Cerebral oxygenation following decompressive hemicraniectomy for the treatment of refractory intracranial hypertension

OBJECT: Medically intractable intracranial hypertension is a major cause of morbidity and mortality after severe brain injury. One potential treatment for intracranial hypertension is decompressive hemicraniectomy (DCH). Whether and when to use DCH, however, remain unclear. The authors therefore studied the effects of DCH on cerebral O2 to develop a better understanding of the effects of this treatment on the recovery from injury and disease. METHODS: The study focused on seven patients (mean age 30.6 +/- 9.7 years) admitted to the hospital after traumatic brain injury (five patients) or subarachnoid hemorrhage (two patients) as part of a prospective observational database at a Level I trauma center. At admission the Glasgow Coma Scale (GCS) score was 6 or less in all patients. Patients received continuous monitoring of intracranial pressure (ICP), cerebral perfusion pressure (CPP), blood pressure, and arterial O2 saturation. Cerebral oxygenation was measured using the commercially available Licox Brain Tissue Oxygen Monitoring System manufactured by Integra NeuroSciences. A DCH was performed when the patient's ICP remained elevated despite maximal medical management. CONCLUSIONS: All patients tolerated DCH without complications. Before the operation, the mean ICP was elevated in all patients (26 +/- 4 mm Hg), despite maximal medical management. After surgery, there was an immediate and sustained decrease in ICP (19 +/- 11 mm Hg) and an increase in CPP (81 +/- 17 mm Hg). Following DCH, cerebral oxygenation improved from a mean of 21.2 +/- 13.8 mm Hg to 45.5 +/- 25.4 mm Hg, a 114.8% increase. The change in brain tissue O2 and the change in ICP after DCH demonstrated only a modest relationship (r2 = 0.3). These results indicate that the use of DCH in the treatment of severe brain injury is associated with a significant improvement in brain O2.     

Clinical efficacy of alprostan in treatment of obliterating multifocal atherosclerotic affection of arteries in patients with critical ischemia of lower extremities

Experience of application of alprostan (PGE1, alprostadil) in 19 patients with atherosclerotic affection of vessels, chronic and acute ischemia of lower extremities in III-IV stage in combination with affection of other vascular basins was summarized. In 10 patients, to whom operative vascular reconstruction was contraindicated and/or technically unrealizable, the conservative treatment was conducted using alprostan during 12-25 days up to the clinical effect achievement (total dose up to 1.6 mg). In 9 patients after performance of conservative treatment using alprostan the vascular bed reconstruction was done. Daily infusion of alprostan in 0.1 mg dose diluted in 250-400 ml of isotonic solution of sodium chloride during 2.5-3 h with duration of course not less than 15 days and 1.2-2.2 mg total dose of preparation constitutes an optimal scheme of treatment. Good result was noted in treatment of patients in stage II of ischemia, application of alprostan in stage IV of ischemia had permitted to reduce the extremity amputation volume or to escape it on the whole, and to restore more rapidly the cutaneous integrity in the trophic disorders regions. The alprostan usage is trustworthy in patients with multifocal atherosclerosis with the cardiac coronary vessels affection in an ischemic heart disease.     

Experience and attitudes of surgeons toward palliation in cancer

BACKGROUND: Surgery can effectively palliate symptoms in patients with advanced malignancy and thereby maintain quality of life. However, the goal of surgical palliation should be balanced with the associated risks, and the decision to operate can be challenging for even the most experienced surgeon. HYPOTHESIS: There are significant deficiencies in training during residency and in continuing medical education in palliative surgical care leading to a lack of agreement for treatment recommendations. DESIGN AND SETTING: A survey of general surgeons involving 4 clinical vignettes of patients with advanced malignancies and varying degrees of symptoms. Respondents were asked to select the best treatment option for each patient from a list of 6 alternatives. Furthermore, respondents identified the clinical factors that most influenced the decision, as well as the major goal of the palliative intervention. SUBJECTS: Surgeons in a midsized urban setting and its surrounding region. RESULTS: Of 124 surveys sent out, 70 (56%) were completed. Significant deficiencies in education were identified; 59 (84%) of the respondents did not receive any education in palliative surgical care during residency and 28 (44%) lacked continuing medical education. A consensus treatment recommendation was not selected in 3 of the 4 clinical vignettes, but the respondents used similar clinical factors and goals of treatment for selection of the specific recommendation. CONCLUSIONS: Palliative care is a major deficiency of postgraduate surgical training. A more focused effort in training surgeons in palliative care may allow for the more uniform and standard provision of palliative surgical care to patients with advanced cancer.     

