H. Laubenthal

Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care--short version.

Targeted monitoring of analgesia, sedation and delirium, as well as their appropriate management in critically ill patients is a standard of care in intensive care medicine. With the undisputed advantages of goal-oriented therapy established, there was a need to develop our own guidelines on analgesia and sedation in intensive care in Germany and these were published as 2nd Generation Guidelines in 2005. Through the dissemination of these guidelines in 2006, use of monitoring was shown to have improved from 8 to 51% and the use of protocol-based approaches increased to 46% (from 21%). Between 2006–2009, the existing guidelines from the DGAI (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) were developed into 3rd Generation Guidelines for the securing and optimization of quality of analgesia, sedation and delirium management in the intensive care unit (ICU). In collaboration with another 10 professional societies, the literature has been reviewed using the criteria of the Oxford Center of Evidence Based Medicine. Using data from 671 reference works, text, diagrams and recommendations were drawn up. In the recommendations, Grade “A” (very strong recommendation), Grade “B” (strong recommendation) and Grade “0” (open recommendation) were agreed. As a result of this process we now have an interdisciplinary and consensus-based set of 3rd Generation Guidelines that take into account all critically illness patient populations. The use of protocols for analgesia, sedation and treatment of delirium are repeatedly demonstrated. These guidelines offer treatment recommendations for the ICU team. The implementation of scores and protocols into routine ICU practice is necessary for their success.

Hydroxyethyl starch antibodies in humans: incidence and clinical relevance.

Hydroxyethyl starch (HES) is a plasma expander used for perioperative IV fluid management, as well as for resuscitation from trauma and shock.HES is very well tolerated, and the incidence of anaphylactic reactions is lower than with dextran or gelatin. Dextran anaphylaxis is caused by circulating dextran-reactive antibodies (ABs) of the immunoglobin G (IgG) class found in most adults. Histamine release from mast cells induces adverse reactions after gelatin infusion. The cause of adverse reactions due to HES is not yet clear. To investigate AB formation due to HES, we collected sera of 1004 patients at least 14 days after starch administration. Using a highly sensitive enzyme-linked immunoabsorbent assay technique, we found one patient with a low 1:10 titer of HES-reactive ABs (immunoglobin M [IgM] class). Despite repeated HES infusions, no clinical reaction could be detected in this patient. On the basis of a binomial distribution, a one-tailed confidence interval (99%) was used to calculate the percentage of the occurrence of ABs in general with maximum of 33 in 10,000 persons (IgM) and 23 in 10,000 persons (IgG). We suggest that HES-reactive ABs are extremely rare and that they do not necessarily induce anaphylaxis. Other mechanisms may be responsible for adverse reactions due to HES. Implications: The frequency of antibody formation due to hydroxyethyl starch, a commonly used plasma expander, was prospectively investigated in 1004 patients. Only one patient showed transient antibody formation, which was not harmful to the patient. This low antigenicity could explain the excellent tolerance of hydroxyethyl starch compared with other plasma expanders. (Anesth Analg 1998;86:1123-6)

