[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]

[Tumor-associated pain]

Tumor-associated pain has a high prevalence and is still a challenging aspect of pain medicine. Treatment-related etiologies often coexist with pain caused by the oncological disease itself. For cancer pain as well, a pathophysiologically oriented analysis of nociceptive, nociplastic and neuropathic pain is advisable for planning a tailored treatment. The analgesic three-step ladder of the World Health Organization (WHO) should be customized in this context, incorporating antineuropathic or antihypersensitizing pharmacological approaches as well as minimally invasive techniques. Psycho-oncological and exercise therapy interventions should be considered. In cases of long-term courses of treatment or following curative oncological treatment, chronically persistent or chronic tumor-associated pain can occur, necessitating multimodal therapeutic approaches analogue to noncancer pain conditions. Close integration with palliative medicine enhances the therapeutic effectiveness during the transition from nonpalliative to palliative treatment phases.

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.

[Perioperative Pain Management - Patient Information, Informed Consent and Discharge Management]

Many surgical procedures are followed by postoperative pain. Acute pain should be treated optimally for medical and ethical reasons. Different psychological, physical, interventional and pharmacological methods are employed in a procedure specific and institution specific matter. For optimum patient care, implementation of acute pain management concepts in recommendations on quality management in German hospitals and outpatient clinics was enacted in September 2020 by Gemeinsamer Bundessausschuss (G-BA). Implementation of discharge management had already been enacted in 2017 for structured prescription of medication after hospital discharge, among other things. On the other hand, new national and international developments require a new weighting of pharmacotherapy in particular. Examples include debates on the safe use of metamizol and the opioid crisis in the US. To address these issues adjustments in informed consent and patient information and education are necessary. This includes also the information and education of caregivers. This article describes the legal framework, technical solutions and the impact of placebo and nocebo effects on doctor-patient communication.