Decision making in palliative surgery

BACKGROUND: Palliative surgery for advanced cancer patients involves complex decision making. Surgeons with a cancer-focused practice were surveyed to determine the extent to which palliative surgery was currently practiced, to identify ethical dilemmas and barriers they faced in performing palliative surgery, and to evaluate their treatment choices in four different clinical scenarios. STUDY DESIGN: A 110-item survey was devised after extensive review of the palliative care and palliative surgery literature to evaluate current practices and attitudes regarding palliative surgery. Case vignettes were devised to evaluate dinical factors influencing surgeons' selection of treatment for symptomatic patients with advanced malignancy. RESULTS: Survey response rate was 24% (419 of 1,740). Respondents reported 74% of their surgery caseload as cancer related, and 21% of these as palliative. On a scale of 1 (uncommon problem) to 7 (common problem), surgeons reported that the most common ethical dilemmas in palliative surgery were providing patients with honest information without destroying hope (5.6 +/- 1.4) (mean +/- standard deviation), and preserving patient choice (5.0 +/- 1.7). Bound on error of the average frequency estimate for ethical dilemmas, based on response rate, was 0.08. On a scale of 1 (not a barrier) to 7 (a severe barrier), surgeons rated the most severe barriers to optimum use of palliative surgery as limitations of managed care (4.1 +/- 2.0) and referral to surgery by other specialists (3.9 +/- 1.8). Bound on error of the estimate for average severity of barriers, based on response rate, was 0.09. They rated the least severe barriers to palliative surgery as surgeon avoidance of dying patients (3.0 +/- 1.8) and surgery department reluctance to perform palliative surgery (2.6 +/- 1.6). Analysis of surgeons' treatment selection in case vignettes indicated that patient age, aggressiveness of tumor biology, local extent of disease, and severity of patient symptoms were all variables of influence for treatment selection in patients with advanced malignancies. CONCLUSIONS: Palliative surgery involves numerous ethical dilemmas, the most prominent being providing honest information to patients without destroying hope, and complex treatment decision making. We have identified variables of major influence to surgeons in the palliative treatment selection for patients with advanced, solid malignancies. Validation of these variables as meaningful will require future studies focusing on patient outcomes.     

Objective evaluation of the quality of palliation in patients with oesophageal cancer comparing surgery, radiotherapy and intubation.

The objective of this study was to prospectively evaluate the quality of palliation of 103 patients presenting to a joint oesophageal cancer clinic while recording the outcome in terms of treatment, morbidity, mortality and long-term survival. Twenty-five patients underwent surgical resection (S), 22 radical radiotherapy (RR), 30 palliative radiotherapy (PR), 13 intubation (I) and 13 had no treatment (NT). The quality of palliation was quantified by plotting a score out of 100 on a graph at each visit for Karnofsky performance, severity of pain and swallowing ability, then calculating the area under each curve created using an algorithm, Simpson's discrete approximation. Efficiency of palliation was estimated by comparing the area calculated to the maximum that could be achieved during the time frame being studied. The incidence of stricture (benign and malignant) was 16% after surgery and 50% after radical radiotherapy. Treatment mortality was as follows: RR, 0; S, 1 (4%); PR, 3 (7%); and I, 0. The median survival was 26 months after surgery and 16 months after radical radiotherapy. It was 6 months for palliative radiotherapy, 4 months for intubation and 4 months for no treatment. The difference in swallowing was the only statistical difference in the quality of palliation of patients having surgery and radical radiotherapy, there being no differences in patients having palliative measures.     

Adoption of self-expanding metallic stents in the palliative treatment of obstructive colorectal cancer-look out for perforations!

Self-expanding metallic stents (SEMSs) are increasingly used for the palliative treatment of inoperable colorectal cancer. The aim of the current study was to analyze the safety and efficacy of SEMS in the palliative treatment of obstructive colorectal cancer. Between 2003 and 2006, SEMS placement was attempted in 26 patients suffering from inoperable obstructive colorectal cancer. The recovery of the patients and the outcome of this treatment modality were analyzed prospectively. SEMS was successfully inserted in 19 (73%) of 26 patients. In 16 (84%) of these 19 cases, the placement of SEMS was the definitive treatment of colorectal obstruction and no additional surgical palliation was needed. There were 3 (16%) colonic perforations related to stent application. SEMS insertion seems to be an effective alternative in the palliative treatment of patients with malignant colorectal obstruction. However, perforation is a dangerous complication of the procedure.     