Postoperative Schmerztherapie in Deutschland Ergebnisse einer Umfrage

ZusammenfassungFragestellung. In einer Umfrage sollte eine Bestandsaufnahme zur Praxis der postoperativen Schmerztherapie in Deutschland erfolgen. Methodik. Fragebögen wurden an die Chefärzte von 773 Anästhesieabteilungen in Deutschland verschickt. Ergebnisse. Es konnten 446 (57,7%) Fragebögen ausgewertet werden; 161 Kliniken (36,1%) hatten einen Akutschmerzdienst (ASD) etabliert, in Kliniken ≥1000 Betten (63%) signifikant häufiger als in Kliniken mit 400–999 Betten (40%) und Kliniken <400 Betten (28%). Die Epiduralanalgesie wurde in 97% der Kliniken angeboten, jedoch für große Baucheingriffe und Oberschenkelamputationen nur von 60,8% bzw. 45,5% favorisiert. Kliniken mit ASD führten die EDA häufiger auf allgemeinen Pflegestationen durch als Kliniken ohne ASD (88,2% vs. 68,4%; p<0,001). Die technisch aufwendigeren Verfahren (PCA, PCEA, Plexuskatheter, i.v.-Infusion von Opioiden) wurden in mehr Kliniken mit ASD als in Kliniken ohne ASD praktiziert (p<0,01). Schlussfolgerung. Die Zahl der Akutschmerzdienste ist deutlich gestiegen. Für die zukünftige Diskussion über Vergütung und Fallpauschalen sollten diese umfangreichen anästhesiologischen Leistungen in der postoperativen Schmerztherapie Berücksichtigung finden.AbstractObjective. A survey was performed to obtain information on the organization and practice of postoperative pain management. Methods. A questionnaire was mailed to 773 directors of German departments of anesthesiology. Results. A total of 446 replies (57.7%) could be analyzed. Of the departments, 161 (36.1%) had established an acute pain service (APS), more often in hospitals ≥1000 beds (63%) than in hospitals with 400–999 beds (40%) and hospitals with <400 beds (27%). Epidural analgesia was practiced in 97% of the departments, however, it was the analgesic technique of choice for larger abdominal surgery or amputation of the lower limb only in 60.8% and 45.5% of the departments, respectively. Departments with APS provided epidural analgesia more often on general wards than departments without APS (88.2% vs. 68.4%, p<0.01). Technically more challenging methods (e. g. catheters for regional anesthesia, PCA, PCEA) were more often provided in hospitals running an APS (p<0.001). Conclusions. The number of departments with APS has increased over the last 10 years. Future decisions on reimbursement should consider this extensive service.

Technical Performance and Reflection Capacity of the Anaesthetic Conserving Device—A Bench Study with Isoflurane and Sevoflurane

ObjectiveThe anaesthetic conserving device (AnaConDa®, Sedana Medical, Sundbyberg, Sweden) facilitates administration of isoflurane or sevoflurane by liquid infusion. An anaesthetic reflector inside the device conserves exhaled anaesthetic and re-supplies it during inspiration. In this bench study, we examined the influence of infusion rates and ventilatory settings on the resulting anaesthetic concentrations on patient (Cpat) and ventilator side of the reflector (Closs) to describe its technical performance.MethodsA Puritan Bennett 840 ICU ventilator (Pleasanton, US), AnaConDa®, and a test lung (3 l-chloroprene-bag) were assembled. Infusion rates (IR, 0.2-50 ml h-), respiratory rates (RR, 5-40 breaths min-1), and tidal volumes (VT, 0.3, 0.5, and 1.0 l) were varied. Cpat was measured via a thin catheter in the middle of the 3 l-bag in steady state (online data storage and averaging over >10 min). Closs was calculated from IR (to yield the volume of vapour per unit of time), and expired minute volume (in which the vapour is diluted) on the assumption that, in the steady state, input by liquid infusion equals output through the reflector.ResultsAt lower concentrations (Cpat< 1 vol%) the ratio Closs/Cpat was constant (RC = 0.096 ±±0.012) for all combinations of IR, RR and VT, both for isoflurane and sevoflurane. The device could efficiently reflect up to 10 ml vapour per breath (e.g. 2 vol% in 0.5 l). When exceeding this capacity, surplus vapour “spilled over” and RC markedly increased indicating decreased performance.ConclusionsThe triple product minute volume times RC times Cpat describes anaesthetic losses through the reflector. It can easily be calculated as long as the 10 ml reflection capacity is not exceeded and thus RC is constant. Increased minute ventilation necessitates increasing the IR to keep Cpat constant. When using large VT and high Cpat “spill over” occurs. This effect offers some protection against an inadvertent overdose.

