[The effects of setting a standard in the acute pain therapy on a ward : Parameters for patient and provider satisfaction and cost structure (STANDAKU)]

[Pain management in German specialized outpatient palliative care : A cross-sectional study to present the current pain management of palliative patients in the home environment]

BACKGROUND

With the help of specialized outpatient palliative care teams (German abbreviation: SAPV), seriously ill and dying patients in Germany can be adequately cared for in their home environment until the end of their lives; however, there are no uniform standards or guidelines for well-executed pain management right now.

OBJECTIVE

This approach serves as basic research in the field of public health research. This is intended to present which methods (use of different professional groups, use of pain medications, alternative medical treatment etc.) the individual SAPV teams use for pain management. From this it can be deduced which procedures can be considered particularly effective.

MATERIAL AND METHODS

This cross-sectional study was conducted in May 2021. All German SAPV teams (n = 307) listed on the homepage of the German Association for Palliative Medicine (DGP) were contacted by post and invited to participate. A total of 175 teams (57%) responded to the request and were included in the evaluation. A descriptive data analysis was performed.

RESULTS

Pain management in the German outpatient care of palliative patients is based on several components. All common pain medications are used, but primarily metamizole (99.4%) as a non-opioid analgesic, morphine (98.3%) from the opiate series and pregabalin (96.6%) as a co-analgesic are mainly prescribed. If pain therapy fails, 22.5% of the SAPV teams perform palliative sedation for symptom control on a regular basis.

CONCLUSION

This cross-sectional study is the first of its kind to provide a general overview of the treatment options for pain management in German outpatient palliative care. In comparison with international studies, the question arises as to whether uniform therapy schemes and a reduction in the medication available in the individual SAPV teams could lead to an improvement in patient care.

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 management in German hospices: a cross-sectional study

BACKGROUND AND OBJECTIVES

Pain management is a necessary component of palliative care as most patients suffer from pain during the final phase of life. Due to the complex causation of pain in the last phase of life, it is important to utilize methods other than pharmacotherapeutic options in order to achieve adequate pain control. As little is known about treatment of pain in German hospices, a nationwide survey was conducted.

MATERIALS AND METHODS

All German hospices (259) were contacted by post in June 2020 and asked to participate in an anonymous cross-sectional survey.

RESULTS

A total of 148 (57%) German hospices took part in the survey. A broad variety of medication is used in the hospice setting. Metamizole is the most commonly used non-opiod analgesic , hydromorphone the most commonly used opioid, and pregabalin is the most commonly prescribed co-analgesic drug. The pain medication is usually prescribed as an oral slow-release substance. Standardized treatment schemes are rare among the responding hospices. Most of the respondents also use complementary treatment options, such as aroma (oil) therapy or music therapy, in the treatment of pain. Palliative sedation is used by nearly all responding hospices if all other treatment options fail.

CONCLUSION

This survey provides an overview of the treatment options for pain management in German hospices. A broad variety of pain medication is used. Compared to international literature, it is debatable whether such a large variety of different types of pain medication is necessary, or whether a reduction in the type of medication available and the use of standardized treatment schemes could benefit everyone involved.

Perioperative pain management in dermatosurgery - current practice in Germany: Data analysis of a Germany-wide online survey among dermatosurgeons

BACKGROUND

Adequate pain management should be part of the standard of care in surgical procedures. However, there is a paucity of data in the field of dermatosurgery. In a standardized online survey among dermatosurgeons working in Germany, the current practice of perioperative pain management was investigated.

METHODS

Members of the German Society for Dermatosurgery (DGDC) and heads of dermatosurgical departments were asked to participate. Questions were related to practical implementation of perioperative pain management, pain documentation and personal sources of information on the topic.

RESULTS

116 questionnaires were analyzed. While prophylactic analgesia is rarely used, the vast majority (86%) reported the use of postoperative on-demand medication. The majority of surgeons do not have a fixed regimen. Mostly NSAIDs and occasionally low potency opioids are used. Pain is documented by the majority (59.1%) as free text. Personal experience (69%) and in-house standards (51%) are the most important factors in pain management. The use of guidelines (25%) plays a minor role.

CONCLUSIONS

Perioperative pain management in dermatosurgery is strongly influenced by personal experience and may vary depending on the surgery performed. Consensus-based standardized recommendations are lacking. For adequate perioperative analgesia, the development of demand-oriented pain concepts is desirable. This requires prospective studies that address the specific patient population and surgical procedures in dermatology.

Perioperative Schmerztherapie bei dermatochirurgischen Eingriffen - aktuelle Praxis in Deutschland: Datenauswertung einer deutschlandweiten Online-Umfrage unter Dermatochirurgen

Hintergrund

Adäquate Schmerztherapie sollte bei operativen Eingriffen zum regelhaften Behandlungskonzept gehören. In der Dermatochirurgie gibt es hierzu jedoch kaum Daten, wie am besten vorgegangen werden sollte. In einer standardisierten Online‐Umfrage unter in Deutschland tätigen Dermatochirurgen wurde die gängige Praxis der perioperativen Schmerztherapie bei dermotochirurgischen Eingriffen erhoben.

Methodik

Mitglieder der Deutschen Gesellschaft für Dermatochirurgie (DGDC) sowie Leiter dermatochirurgischer Abteilungen wurden um Teilnahme gebeten. Fragen bezogen sich auf praktische Umsetzung des perioperativen Schmerzmanagements, Schmerzdokumentation und persönliche Informationsquellen zum Themenkomplex.

Ergebnisse

116 Fragebögen konnten ausgewertet werden. Während prophylaktische Analgesie kaum angewandt wird, berichtet die überwiegende Mehrzahl (86%), eine postoperative Bedarfsmedikation einzusetzen. Feste Therapieregime existieren mehrheitlich nicht. Zumeist werden NSAR und gelegentlich niedrigpotente Opioide verwendet. Schmerzen werden von der Mehrzahl (59,1%) als Freitext dokumentiert. Die größte Bedeutung beim schmerztherapeutischen Management besitzen persönliche Erfahrungswerte (69%) und hausinterne Standards (51%). Die Nutzung von Leitlinien (25%) spielt eine untergeordnete Rolle.

Schlussfolgerungen

Perioperatives Schmerzmanagement in der Dermatochirurgie ist stark von persönlichen Erfahrungswerten geprägt und kann je nach durchgeführtem Eingriff unterschiedlich ausfallen. Konsensbasierte standardisierte Empfehlungen hierfür fehlen. Für eine suffiziente perioperative Analgesie ist die Entwicklung bedarfsorientierter Schmerzkonzepte wünschenswert. Dafür bedarf es prospektiver Studien, die das spezielle Patientenklientel und operative Vorgehen in der Dermatologie berücksichtigen.

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.

[Current aspects of pain management during and after dermatologic surgery]

The project "Pain-free Hospital" was the first attempt to improve the level of postoperative care by standardizing pain therapy standards (concepts) in the individual surgical disciplines. Dermatosurgery is no exception. In addition to drug therapy, it is also important to consider biopsychosocial aspects of the symptom pain, as this is the only way to prevent chronification of acute pain in the further course of a disease. Drug therapy should not only be adapted to the classic WHO system (only considering pain intensity), but should also address aspects of pain quality. In this article, we discuss these aspects in more detail and present our treatment concept for dermatosurgery.