Outcomes following reirradiation of patients with head and neck cancer

BACKGROUND: This study reports the outcomes for patients with head and neck cancer who received reirradiation with palliative or curative intent. METHODS: A retrospective review of 41 patients treated with curative (n = 28) or palliative (n = 13) reirradiation was conducted. Survival was calculated from the start of the reirradiation. Radiation-related toxicities were classified according to Radiation Therapy Oncology Group criteria. Disease-related problems included adverse events during or after reirradiation that were not directly related to reirradiation. RESULTS: The observed 1-year survival for all patients was 39.0% (23.0% palliative, 46.3% curative). Median survival for all patients was 10.2 months. Seventy-five percent of curative and 53.8% of palliative patients had grade 3 or 4 radiation-related toxicities and/or major disease-related problems. CONCLUSION: A second course of radiotherapy in patients with head and neck cancer should be offered with a clear understanding that survival is poor and many of these patients will suffer severe radiation-related or disease-related insults to their quality of life during and after treatment.     

The transplantation of revascularized tracheolung complex: the experimental study

The osteoplastic tracheobronchopathy affects the trachea, main, lobar and smaller bronchi, causing their stenosis. Nowadays the mainstay of the treatment of such patients is the cryodestruction, laser destruction and the endoscopic buginage of the trachea and bronchi. The palliative nature and low efficacy of these procedures forces to search new ways of treatment. The traditional lung transplantation or separate trachea and lung transplantation is inappropriate because of the complex affection of both trachea and bronchi. The experimental study aimed the possibility of thyreotracheolung revascularized donor complex transplantation.     

The role of revascularization in the foot salvage in patients suffering diabetes mellitus with occlusion-stenotic lesions of the shin arteries

There were examined 1363 patients suffering diabetes mellitus with trophic ulcer and purulent-necrotic affection of foot. Conservative treatment or operative intervention on the foot were conducted according to indications in 1176 (86.3%) patients, who no needed revascularization. Revascularization was done in 187 (13.7%) patients. Necessity of reconstruction for occlusion-stenotic affection of the shin arteries was established in 125 (66.8%) of them, shunting into the foot arteries was done in 52 (41.6%). High amputation of the limb was performed in 73 (58.4%) of patients in presence of contraindications for the foot revascularization. In 83.5% of patients suffering diabetes mellitus with occlusion-stenotic affection of the shin segment arteries there were two or one passable arteries of foot, fit for shunting operation.     

Palliativpatienten und Patienten am Lebensende in Notfallsituationen

Background

At the end of life acute exacerbations of medical symptoms (e.g. dyspnea) in palliative care patients often result in emergency medical services being alerted. The goals of this study were to discuss cooperation between emergency medical and palliative care structures to optimize the quality of care in emergencies involving palliative care patients.

Methods

For data collection an open discussion of the main topics by experts in palliative and emergency medical care was employed. Main outcome measures and recommendations included responses regarding current practices related to expert opinions and international literature sources.

Results

As the essential points of consensus the following recommendations for optimization of care were named: (1) integration of palliative care in the emergency medicine curricula for pre-hospital emergency physicians and paramedics, (2) development of outpatient palliative care, (3) integration of palliative care teams into emergency medical structures, (4) cooperation between palliative and emergency medical care, (5) integration of crisis intervention into outpatient palliative emergency medical care, (6) provision of emergency plans and emergency medical boxes, (7) provision of palliative crisis cards and do not attempt resuscitation (DNAR) orders, (8) psychosocial aspects concerning palliative emergencies and (9) definition of palliative patients and their special situation by the physician responsible for prior treatment.

Conclusions

Prehospital emergency physicians are confronted with emergencies in palliative care patients every day. In the treatment of these emergencies there are potentially serious conflicts due to the different therapeutic concepts of palliative medical care and emergency medical services. This study demonstrates that there is a need for regulated criteria for the therapy of palliative patients and patients at the end of life in emergency situations. Overall, more clinical investigations concerning end-of-life care and unresponsive palliative care patients in emergency medical situations are necessary.     