Postoperative pain therapy in Germany

ZusammenfassungFragestellung. In einer Umfrage sollte eine Bestandsaufnahme zur Praxis der postoperativen Schmerztherapie in Deutschland erfolgen. Methodik. Fragebögen wurden an die Chefärzte von 773 Anästhesieabteilungen in Deutschland verschickt. Ergebnisse. Es konnten 446 (57,7%) Fragebögen ausgewertet werden; 161 Kliniken (36,1%) hatten einen Akutschmerzdienst (ASD) etabliert, in Kliniken ≥1000 Betten (63%) signifikant häufiger als in Kliniken mit 400–999 Betten (40%) und Kliniken <400 Betten (28%). Die Epiduralanalgesie wurde in 97% der Kliniken angeboten, jedoch für große Baucheingriffe und Oberschenkelamputationen nur von 60,8% bzw. 45,5% favorisiert. Kliniken mit ASD führten die EDA häufiger auf allgemeinen Pflegestationen durch als Kliniken ohne ASD (88,2% vs. 68,4%; p<0,001). Die technisch aufwendigeren Verfahren (PCA, PCEA, Plexuskatheter, i.v.-Infusion von Opioiden) wurden in mehr Kliniken mit ASD als in Kliniken ohne ASD praktiziert (p<0,01). Schlussfolgerung. Die Zahl der Akutschmerzdienste ist deutlich gestiegen. Für die zukünftige Diskussion über Vergütung und Fallpauschalen sollten diese umfangreichen anästhesiologischen Leistungen in der postoperativen Schmerztherapie Berücksichtigung finden.AbstractObjective. A survey was performed to obtain information on the organization and practice of postoperative pain management. Methods. A questionnaire was mailed to 773 directors of German departments of anesthesiology. Results. A total of 446 replies (57.7%) could be analyzed. Of the departments, 161 (36.1%) had established an acute pain service (APS), more often in hospitals ≥1000 beds (63%) than in hospitals with 400–999 beds (40%) and hospitals with <400 beds (27%). Epidural analgesia was practiced in 97% of the departments, however, it was the analgesic technique of choice for larger abdominal surgery or amputation of the lower limb only in 60.8% and 45.5% of the departments, respectively. Departments with APS provided epidural analgesia more often on general wards than departments without APS (88.2% vs. 68.4%, p<0.01). Technically more challenging methods (e. g. catheters for regional anesthesia, PCA, PCEA) were more often provided in hospitals running an APS (p<0.001). Conclusions. The number of departments with APS has increased over the last 10 years. Future decisions on reimbursement should consider this extensive service.

Klinische Studien zur peripheren Wirksamkeit von Opioiden nach Kniegelenk-Operationen Ein Literaturüberblick

ZusammenfassungIn dieser Literaturübersicht werden 34 randomisierte kontrollierte klinische Studien zur peripheren Wirksamkeit von Opioiden an dem bislang vielversprechenden Modell des postoperativen Schmerzes nach Kniegelenk-Arthroskopien besprochen. Diese Arbeiten erzeugen kein einheitliches Bild. Eine Metaanalyse der Daten ist jedoch wegen stark differierender Studiendesigns nicht durchführbar. Einflußfaktoren: Einige Faktoren, die häufig diskutiert werden, um die widersprüchlichen Ergebnisse zu erklären, werden besprochen: Die verwendeten Konzentrationen, Volumina und Dosen der Testsubstanz (in allen Fällen Morphin) spielen keine entscheidende Rolle. Ein Adrenalinzusatz zur Testsubstanz, die Anlage einer Blutleere bzw. die Zeitspanne zwischen Medikamentenapplikation und Öffnen der Blutleere, ferner die Verwendung einer intraartikulären Saugdrainage (die erst 10 Minuten postoperativ geöffnet wird) und die Patienten-kontrollierte-Analgesie als Evaluationsmethode sind ebenfalls von untergeordneter Bedeutung. Es fällt jedoch auf, daß periphere Opioidwirkungen häufig nach Allgemein- und Lokalanästhesien, aber nur ein einziges Mal nach rückenmarknahen Leitungsblockaden beobachtet wurden. Läßt man die Patientenkollektive, die ein rückenmarknahes Anästhesieverfahren erhalten haben, aus der Betrachtung fort, so konnten von 29 Studien 20 eine periphere Opioidwirkung belegen, 9 dagegen nicht. Von einer peripheren Wirksamkeit von ganz niedrigen Dosen Morphin intraartikulär kann somit ausgegangen werden. Wirkdauer: Die Wirkdauer wird sehr unterschiedlich angegeben. In einigen Studien erstreckte sie sich über 48 h. Zumindest währen der ersten beiden Stunden postoperativ ist die Wirkung aber zweifelhaft. Eine Kombination mit dem rasch, aber nicht so lange wirkenden Bupivacain bietet sich an. Die meisten Autoren, die eine solche Kombination testeten, kamen zu dem Schluß, daß diese Kombination empfehlenswert sei.AbstractIn this article 34 randomized controlled trials examining peripherally mediated opioid effects after knee surgery are discussed. All studies examined small doses of morphine injected intraarticularly at the end of knee surgery, but not all studies did show an analgesic effect of the peripheral opioid. Because of differing study designs a meta-analysis of the data is not possible.Some important factors like those that the respective authors try to explain the contradictory results with are discussed here: The used concentrations, volumes and doses of morphine are not of major importance. An addition of adrenaline to the study drug, as well as the use of a tourniquet and the time interval between the intra-articular injection and tourniquet release do not seem crucial either. The use of intra-articular drainage (which is opened 10 min after injection of the study drug) and of patient-controlled analgesia as an evaluative method also do not seem to play a major role. But it is remarcable that peripheral opioid effects have often been described after general and local anesthesia but only once after regional anaesthesia. It may be that the activation or expression of peripheral opioid receptors is inhibited by the blockade of input to the central nervous system. Animal experiments are needed to clarify this issue. But it may also be that postoperative pain after regional anaesthesia does not reach a level high enough to make an analgesic effect measurable. If patients after regional anesthesia are not considered, 20 studies out of 29 were able to demonstrate opioid effects whereas 9 were not: The work of Heard and coll. [14] as well as Ruwe and coll. [44] must be criticized because of methodological shortcomings. In the remaining 7 studies the patients of the comparative groups only show low pain scores which may make it impossible to measure an analgesic effect by intraarticular morphine. In summary it can be concluded that very small doses of morphine injected intraarticularly after knee surgery do exert an analgesic effect. In some studies this effect lasted even up to 48 h. But at least during the first two hours the effect is small or else doubtfull. Therefore a combination with bupivacain, a local anesthetic which acts rapidly but only for some hours can be recommended. Most authors testing this combination found it most useful.

