Schmerzmanagement im Krankenhaus – aktuelle Praxis, Qualität und Organisation in der nichtoperativen Medizin
01 Sep 2021-Anasthesiologie Intensivmedizin Notfallmedizin Schmerztherapie (Georg Thieme Verlag KG)-Vol. 56, Iss: 09, pp 599-613
TL;DR: In this article, a legal requirement to establish a structured perioperative pain management in non-surgical hospital settings was introduced, which should not be seen as a signal that pain management is less important than acute and chronic pain management.
Abstract: For many years now, effective pharmacological and non-pharmacological treatment approaches for acute and chronic pain exist, as well as organisational strategies for their implementation in hospitals. Nevertheless, there remain considerable deficits in pain management and the portion of patients with severe or long-lasting pain in non-surgical units is often high. There is a considerable potential to improve quality and structures of pain mangement in non-surgical hospital settings in Germany. Recently, legal requirements to establish a structured perioperative pain management were introduced. This should not be seen as a signal that pain management is less important in non-surgical disciplines. On the contrary - it should raise awareness for more clinical and health services research to further develop and validate appropriate approaches and concepts to improve pain treatment in this field.
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TL;DR: In this article, eine Ubersicht zu Therapieansatzen und Konzepten bei den nichtoperativen Schmerzentitaten is presented.
Abstract: Patienten nichtoperativer Abteilungen machen in den meisten Krankenhausern einen relevanten Anteil an Patienten mit Schmerzen aus. Ziel dieses Beitrags ist es, eine Ubersicht zu Therapieansatzen und Konzepten bei den nichtoperativen Schmerzentitaten fur die Tatigkeit im Schmerzdienst oder im Bereitschaftsdienst zu geben.
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TL;DR: Several common minor- to medium-level surgical procedures, including some with laparoscopic approaches, resulted in unexpectedly high levels of postoperative pain, including appendectomy, cholecystectomy, hemorrhoidectomy, and tonsillectomy.
Abstract: Background Severe pain after surgery remains a major problem, occurring in 20-40% of patients. Despite numerous published studies, the degree of pain following many types of surgery in everyday clinical practice is unknown. To improve postoperative pain therapy and develop procedure-specific, optimized pain-treatment protocols, types of surgery that may result in severe postoperative pain in everyday practice must first be identified. Methods This study considered 115,775 patients from 578 surgical wards in 105 German hospitals. A total of 70,764 patients met the inclusion criteria. On the first postoperative day, patients were asked to rate their worst pain intensity since surgery (numeric rating scale, 0-10). All surgical procedures were assigned to 529 well-defined groups. When a group contained fewer than 20 patients, the data were excluded from analysis. Finally, 50,523 patients from 179 surgical groups were compared. Results The 40 procedures with the highest pain scores (median numeric rating scale, 6-7) included 22 orthopedic/trauma procedures on the extremities. Patients reported high pain scores after many "minor" surgical procedures, including appendectomy, cholecystectomy, hemorrhoidectomy, and tonsillectomy, which ranked among the 25 procedures with highest pain intensities. A number of "major" abdominal surgeries resulted in comparatively low pain scores, often because of sufficient epidural analgesia. Conclusions Several common minor- to medium-level surgical procedures, including some with laparoscopic approaches, resulted in unexpectedly high levels of postoperative pain. To reduce the number of patients suffering from severe pain, patients undergoing so-called minor surgery should be monitored more closely, and postsurgical pain treatment needs to comply with existing procedure-specific pain-treatment recommendations.
1,060 citations
TL;DR: Pain management seems to be worse for non-surgical patients (cancer patients excepted) than for surgical patients: waiting times for medication are longer, and ineffective medications are given more often.
Abstract: Background
The Pain-Free Hospital Project was initiated in 2003 with the aim of improving pain management throughout Germany. We assessed the current state of pain management in German hospitals.
202 citations
TL;DR: Pain prevalence and intensity in this German university hospital were high and pain therapy was inadequate in many cases, and pain management needs to be improved by continuous assessment and adequate pain medication.
166 citations
TL;DR: No evidence was found that directly linked the timing, frequency, or method of pain assessment with outcomes or safety in medical inpatients, and evidence for managing pain in patients with substance abuse disorders or chronic opioid use is weak.