Notärztliche Behandlung akuter Schmerzexazerbationen bei ambulanten Palliativpatienten in Deutschland

Background

Breakthrough cancer pain is a symptom often reported by out-of-hospital palliative care patients in an advanced stage of cancer. Therefore, prehospital emergency physicians (EP) may be confronted with the acute care of breakthrough pain in palliative care patients in a home-care setting. Up to now, there is a lack of specialized out-of-hospital palliative care teams. There is also a lack of concepts for emergency care of palliative patients at the end of their lives given their specific symptoms.

Methods

Over a 24 month period all emergency medical missions for patients with breakthrough cancer pain (four emergency medical systems) were retrospectively investigated. Only services for palliative care patients with cancerous diseases were included (diagnosis of breakthrough pain).

Results

The primary service diagnosis of breakthrough pain in palliative care patients occurred 17 times within the defined period (4.6% of all emergency medical missions for palliative patients during the defined time period). After emergency therapy 15 of these patients were admitted into hospital. In 10 cases no adequate relief by pain therapy was possible. A specialized palliative care team (PCT) was integrated into the out-of-hospital therapy 2 times by an EP.

Conclusions

Concerning the emergency medical setting, breakthrough cancer pain in palliative care patients seems to be rare. However, such a situation can dramatically develop for patients and care-giving relatives. Therefore, an adequate and fast cancer pain therapy is necessary to allow the patient to stay at home after such an acute situation. The use of specialized outpatient PCT to support emergency situations motivated by palliative care patients should be encouraged. Basic principles of cancer pain therapy and palliative medical care (end-of-life care) should be integrated into emergency medical curricula to comply with the ethical principles of medical treatment at the end of life.     

OBJECTIVE EVALUATION OF THE QUALITY OF PALLIATION IN PATIENTS WITH OESOPHAGEAL CANCER COMPARING SURGERY,RADIOTHERAPY AND INTUBATION

The objective of this study was to prospectively evaluate the quality of palliation of 103 patients presenting to a joint oesophageal cancer clinic while recording the outcome in terms of treatment, morbidity, mortality and long-term survival. Twenty-five patients underwent surgical resection (S), 22 radical radiotherapy (RR), 30 palliative radiotherapy (PR), 13 intubation (I) and 13 had no treatment (NT). The quality of palliation was quantified by plotting a score out of 100 on a graph at each visit for Karnofsky performance, severity of pain and swallowing ability, then calculating the area under each curve created using an algorithm, Simpson's discrete approximation. Efficiency of palliation was estimated by comparing the area calculated to the maximum that could be achieved during the time frame being studied. The incidence of stricture (benign and malignant) was 16% after surgery and 50% after radical radiotherapy. Treatment mortality was as follows: RR, 0; S. I (4%); PR, 3 (7%); and I, 0. The median survival was 26 months after surgery and 16 months after radical radiotherapy. It was 6 months for palliative radiotherapy. 4 months for intubation and 4 months for no treatment. The difference in swallowing was the only statistical difference in the quality of palliation of patients having surgery and radical radiotherapy, there being no differences in patients having palliative measures.     

Surgery: Independent Prognostic Factor in Curable and Far Advanced Gastric Cancer

The hospital records of 639 patients affected by primary gastric cancer who were consecutively admitted to our unit during the period 1981–1995 were reviewed. Overall 220 underwent total gastrectomy (38 palliative), 12 had resection of the gastric stump, 195 had distal subtotal gastrectomy (55 palliative), 78 had bypass procedures, 72 had explorative laparotomy, and 62 had no operation. Univariate and multivariate analyses were used to evaluate 5-year survival with respect to the main clinical, pathologic, and treatment variables after both curative and palliative treatments. Overall the 5-year survival after curative treatment (320 patients—operative mortality excluded) was 55.5%: 91.1% for stage IA, 71.5% IB, 62.4% II, 37.5% IIIA, 31.5% IIIB. Among patients who underwent palliative treatment 5-year survival was 13.1% after gastric resection (total or distal subtotal), 4.9% after the bypass procedures, 0 after explorative laparotomy, and 0 after no operation. Univariate and multivariate survival analyses showed that variables independently associated with poor survival were advanced stage, upper location and D1 lymphadenectomy after curative treatment, tumor spread to distant sites, and nonresectional surgery after palliative treatment. Multivariate analysis showed that even though survival with gastric cancer depends on predetermined factors, the type of surgery can have a significant effect on prognosis after both curative and palliative treatment.     

