work experience had an influence on knowledge. Independent from work experience the educational level of nurses is important for their knowledge in pediatric pain management.

Results

On average nurses obtained a mean individual test score of 69.3%. Nurses with advanced qualification and nurses with 6?C10?years work experience obtained the highest scores.

Conclusion

Pediatric nurses must be trained more efficiently in pediatric pain management so that an adequate pain management is available for children and adolescents.     

Perioperative systemische Schmerztherapie 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.     

« Mon doulèr, mon soufrans »: représentations et vécu psychique de la douleur viscérale à l’île de La Réunion

Aims

Pain covers several realities: individual, social, and cultural. To seize it, it is useful to be able to deal with the glance of several disciplines, especially when there is a strong influence of social and cultural data on how an individual is going to live the pain, in his individuality. Is it the case for abdominal pain in the Reunion Island, where the identity of each builds itself in interaction of two different and complementary dimensions: the cultural universe of origin and the “Creole,” the real cement which unites the subjects around common customs, patiently constructed in time?

Procedure

Case report.

Results

The psychic experience is filled with strong and sometimes paradoxical cultural representations: its own culture and the culture of the “Creole people.”

Conclusion

In this context, this article investigates the possible implications of the visceral pain in patients living in the Reunion Island.     

Cardiogoniometry as a diagnostic tool in patients with acute coronary syndromes: results of the CGM@ACS trial

Background

Cardiogoniometry (CGM) is a novel electrocardiac method utilising computer-assisted three-dimensional information on cardiac potentials.

Objective

To investigate the potential of CGM in discriminating non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and relevant coronary stenosis upon hospital admission by prospectively comparing its sensitivity, specificity and accuracy against those of a single troponin test and a 12-lead ECG performed on admission

Design

A multicenter prospective observational trial.

Setting

Eight interventional cardiac centres in Germany.

Patients

A cohort of 216 patients (mean age 67?years, 34.7?% female) who presented with acute chest pain or dyspnoea without ST-segment elevation and were scheduled for coronary angiography within 72?h of admission.

Intervention

Pre-angiography screening by CGM, troponin test, 12-lead ECG

Main outcome measures

ECG, troponin and CGM on admission compared with final diagnosis of NSTE-ACS or relevant diameter stenosis ≥70?% verified by an independent review board and an angiographic core laboratory.

Results

NSTE-ACS was finally confirmed in 162 cases, whereas the remaining 54 cases without proof of NSTE-ACS served as controls. Diagnostic sensitivity for NSTE-ACS was 28, 50 and 69?% and specificity 78, 96 and 54?% for first ECG, serial troponin and first CGM, respectively. Accuracy was 40, 62 and 65?%. The sensitivity of the tests to detect relevant coronary stenosis (n?=?126) was 32, 53 and 74?%, respectively. The sensitivity of CGM to detect NSTE-ACS (65?%) or relevant stenosis (71?%) was high even in patients with normal troponin and ECG.

Conclusions

CGM can detect NSTE-ACS at first medical contact. CGM in conjunction with traditional markers, 12-lead ECG and troponin may effectively aid early decision making in patients presenting with acute chest pain.     

Wissen verschiedener Arztgruppen ��ber die Tumorschmerztherapie

Background

Palliative care needs a high level of expertise. In particular, there are some potential difficulties in the treatment of patients with the symptom cancer pain (for example lack of education). In Germany, various physicians are involved in cancer pain treatment but in general palliative care patients are treated by a physician who is educated in palliative medicine. In special circumstances prehospital emergency physicians and other physicians are involved in therapy decisions in palliative care patients as well. The authors surveyed different groups of physicians in Germany about their specific knowledge of cancer pain management.

Material and methods

A self-designed, standardized questionnaire (50 items) was given to palliative physicians in training (PP). The survey asked prospectively for knowledge on the World Health Organization (WHO) step ladder of cancer pain therapy. The results were retrolectively compared with an earlier investigation with the same background (emergency physicians in training EP).

Results

There was a 99.5% response rate with a total of 654 respondents (PP 185, EP 469) and 461 (70.5%) of the respondents had knowledge of the WHO step ladder for the treatment of cancer pain [PP 164/185 (88.6%), EP 297/469 (63.3%), PP versus EP p?Conclusions The results of this study verified that the highest knowledge scores were achieved by PPs and overall, the knowledge scores showed an improvement in comparison to previous investigations. In recent years there seems to have been an improvement in education on pain treatment,for example during medical school. Whether this also leads to an improvement of patient care and the relevance of these data for the clinical practice needs to be investigated in further studies.     

Einfluss präoperativer Patienteninformationen auf postoperative Schmerzen unter Berücksichtigung individueller Stressverarbeitung

Objective

The German guideline for the treatment of acute perioperative and post-traumatic pain (S3-Leitlinie zur Behandlung akuter perioperativer und posttraumatischer Schmerzen) recommends giving preoperative information about postoperative pain and how to influence it. It is expected that the effect of preoperative information is modified by psychological characteristics of the patient. One of these psychological characteristics is the individual coping style. The purpose of the study is to evaluate whether or not patients benefit from preoperative education in relation to their level of negative coping style.

Methods

The study is based on a 2×2 factorial experimental design with the experimental factor “treatment” (education vs control condition) and the factor “negative coping style” (high vs low). After informed consent 96 patients undergoing abdominal or vascular surgery were enrolled in the study. Outcomes were pain intensity, pain quality and psychic state. They were assessed by using numerical rating scales and psychometric methods of self-assessment. The data were collected preoperatively and on the first to third postoperative day.

Results

Patients who received preoperative education experience a greater reduction in postoperative pain than patients without preoperative education do (ES=0.48). The risk for stronger pain (NRS>3) on the third postoperative day is decreased (2.1 vs 14.6%). The influence of negative coping style is altogether minimal.

Conclusions

Preoperative patient information has positive effects on the postoperative development of pain. Patient information is a valuable addition to the drug pain treatment. The application can be recommended regardless of the level of the patients’ negative coping style     

Stress et douleurs viscérales: une revue

Aim

To review the various psychological theories of stress, to better understand how this takes place in the question of visceral pain, in particular, abdominal pain.

Procedure

Systematic review of significant articles on stress and visceral pain, in both the child and the adult.

Results

A great influence of the events suppliers of stress in the visceral pain is demonstrated. However, the link of causality cannot be demonstrated.

Conclusion

The clinical approach of visceral pain is complex. Therefore, it is open toward complementary therapeutic ways, which seem to bring satisfaction in many situations.