Interdisziplinäres Positionspapier „Perioperatives Schmerzmanagement“

[What determines the overall quality of postoperative pain management? A question of perspective]

BACKGROUND

The outcome domains pain intensity, pain-related interference, side effects, (treatment) information, participation and personal interaction have all been identified as relevant factors in the management of perioperative pain. However, it is not yet clear which of these are particularly significant for the subjectively perceived overall quality of postoperative pain management.

AIM

A newly developed questionnaire was used in this cross-sectional study to assess the relevance of these domains for patients and compare the relevance to healthcare professionals (HCP).

METHODS

The patient survey (n = 40) was conducted on the first postoperative day at Jena University Hospital, Germany. In order to investigate group differences, 63 HCP (disciplines: n = 15 anaesthesiology, n = 17 surgery, n = 31 nursing) were recruited. The questionnaire primarily included all pairwise comparisons between the domains with regard to the overall quality of postoperative pain management. The resulting sum scores for each domain were the primary outcome measure, which were analysed using generalized estimating equations.

RESULTS

Within the group of patients, there were significant differences in the prioritization of the six outcome domains, with personal interaction followed by intensity and interference having received the highest ratings. There were also significant differences within the domains between the perspectives of patients and HCP, as well as between the HCP themselves.

CONCLUSIONS

The study demonstrates that personal interaction and the reduction of pain intensity and interference are three key factors that are significant for patients' experience of postoperative pain management. However, the extent to which the harmonisation of these three factors with those given prominence by HCP would positively impact postoperative pain management remains unclear and should be investigated further.

Perioperatives Schmerzempfinden von Patienten bei dermatochirurgischen Eingriffen in Lokalanästhesie – Eine prospektive Beobachtungsstudie

Hintergrund

Dermatochirurgische Eingriffe finden überwiegend in Lokalanästhesie statt, jedoch gibt es nur wenig Studien zum perioperativen Schmerzmanagement ausgedehnter oder mehrzeitiger Operationen. Das Ziel dieser Erhebung ist die Erfassung von Schmerzen im Rahmen dermatochirurgischer Eingriffe, der Darstellung der perioperativen Schmerztherapie sowie der Identifizierung von Einflussfaktoren auf das Schmerzempfinden.

Patienten und Methodik

In diese prospektive, monozentrische Studie wurden stationäre Patienten von April bis Dezember 2021 eingeschlossen, die einen dermatochirurgischen Eingriff in Lokalanästhesie erhielten. Präoperativ wurden demographische Fragen, ein Schmerzfragebogen und vier psychometrische Fragebögen (PCS, LOT‐R, SFQ, PHQ‐9) erhoben. Postoperativ empfundene Schmerzen und benötigte Schmerzmedikamente der ersten 24 Stunden wurden erhoben.

Ergebnisse

120 Patienten (mit insgesamt 191 Eingriffen) wurden eingeschlossen. Durchschnittliche postoperative Schmerzen wurden sehr niedrig (NRS < 2) angegeben. Präoperativ bestehende Schmerzen und postoperativ erwartete Schmerzen zeigten sich als prädiktive Merkmale für postoperativen Schmerz. Ein starker Zusammenhang zwischen Katastrophisieren und Angst vor der Operation (r = 0,65) sowie ein mittlerer Zusammenhang für Depression und Angst vor der Operation (r = 0,46) konnten dargestellt werden.

Schlussfolgerungen

Dermatochirurgische Eingriffe in Lokalanästhesie werden insgesamt als schmerzarm empfunden. Bei der präoperativen Aufklärung und Untersuchung sollte auf Patienten geachtet werden, die bereits Schmerzen angeben oder postoperativ Schmerzen erwarten, da sie ein erhöhtes Risiko für die Entwicklung postoperativer Schmerzen zeigten.