Endoscopic laser therapy for neoplastic lesions of the colorectum.

Surgical resection is the therapy of choice for most colorectal neoplasms. Endoscopic laser therapy (ELT) is a recently developed alternative for treatment of colorectal neoplasms and is applicable in a variety of clinical circumstances in which nonoperative treatment is preferable. The experience with ELT using the Nd:YAG (neodynium:yttrium-aluminum-garnet) laser in 42 patients was analyzed. The diagnosis was colorectal adenocarcinoma in 32 patients (76%) and neoplastic polyps in 10 (24%). ELT was undertaken either as a palliative treatment for malignant disease (60%), with curative intent for benign disease (26%), or as a temporizing measure (14%) in a total of 84 treatment sessions. Successful palliation or cure was achieved in 40 patients (95%) with 4 minor complications (9%) and no procedure-related deaths. This experience confirms ELT as an effective alternative to surgical therapy in the palliative, curative, or interim treatment of certain colorectal neoplasms in patients with prohibitive operative risk, limited anticipated survival, incurability, or diffidence toward operation.     

Noncurative total gastrectomy and oesophagogastrectomy in the treatment of advanced gastric carcinoma in a country with high incidence

The role of extensive resectional surgery, including total gastrectomy for the palliation of advanced gastric cancer is controversial. This study shows operative results with complications and mortality occurring after total gastrectomy in patients with advanced stage gastric carcinoma. The study included 83 (48 males and 35 females, median age was 54.6 +/- 11.4 years) patients who underwent palliative total gastrectomy or oesophagogastrectomy (distal oesophagectomy in continuity with total gastrectomy). The reason for nonradical treatment was a too locally advanced disease. There was no case of carcinoma without serosal extension. Only five patients were free of histological lymph node metastases. A total of 72 (86.7%) early postoperative complications, including 17 self-limited wound complications, and 21 pulmonary complications were noted. Dehiscence of the oesophagojejunal anastomosis was noted in 7 patients, 3 of whom subsequently died. A total of 8 (9.6%) patients died in the postoperative period. The mean survival period was 12.8 +/- 0.8 months for all patients. It was 18.16 +/- 2.04 months in stage IIIA patients, 13.37 +/- 0.79 months in stage IIIB, and 7.51 +/- 0.97 months in stage IV patients. Total gastrectomy is a relatively safe procedure even when performing as a palliative procedure, with acceptable mortality and low lethal complication rate, and should be considered an alternative option in palliative treatment of advanced gastric cancer.     

Somatostatin analog: effects on hypergastrinemia and hypercalcitoninemia

A somatostatin analog (SMS 201-995) was used to treat symptomatic patients with a residual tumor burden of gastrinoma or medullary thyroid carcinoma and pathologic elevations of circulating marker peptides associated with these neuroendocrine tumors. Possible inhibitory effects of the analog on marker peptides, patients' symptoms, or tumor progression were studied in a dose-response protocol and during several months of self-injection of SMS 201-995. Both patients reported remarkable relief of secretory diarrhea and other symptoms, and serum gastrin was successfully suppressed by increasing doses of the analog. However, no effect was seen in reduction of hypercalcitoninemia. Morphologic imaging of residual tumor showed no progression of medullary thyroid carcinoma during treatment and, in the case of hepatic gastrinoma metastases, remarkable tumor regression was confirmed. No toxicity or glucose intolerance was experienced. Somatostatin analog shows promise for palliative management of endocrinologic symptoms due to neuroendocrine tumors, and an inhibitory effect can be measured in some but not all peptide markers. Further evidence of its negative trophic effect on tumor blood flow may suggest an antineoplastic potential, as well as palliative use of this new treatment.     

Palliative medicine in the surgical intensive care unit and trauma

The purpose of palliative medicine is to prevent and relieve suffering and to help patients and their families set informed goals of care and treatment. Palliative medicine can be provided along with life-prolonging treatment or as the main focus of treatment. Increasingly, palliative medicine has a role in the surgical intensive care unit (SICU) and trauma. Data show involving palliative medicine in the SICU results in decreased length of stay, improved communication with families and patients, and earlier setting of goals of care, without increasing mortality. The use of triggers for palliative medicine consultation improves patient-centered care in the SICU.     

