R. Laufenberg-Feldmann

Medikamente zur postoperativen Schmerztherapie: Bewährtes und Neues

In part 1 of this review the perioperative aspects of the use of non-opioids (acetaminophen, dipyrone, traditional NSAR, coxibs) and in part 2 of opioids (weak opioids: tramadol, tilidine with naloxone, strong opioids: morphine, piritramide, oxycodone, hydromorphone, fentanyl, methadone, buprenorphine) and coanalgesics (gabapentinoids, ketamine) will be discussed. The main aim is to describe the relationship between analgesic efficacy and side effects to make clinical decisions easier in patients with preoperative renal, gastrointestinal, cardiovascular and other diseases. Some new aspects concerning perioperative administration of gabapentinoids and ketamine in patients with perioperative neuropathic pain are discussed.

[Drugs for postoperative analgesia: routine and new aspects. Part 1: non-opioids].

In part 1 of this review the perioperative aspects of the use of non-opioids (acetaminophen, dipyrone, traditional NSAR, coxibs) and in part 2 of opioids (weak opioids: tramadol, tilidine with naloxone, strong opioids: morphine, piritramide, oxycodone, hydromorphone, fentanyl, methadone, buprenorphine) and coanalgesics (gabapentinoids, ketamine) will be discussed. The main aim is to describe the relationship between analgesic efficacy and side effects to make clinical decisions easier in patients with preoperative renal, gastrointestinal, cardiovascular and other diseases. Some new aspects concerning perioperative administration of gabapentinoids and ketamine in patients with perioperative neuropathic pain are discussed.

Fragen-Identifikationsliste für das Prämedikationsgespräch

BACKGROUND The anesthesia premedication consultation is an obligatory procedure prior to any upcoming surgery. It is the anesthesiologists responsibility to collect all necessary information regarding the patients medical condition to decide on the appropriate narcosis and to ensure that the patient comprehends the anesthesia procedure and its effects. AIM Information needs of patients regarding anesthesia are often not adequately fulfilled. This study was carried out to develop a structured questionnaire containing questions that patients may wish to ask the anesthesiologist (question prompt list anesthesiology QPL-A) to support information transfer from the anesthesiologist to the patient in the premedication consultation. The questionnaire should measure the information needs of the patient regarding different aspects of the anesthesia process with good psychometric qualities. MATERIAL AND METHODS Based on a literature review and interviews with experts a list of anesthesia-related questions was developed and distributed to patients receiving premedication consultation at the University Medical Center in Mainz, Germany (n = 202). In addition, patients were also asked to complete the state trait operation anxiety inventory (STOA). RESULTS Using principal component analysis and subsequent varimax rotation (declaration of total variance 68 %), four reliable information needs scales were extrapolated: (1) anesthesia procedure and effects (QPL-A-E, α = 0.92), (2) anesthesia safety (QPL-A-S, α = 0.86), (3) advice concerning preanesthesia behavior (QPL-A-B, α = 0.85) and (4) anesthetists actions (QPL-A-A, α = 0.79). In order to obtain sufficient information regarding the QPL-A-S, the procedure itself and its effects (QPL-A-E) were found to be of greatest importance for the patients and behavioral changes (QPL-A-B), e. g. stopping smoking, were judged to be less important by the patients. Women scored higher on the QPL-A-E (U-test p ≤ 0.001) and QPL-A-A (U-test p ≤ 0.05) than men. Elderly patients (≥ 70) showed significantly more interest in safety information (QPL-A-S) than younger patients (≤ 39, U-test p ≤ 0.05). All scales showed a significant positive correlation with STOA trait anxiety (r = 0.29-0.50) but only the QPL-A-E and the QPL-A-S scales were associated with STOA state anxiety (QPL-A-E: affective r = 30, cognitive r = 0.36, both p ≤ 0.001; QPL-A-S: affective r = 19, p ≤ 0.05, cognitive r = 0.23, p ≤ 0.01). Self-assessed knowledge on narcosis correlated only weakly with the QPL-A-E (r = 0.21 p ≤ 0.01) but not with the other information areas. Information needs were not associated with the education level of the patient, American Society of Anesthesiologists (ASA) classification and malignancy of the disease. Most of the participants (77 %) evaluated the QPL-A to be very or fairly helpful for the expression of their information needs. CONCLUSION The QPL-A is a useful tool for meeting the subjective information needs of patients which could improve the patient orientation of the anesthesia premedication consultation.

[Question prompt list for premedication consultation : Patient-oriented information on anesthesia].