Perioperative pain perception in patients undergoing dermatologic surgery with local anesthesia - A prospective observational study

BACKGROUND

Dermatosurgical procedures are predominantly performed under local anesthesia, yet there are few studies on perioperative pain management for extensive or staged procedures under local anesthesia. The purpose of this study was to assess pain during dermatologic surgery, describe perioperative pain management, and identify factors that influence pain perception.

PATIENTS AND METHODS

This prospective, monocentric study included inpatients undergoing dermatologic surgery under local anesthesia from April to December 2021. Preoperative demographic data, a pain questionnaire, and four psychometric questionnaires (PCS, LOT-R, SFQ, PHQ-9) were collected. Postoperative pain and analgesic use during the first 24 hours were recorded.

RESULTS

A total of 120 patients (with a total of 191 interventions) were included in the study. Mean postoperative pain was reported to be very low (NRS < 2). Preoperative pain and expected postoperative pain were found to be predictive of postoperative pain. There was a strong correlation between catastrophizing and preoperative anxiety (r = 0.65) and a moderate correlation between depression and preoperative anxiety (r = 0.46).

CONCLUSIONS

Dermatologic surgery under local anesthesia is generally considered painless. During preoperative counseling and assessment, attention should be paid to patients who fear surgery, report pain, or anticipate postoperative pain, as they have an increased risk of experiencing postoperative pain.

[Pain relief after abdominal oncologic surgery. Evaluation of the effectiveness and safety of a fixed combination of diclofenac and orphenadrine]

OBJECTIVE

Evaluation of the analgesic, opioid-sparing, anti-inflammatory and adverse effects of the diclofenac and orphenadrine (Neodolpasse) fixed combination for analgesia in the postoperative period of surgical cancer patients.

MATERIAL AND METHODS

A randomized, single-center, prospective, comparative study evaluated two analgesic regimens in 40 cancer patients undergoing various open cavity surgeries, including extensive combined interventions associated with the resection of 3 or more organs. The study was conducted following the transfer from the ICU to the surgical department during the early activation period, within the first two postoperative days. In the first group N (n=20), "Neodolpasse" (a fixed combination of 75 mg Diclofenac and 30 mg Orphenadrine) was administered as an infusion, twice daily. In the second group K (n=20) analgesia was performed with ketoprofen as an intravenous infusion at a daily dose of 200 mg. Patients in both groups received scheduled prolonged epidural analgesia with 0.2% ropivacaine, and when the severity of pain in a visual analogue scale (VAS) increased to more than 40 mm, so an additional dose of 100 mg tramadol was administered intramuscularly. Daily measurments of blood creatinine level and C-reactive protein were taken, postoperative blood loss was accounted for, as well as postoperative complications according to the Clavien-Dindo classification.

RESULTS

The comparative analysis of the indicators of pain syndrome severity showed that the patients in group N exhibited a more pronounced analgesic effect, so on the second postoperative day 30% of patients reported moderate pain (from 50 to 60 mm on the pain scale), on the third day - 15%, and by the fourth day - all 100% of patients experienced pain of low intensity. The additional analgesia with tramadol in group N was required twice less than in the comparison group, and such adverse effects as nausea, drowsiness, and weakness were significantly more common in the ketoprofen group. In both groups, the average blood creatinine level did not exceed permissible values, and the C-reactive protein was elevated at all stages of the study but tended to decrease by the fourth day. The analysis of postoperative complications according to the Clavien-Dindo scale at the time of discharge did not reveal a direct correlation between the occurred complications and the use of NSAIDs. Adverse effects such as anastomotic failure, gastrointestinal complications, or other hemorrhagic manifestations were not recorded.

CONCLUSION

The inclusion of Neodolpasse into multimodal analgesic regimens resulted in the most pronounced analgesic and opioid-sparing effects in surgical cancer patients using laparotomy access. Additionally, the application of short courses of nonsteroidal anti-inflammatory drugs (NSAIDs) was associated with a favorable safety profile.