Struktur der schmerzmedizinischen Versorgung in Deutschland

ZusammenfassungIm Auftrag der schmerzmedizinischen/psychologischen Fachgesellschaften, der Selbsthilfeorganisation der Schmerzpatienten und des Berufsverbandes der Schmerztherapeuten und Schmerzpsychologen hat die Gemeinsame Kommission der Fachgesellschaften und Verbände für Qualität in der Schmerzmedizin unter Mitwirkung der jeweiligen Präsidenten überprüfbare Struktur- sowie Prozesskriterien entwickelt, um schmerzmedizinische Einrichtungen in Deutschland klassifizieren zu können. Grundlage sind das in Deutschland etablierte System der abgestuften Versorgung sowie bestehende Qualifikationen, Weiterbildungen und Zusatzbezeichnungen. Die Einführung eines Fachkundenachweises Schmerzmedizin wird empfohlen. Neben den erstmals beschriebenen schmerzpsychotherapeutischen Einrichtungen können anhand der Kriterien fünf Ebenen von der Einrichtung mit Fachkunde Schmerzmedizin über spezialisierte Einrichtungen bis zum Zentrum für interdisziplinäre Schmerzmedizin definiert werden. Ziel der Empfehlungen ist es, verbindliche und überprüfbare Kriterien zur Qualitätssicherung in der Schmerzmedizin zu etablieren und die Versorgung zu verbessern.AbstractOn behalf of the Medical/Psychological Pain Associations, Pain Patients Alliance and the Professional Association of Pain Physicians and Psychologists, the Joint Commission of Professional Societies and Organizations for Quality in Pain Medicine, working in close collaboration with the respective presidents, has developed verifiable structural and process-related criteria for the classification of medical and psychological pain treatment facilities in Germany. Based on the established system of graded care in Germany and on existing qualifications, these criteria also argue for the introduction of a basic qualification in pain medicine. In addition to the first-ever comprehensive description of psychological pain facilities, the criteria presented can be used to classify five different levels of pain facilities, from basic pain management facilities, to specialized institutions, to the Centre for Interdisciplinary Pain Medicine. The recommendations offer binding and verifiable criteria for quality assurance in pain medicine and improved pain treatment.On behalf of the Medical/Psychological Pain Associations, Pain Patients Alliance and the Professional Association of Pain Physicians and Psychologists, the Joint Commission of Professional Societies and Organizations for Quality in Pain Medicine, working in close collaboration with the respective presidents, has developed verifiable structural and process-related criteria for the classification of medical and psychological pain treatment facilities in Germany. Based on the established system of graded care in Germany and on existing qualifications, these criteria also argue for the introduction of a basic qualification in pain medicine. In addition to the first-ever comprehensive description of psychological pain facilities, the criteria presented can be used to classify five different levels of pain facilities, from basic pain management facilities, to specialized institutions, to the Centre for Interdisciplinary Pain Medicine. The recommendations offer binding and verifiable criteria for quality assurance in pain medicine and improved pain treatment.