Self expanding metallic stent in the management of malignant colonic obstruction

INTRODUCTION: Fifteen to thirty percent of colonic cancers are diagnosed at acute colic obstruction stage. In this situation surgery is associated with a high morbi-mortality. The self-expandable metallic stents (SEM) have two objectives: (a) resolution of the obstructive to allow secondary planified radical surgical procedure; (b) palliative in the event of advanced disease. PATIENTS AND METHODS: From May 2001 to December 2002, 11 patients, mean age 75 +/- 8 years, presenting with acute colic obstruction were initially treated by SEM placed by endoscopy. Four patients were classified score ASA 4. Ten patients had a colonic cancer, and a patient presented a peritoneal carcinomatosis from an ovarian carcinoma. Overall five patients had a carcinomatosis. Stenosis, mean length 4 +/- 3 cm, were located on the left colon. In five patients the SEM was proposed as a palliative treatment. RESULTS: Successfully placement of SEM was obtained in 10 (91%) patient without perforation. Three complications (bleeding, reobstruction, migration) were observed. Clinical success (colonic decompression within 96 h without endoscopic or surgical reintervention) was observed in nine out of ten (90%) patients. Six patients had a SEM with curative attempt allowing (i) colonic resection (9 +/- 2 days) without stomy (one postoperative death) in five patients; (ii) a colo-colic derivation for diffuse carcinomatosis discovered peroperatively. A diverting colostomy was carried out in two of the four patients (j6, j30) (reobstruction, migration) for whom the SEM had been proposed as palliative treatment. CONCLUSIONS: This study confirms that SEM and surgery are not competitive but complementary techniques. When the SEM is placed with curative attempt, it allows resolution of the obstructive syndrome and secondary planified radical surgical procedure under better conditions. The results observed in the palliative SEM group suggested to reconsider this indication.     

Palliative medicine in the surgical intensive care unit and trauma

The purpose of palliative medicine is to prevent and relieve suffering and to help patients and their families set informed goals of care and treatment. Palliative medicine can be provided along with life-prolonging treatment or as the main focus of treatment. Increasingly, palliative medicine has a role in the surgical intensive care unit (SICU) and trauma. Data show involving palliative medicine in the SICU results in decreased length of stay, improved communication with families and patients, and earlier setting of goals of care, without increasing mortality. The use of triggers for palliative medicine consultation improves patient-centered care in the SICU.     

Pain therapy in pediatric oncology: pain experience, drugs and pharmacokinetics

Paediatric cancer patients often experience fear and pain from the disease but also in connection with the necessary diagnostic and therapeutic procedures. The treatment of pain is a priority for all patients, especially for critically ill children because of their vulnerability and limited understanding. The experience of pain is always subjective and depends on the age, the pain experience and the environment.In contrast to adults, it is often difficult to detect character of pain, pain intensity and pain localization in very young patients. Diagnostic and therapeutic procedures are performed in analgosedation for a given drug scheme by a pediatrician experienced in intensive care.In addition, a local anesthetic for an access system/lumbar punctures in the form of EMLA? patch is to be carried out. A rapid and effective treatment of pain and appropriate analgesia can prevent patients from being traumatized.For severe pain, malignancy- or chemotherapy-induced (eg. mucositis WHO grade 3 and 4) initial use of strong opiates is recommended instead of climbing the WHO ladder. For strong opiates, there is no maximum dose, as long as a dose increase leads to clinically observable increase in analgesia, without severe side effects. Patient-controlled analgesia with morphine as continuous subcutaneous or intravenous infusions and the possibility of a bolus injection is suited for children aged 6 years. A measurement of O2-saturation is essential during this infusion. Prophylactic approaches also must be used consistently in regard to the acute side effect of opiate treatment. Good experience, we have also made a non-drug therapy, e.g. personnel/physical affection, cuddling, massage, etc.The choice of analgesia depends on the nature and cause of pain. In neuropathic pain or phantom pain coanalgetics should be used to effectively treat pain in young patients. Different analgesic treatment approaches of the appropriate indications and adverse effects are presented. A particular challenge for the pediatrician is the sufficient and adequate pain therapy in palliative care.