[Perioperative pain therapy in minimally invasive thoracic surgery]

Thoracic surgery is often associated with severe postoperative pain levels. Even though these are less pronounced in thoracoscopic approaches, mechanical irritation, compression or injury of intercostal nerves and placement of chest tubes can cause pain levels, which must be treated. An adequate pain therapy in thoracic surgery is essential as insufficient inspiration due to inadequate analgesia may result in postoperative complications. Epidural anesthesia was considered the gold standard in thoracotomy for a long time. For video-assisted thoracoscopy, however, it is sometimes no longer recommended due to its benefit-risk ratio. Alternative thoracic blocks are the paravertebral block, the erector spinae plane block and the serratus anterior block, for which research has found heterogeneous results.This article summarizes the current recommendations for perioperative management of thoracoscopic surgery and gives an overview of the PROSPECT recommendations as well as the current Association of the Scientific Medical Societies in Germany (AWMF) guidelines for perioperative and postoperative pain therapy. In particular, individual regional anesthesia techniques and their current evidence are reviewed.

Status of inpatient pain therapy using the example of a general and abdominal surgery normal ward - a prospective questionnaire study to review a pain therapy algorithm ("real-world data")

Objectives

The mean pain intensity for inpatient consultations, for example in cancer patients, is known. However, the proportion of necessary consultations in the total volume of patients of a ward or a hospital, the general pain intensity in a surgical ward and the relationship between pain medication, length of stay and therapeutic success are unknown. The aim of the study was to examine surgical patients in a single normal ward subclassified into various groups (-/+ surgery, ICU stay, cancer, consultation for pain therapy etc.) during half a year with regard to their pain. For this purpose, the pain score (NAS) was recorded daily for each patient during the entire hospital stay and the change was assessed over the clinical course.

Methods

In 2017, all consecutive new admissions to a normal ward of general surgery at a university hospital ("tertiary center") were monitored over half a year according to a standardized procedure. Pain severity (measured by the "Numeric rating scale" [NRS] respectively "Visual analogue scale" [VAS]) from admission to discharge was recorded, as well as the length of stay and the administered medication. Patient groups were sub-classified as surgery, intensive care unit, cancer and pain consultation. An algorithm in two parts (part 1, antipyretics and piritramide; part 2, WHO-scheme and psychotropic drugs), which was defined years before between surgeons and pain therapists, was pursued and consequently used as a basis for the evaluation of the therapeutic success.

Results

269 patients were included in the study. The mean pain intensity of all patients at admission was VAS 2.2. Most of the groups (non-cancer, intensive care unit [ICU], non-ICU, surgical intervention (=Operation [OP]), non-OP, pain intensity greater than VAS 3) were significantly reduced in pain at discharge. An exception in this context was patients with cancer-associated pain and, thus, initiated pain consultation.

Conclusions

Since three quarters of the consultation patients also reported cancer pain, it might be possible that the lack of treatment success in both the consultation and cancer groups is associated with cancer in these patients. However, it can be shown that the successfully treated groups (without ICU-based course) had a mean length of stay from 4.2 ± 3.9 up to 8.4 ± 8.1 days (d), while the two unsuccessfully treated groups experienced a longer stay (mean"cancer", 11.1 ± 9.4 d; mean"consulation", 14.2 ± 10.3 d). Twenty-one consultation patients, in whom it had been intended to improve pain intensity, could not be successfully treated despite adapted therapy - this can be considered a consequence of the low number of patients. Since the consultation patients were the only patient group treated with part 2 of the algorithm, it can be concluded that part 1 of the algorithm is sufficient for a mean length of stay up to 9 days. For all patients above this time point, a pain consultation with adaption of medical treatment should be considered.

[Analgesic and opioid-sparing effects of a fixed combination of diclofenac and orphenadrine in the early postoperative period in cardiac surgery patients]

OBJECTIVE

Evaluation of the effectiveness of a multimodal scheme of postoperative analgesia based on a fixed combination of orphenadrine and diclofenac against the background of patient-controlled analgesia with morphine in the early postoperative period in cardiac surgery patients.