Abstract: Objective. To review the literature addressing effective care for acute pain in inpatients on medical wards.
Methods. We searched Medline, PubMed Clinical Queries, and the Cochrane Database for systematic reviews published in 1996 through April 2007 on the assessment and management of acute pain in inpatients, including patients with impaired self-report or chemical dependencies. We conducted a focused search for studies on the timing and frequency of assessment, and on the use of patient-controlled analgesia (PCA) for nonsurgical pain. Two investigators performed a critical analysis of the literature and compiled narrative summaries to address the key questions.
Results. We found no evidence that directly linked the timing, frequency, or method of pain assessment with outcomes or safety in medical inpatients. There is good evidence that treating abdominal pain does not compromise timely diagnosis and treatment of the surgical abdomen. Pain management teams and other systemwide interventions improve assessment and use of analgesics, but do not clearly affect pain outcomes. The safety and effectiveness of PCA in medical patients have not been studied. There is weak evidence that most cognitively impaired individuals can understand at least one self-assessment measure. Almost no evidence is available to guide management of pain in delirium. Evidence for managing pain in patients with substance abuse disorders or chronic opioid use is weak, being derived from case reports, retrospective studies, and expert opinion.
Conclusions. Pain is a prevalent problem for medical inpatients. Clinical research is needed to guide the assessment and management of pain in this setting.
78 citations
TL;DR: The planmasige zweite Aktualisierung der S3-Leitlinie LONTS (Langzeitanwendung of Opioiden bei chronischen nicht-tumorbedingten Schmerzen) [CNTS]), AWMF(Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften)-Registernummer 145-003, wurde ab Dezember 2018 vorgenommen.
Abstract: Die planmasige zweite Aktualisierung der S3-Leitlinie LONTS („Langzeitanwendung von Opioiden bei chronischen nicht-tumorbedingten Schmerzen“ [CNTS]), AWMF(Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften)-Registernummer 145-003, wurde ab Dezember 2018 vorgenommen. Die Leitlinie wurde unter Koordination der Deutschen Schmerzgesellschaft von 28 wissenschaftlichen Fachgesellschaften und zwei Patientenselbsthilfeorganisationen entwickelt. Die Literaturrecherche erfolgte uber die Datenbanken CENTRAL, MEDLINE und Scopus (bis Dezember 2018). Die systematischen Ubersichtsarbeiten und Metaanalysen von randomisierten, kontrollierten Studien zur Wirksamkeit und Sicherheit von Opioiden beim CNTS der fruheren Versionen der Leitlinie wurden aktualisiert. Die Graduierung der Evidenzstarke erfolgte nach dem Schema des Oxford Centre for Evidence-Based Medicine. Die Formulierung und Graduierung der Empfehlungen erfolgte in einem mehrstufigen, formalisierten Konsensusverfahren nach dem Regelwerk der AWMF. Die Leitlinie wurde von vier externen Schmerzmedizinern begutachtet. Eine offentliche Kommentierung war uber vier Wochen moglich. Opioidhaltige Analgetika sind eine medikamentose Therapieoption in der kurz- (4–12 Wochen), mittel- (13–25 Wochen) und langfristigen Therapie (≥26 Wochen) von chronischen Arthrose- und Ruckenschmerzen sowie chronischen Schmerzen bei diabetischer Polyneuropathie und Postzosterneuralgie. Kontraindikationen sind primare Kopfschmerzen sowie funktionelle und psychische Storungen mit dem (Leit‑)Symptom Schmerz. Die Leitlinie nennt weitere Krankheitsbilder, bei denen ein individueller Therapieversuch erwogen werden kann. Eine Langzeittherapie mit Opioiden beim CNTS ist mit relevanten Risiken verbunden. Ein verantwortungsvoller Einsatz von Opioiden verlangt die Berucksichtigung moglicher Indikationen und Kontraindikationen sowie eine regelmasige Erfassung von Wirksamkeit und Nebenwirkungen. Opioide bleiben eine Behandlungsoption fur CNTS, wenn nicht-medikamentose Therapien nicht ausreichend wirksam sind und/oder medikamentose Alternativen nicht wirksam waren oder nicht vertragen wurden oder kontraindiziert sind.
52 citations