Struktur der schmerzmedizinischen Versorgung in Deutschland: Klassifikation schmerzmedizinischer Einrichtungen

ZusammenfassungIm Auftrag der schmerzmedizinischen/psychologischen Fachgesellschaften, der Selbsthilfeorganisation der Schmerzpatienten und des Berufsverbandes der Schmerztherapeuten und Schmerzpsychologen hat die „Gemeinsame Kommission der Fachgesellschaften und Verbände für Qualität in der Schmerzmedizin“ unter Mitwirkung der jeweiligen Präsidenten überprüfbare Struktur- sowie Prozesskriterien entwickelt, um schmerzmedizinische Einrichtungen in Deutschland klassifizieren zu können. Grundlage ist das in Deutschland etablierte System der abgestuften Versorgung sowie bestehende Qualifikationen, Weiterbildungen und Zusatzbezeichnungen. Die Einführung eines Fachkundenachweises Schmerzmedizin wird empfohlen.Neben den erstmals beschriebenen Schmerzpsychotherapeutischen Einrichtungen können anhand der Kriterien fünf Ebenen von der Einrichtung mit Fachkunde Schmerzmedizin über spezialisierte Einrichtungen bis zum Zentrum für Interdisziplinäre Schmerzmedizin definiert werden.Ziel der Empfehlungen ist es, verbindliche und überprüfbare Kriterien zur Qualitätssicherung in der Schmerzmedizin zu etablieren und die Versorgung zu verbessern.SummaryOn behalf of the Medical / Psychological Pain Associations, Pain Patients Alliance and the Professional Association of Pain Physicians and Psychologists, the “Joint Commission of Professional Societies and Organizations for Quality in Pain Medicine,” working in close collaboration with the respective presidents, has developed verifiable structural and process-related criteria for the classification of medical and psychological pain treatment facilities in Germany.Based on the established system of graded care in Germany and on existing qualifications, these criteria also argue for the introduction of a basic qualification in pain medicine.In addition to the first-ever comprehensive description of psychological pain facilities, the criteria presented can be used to classify five different levels of pain facilities, from basic pain management facilities, to specialized institutions, to the Centre for Interdisciplinary Pain Medicine.The recommendations offer binding and verifiable criteria for quality assurance in pain medicine and improved pain treatment.

Struktur der schmerzmedizinischen Versorgung in DeutschlandStructure of pain management facilities in Germany

ZusammenfassungIm Auftrag der schmerzmedizinischen/psychologischen Fachgesellschaften, der Selbsthilfeorganisation der Schmerzpatienten und des Berufsverbandes der Schmerztherapeuten und Schmerzpsychologen hat die Gemeinsame Kommission der Fachgesellschaften und Verbände für Qualität in der Schmerzmedizin unter Mitwirkung der jeweiligen Präsidenten überprüfbare Struktur- sowie Prozesskriterien entwickelt, um schmerzmedizinische Einrichtungen in Deutschland klassifizieren zu können. Grundlage sind das in Deutschland etablierte System der abgestuften Versorgung sowie bestehende Qualifikationen, Weiterbildungen und Zusatzbezeichnungen. Die Einführung eines Fachkundenachweises Schmerzmedizin wird empfohlen. Neben den erstmals beschriebenen schmerzpsychotherapeutischen Einrichtungen können anhand der Kriterien fünf Ebenen von der Einrichtung mit Fachkunde Schmerzmedizin über spezialisierte Einrichtungen bis zum Zentrum für interdisziplinäre Schmerzmedizin definiert werden. Ziel der Empfehlungen ist es, verbindliche und überprüfbare Kriterien zur Qualitätssicherung in der Schmerzmedizin zu etablieren und die Versorgung zu verbessern.AbstractOn behalf of the Medical/Psychological Pain Associations, Pain Patients Alliance and the Professional Association of Pain Physicians and Psychologists, the Joint Commission of Professional Societies and Organizations for Quality in Pain Medicine, working in close collaboration with the respective presidents, has developed verifiable structural and process-related criteria for the classification of medical and psychological pain treatment facilities in Germany. Based on the established system of graded care in Germany and on existing qualifications, these criteria also argue for the introduction of a basic qualification in pain medicine. In addition to the first-ever comprehensive description of psychological pain facilities, the criteria presented can be used to classify five different levels of pain facilities, from basic pain management facilities, to specialized institutions, to the Centre for Interdisciplinary Pain Medicine. The recommendations offer binding and verifiable criteria for quality assurance in pain medicine and improved pain treatment.On behalf of the Medical/Psychological Pain Associations, Pain Patients Alliance and the Professional Association of Pain Physicians and Psychologists, the Joint Commission of Professional Societies and Organizations for Quality in Pain Medicine, working in close collaboration with the respective presidents, has developed verifiable structural and process-related criteria for the classification of medical and psychological pain treatment facilities in Germany. Based on the established system of graded care in Germany and on existing qualifications, these criteria also argue for the introduction of a basic qualification in pain medicine. In addition to the first-ever comprehensive description of psychological pain facilities, the criteria presented can be used to classify five different levels of pain facilities, from basic pain management facilities, to specialized institutions, to the Centre for Interdisciplinary Pain Medicine. The recommendations offer binding and verifiable criteria for quality assurance in pain medicine and improved pain treatment.