MATERIAL AND METHODS

A prospective, randomized, comparative study evaluated two analgesic regimens. In 20 patients (group 1), «Neodolpasse» (a fixed combination of 30 mg Orphenadrine and 75 mg Diclofenac) was administered immediately after trachea extubation. The second injection was performed at VAS>50 mm not earlier than 12 hours after the first one. Patient-controlled analgesia (PCA) with morphine was started 2 hours after extubation, 20 patients of group 2 who were used PCA with Morphine as monotherapy. The intensity of pain taking into account the motor activity of patients was assessed a 100 mm visual-analog scale (VAS), as an additional objective criterion for the effectiveness of analgesia, the method of incentive spirometry was used.

RESULTS

A decrease in the severity of pain according to VAS from an average of 41 to 19 mm (p=0.036) was achieved already by the 1st hour from the start of Neodolpasse infusion, and in 80% of patients this effect persisted for 24 hours. 2 patients (10%) needed the administration of the 2nd dose after 12 hours. The infusion of Morphine was started 2 hours after extubation, a significant decrease in pain intensity was noted only at 4th hour, a significant decrease in pain intensity was noted only by 4 hours, and significant differences in the severity of pain in the comparison groups persisted at almost all stages of the study. The analgesic effect of the combination of orphenadrine and diclofenac had a positive effect on the function of respiration system with an increase in MILC by 1.5 times from the beginning of the study. In group 2, the observed adverse effects were associated with the use of Morphine and depended on its dose. No adverse effects of Neodolpasse were noted. The total 24 hour consumption of Morphine at PCA averaged 22.6 mg, and in the Neodolpasse group - 9.35 mg (p<0.001).

CONCLUSION

There were demonstrated high analgesic efficacy, safety and significant opioid-sparing effect of a fixed combination of orphenadrine and diclofenac in the early postoperative period of cardiac surgery patients.

Quality Indicators (QI) of Acute Pain after Surgery in European Countries

OBJECTIVES

It is common practice to use pain quality indicators (QI) to accurately assess the medical care situation of patients. This literature review identifies the status quo of acute pain QI among adult inpatients.

DATA SOURCES

Studies published in English or German were identified using a systematic search on CINAHL, Cochrane Library, PubMed, Web of Science, and Google Scholar from 01/2007 to 02/2018. Additional pain management journals, conference proceedings, and websites of health organizations and pain societies were manually screened. Studies about postoperative pain in adults (≥18 years) during inpatient stay after all types of surgery in Europe were included in this review.

REVIEW/ANALYSIS METHODS

The identified study results were categorized into structural, process, and outcome indicators based on Donabedian's framework of evaluating care quality.

RESULTS

The search identified 319 citations, of which 20 studies used structure, process, and outcome data including 180,988 patients and 1,970 health care professionals to gain insight into the quality of acute pain management. Overall, 80% used patient surveys to collect data. National data on pain management are reported in five European studies (France [2], the Netherlands, Spain, and Austria).

CONCLUSIONS

European studies comprehensively comparing acute pain management results are currently missing. Thus, this report highlights the need to develop consensus-based quality indicators in management of acute pain, which take into account both the methodologic quality and the relevance to clinical practice.

[Ketamine in the therapy of chronic pain and depression]

Although ketamine has been known and clinically applied for a long time, questions still arise around the many possible indications in which the anesthetic and analgesic substance could be used. In particular, these questions relate to new indications in which ketamine is used in low subanesthetic doses.The mechanism of action at the NMDA receptor clearly distinguishes ketamine from all other analgesics. Possible applications include the prevention of chronic postoperative pain as well as the treatment of neuropathic pain. With the treatment of refractory depression completely new therapeutic areas for ketamine could be established.