[Structure of pain management facilities in Germany : Classification of medical and psychological pain treatment services-Consensus of the Joint Commission of the Professional Societies and Organizations for Quality in Pain Medicine].

ZusammenfassungIm Auftrag der schmerzmedizinischen/psychologischen Fachgesellschaften, der Selbsthilfeorganisation der Schmerzpatienten und des Berufsverbandes der Schmerztherapeuten und Schmerzpsychologen hat die Gemeinsame Kommission der Fachgesellschaften und Verbände für Qualität in der Schmerzmedizin unter Mitwirkung der jeweiligen Präsidenten überprüfbare Struktur- sowie Prozesskriterien entwickelt, um schmerzmedizinische Einrichtungen in Deutschland klassifizieren zu können. Grundlage sind das in Deutschland etablierte System der abgestuften Versorgung sowie bestehende Qualifikationen, Weiterbildungen und Zusatzbezeichnungen. Die Einführung eines Fachkundenachweises Schmerzmedizin wird empfohlen. Neben den erstmals beschriebenen schmerzpsychotherapeutischen Einrichtungen können anhand der Kriterien fünf Ebenen von der Einrichtung mit Fachkunde Schmerzmedizin über spezialisierte Einrichtungen bis zum Zentrum für interdisziplinäre Schmerzmedizin definiert werden. Ziel der Empfehlungen ist es, verbindliche und überprüfbare Kriterien zur Qualitätssicherung in der Schmerzmedizin zu etablieren und die Versorgung zu verbessern.AbstractOn behalf of the Medical/Psychological Pain Associations, Pain Patients Alliance and the Professional Association of Pain Physicians and Psychologists, the Joint Commission of Professional Societies and Organizations for Quality in Pain Medicine, working in close collaboration with the respective presidents, has developed verifiable structural and process-related criteria for the classification of medical and psychological pain treatment facilities in Germany. Based on the established system of graded care in Germany and on existing qualifications, these criteria also argue for the introduction of a basic qualification in pain medicine. In addition to the first-ever comprehensive description of psychological pain facilities, the criteria presented can be used to classify five different levels of pain facilities, from basic pain management facilities, to specialized institutions, to the Centre for Interdisciplinary Pain Medicine. The recommendations offer binding and verifiable criteria for quality assurance in pain medicine and improved pain treatment.On behalf of the Medical/Psychological Pain Associations, Pain Patients Alliance and the Professional Association of Pain Physicians and Psychologists, the Joint Commission of Professional Societies and Organizations for Quality in Pain Medicine, working in close collaboration with the respective presidents, has developed verifiable structural and process-related criteria for the classification of medical and psychological pain treatment facilities in Germany. Based on the established system of graded care in Germany and on existing qualifications, these criteria also argue for the introduction of a basic qualification in pain medicine. In addition to the first-ever comprehensive description of psychological pain facilities, the criteria presented can be used to classify five different levels of pain facilities, from basic pain management facilities, to specialized institutions, to the Centre for Interdisciplinary Pain Medicine. The recommendations offer binding and verifiable criteria for quality assurance in pain medicine and improved pain treatment.