BACKGROUND The anesthesia premedication consultation is an obligatory procedure prior to any upcoming surgery. It is the anesthesiologists responsibility to collect all necessary information regarding the patients medical condition to decide on the appropriate narcosis and to ensure that the patient comprehends the anesthesia procedure and its effects. AIM Information needs of patients regarding anesthesia are often not adequately fulfilled. This study was carried out to develop a structured questionnaire containing questions that patients may wish to ask the anesthesiologist (question prompt list anesthesiology QPL-A) to support information transfer from the anesthesiologist to the patient in the premedication consultation. The questionnaire should measure the information needs of the patient regarding different aspects of the anesthesia process with good psychometric qualities. MATERIAL AND METHODS Based on a literature review and interviews with experts a list of anesthesia-related questions was developed and distributed to patients receiving premedication consultation at the University Medical Center in Mainz, Germany (n = 202). In addition, patients were also asked to complete the state trait operation anxiety inventory (STOA). RESULTS Using principal component analysis and subsequent varimax rotation (declaration of total variance 68 %), four reliable information needs scales were extrapolated: (1) anesthesia procedure and effects (QPL-A-E, α = 0.92), (2) anesthesia safety (QPL-A-S, α = 0.86), (3) advice concerning preanesthesia behavior (QPL-A-B, α = 0.85) and (4) anesthetists actions (QPL-A-A, α = 0.79). In order to obtain sufficient information regarding the QPL-A-S, the procedure itself and its effects (QPL-A-E) were found to be of greatest importance for the patients and behavioral changes (QPL-A-B), e. g. stopping smoking, were judged to be less important by the patients. Women scored higher on the QPL-A-E (U-test p ≤ 0.001) and QPL-A-A (U-test p ≤ 0.05) than men. Elderly patients (≥ 70) showed significantly more interest in safety information (QPL-A-S) than younger patients (≤ 39, U-test p ≤ 0.05). All scales showed a significant positive correlation with STOA trait anxiety (r = 0.29-0.50) but only the QPL-A-E and the QPL-A-S scales were associated with STOA state anxiety (QPL-A-E: affective r = 30, cognitive r = 0.36, both p ≤ 0.001; QPL-A-S: affective r = 19, p ≤ 0.05, cognitive r = 0.23, p ≤ 0.01). Self-assessed knowledge on narcosis correlated only weakly with the QPL-A-E (r = 0.21 p ≤ 0.01) but not with the other information areas. Information needs were not associated with the education level of the patient, American Society of Anesthesiologists (ASA) classification and malignancy of the disease. Most of the participants (77 %) evaluated the QPL-A to be very or fairly helpful for the expression of their information needs. CONCLUSION The QPL-A is a useful tool for meeting the subjective information needs of patients which could improve the patient orientation of the anesthesia premedication consultation.

Tumorschmerz in der Palliativmedizin

ZusammenfassungIm Verlauf einer Tumorerkrankung leiden bis zu 90% der Patienten an Schmerzen, die nozizeptiven, neuropathischen oder gemischt nozizeptiv/neuropathischen Charakter haben können. Psychische, soziale und existenzielle Belastungsfaktoren beeinflussen das Schmerzgeschehen zusätzlich (Konzept des „totalen Schmerzes“). Mit den Präparaten des WHO-Stufenschemas stehen dem Therapeuten eine Vielzahl wirksamer Substanzen zur Verfügung, die entsprechend dem spezifischen Schmerzgeschehen differenziert einzusetzen sind. Parenterale und rückenmarknahe Opioidtherapie sowie neurodestruktive Verfahren können im Einzelfall entscheidend zur Schmerzlinderung beitragen.AbstractDuring the course of cancer progression up to 90% of the patients suffer from pain of nociceptive, neuropathic or mixed nociceptive/neuropathic origin. Psychological, social or existential factors may additionally affect the intensity of pain (concept of “total pain”). The WHO “analgesic ladder” provides a large variety of effective drugs that can be used according to the specific pain type. Parenteral or peridural opioid therapy as well as neurodestructive methods can effectively support the analgesic treatment in selected cases.

Risikoabwägung vor Periduralkatheterentfernung bei akutem Koronarsyndrom

Perioperative pain therapy using an epidural catheter is the standard operating procedure for numerous surgical interventions. The necessity of initiating anticoagulant therapy in a patient with an epidural catheter requires a careful weighing up between thromboembolic complications and epidural hematoma. The case presented here of a 47-year-old female patient who was operated on for mastectomy with a latissimus dorsi myocutaneous flap demonstrates a possible solution to this dilemma. The patient sustained a perioperative ST elevation myocardial infarction treated with drug-eluting stents while undergoing epidural pain therapy. By using the short-acting antiplatelet drug tirofiban over a time period of 7 days the gap for dual antiplatelet therapy was reduced with the help of specific platelet aggregation assays to a time frame of a few hours to minimize the risk of stent thrombosis. The epidural catheter was removed without complications under consideration of the current recommendations for regional anesthesia and antithrombotic agents.

Risikoabwägung vor Periduralkatheterentfernung bei akutem Koronarsyndrom@@@Risk consideration for peridural catheter removal in acute coronary syndrome: Epidurales Hämatom vs. Stent-Thrombose@@@Epidural hematoma versus stent thrombosis

Perioperative pain therapy using an epidural catheter is the standard operating procedure for numerous surgical interventions. The necessity of initiating anticoagulant therapy in a patient with an epidural catheter requires a careful weighing up between thromboembolic complications and epidural hematoma. The case presented here of a 47-year-old female patient who was operated on for mastectomy with a latissimus dorsi myocutaneous flap demonstrates a possible solution to this dilemma. The patient sustained a perioperative ST elevation myocardial infarction treated with drug-eluting stents while undergoing epidural pain therapy. By using the short-acting antiplatelet drug tirofiban over a time period of 7 days the gap for dual antiplatelet therapy was reduced with the help of specific platelet aggregation assays to a time frame of a few hours to minimize the risk of stent thrombosis. The epidural catheter was removed without complications under consideration of the current recommendations for regional anesthesia and antithrombotic agents.

Risk consideration for peridural catheter removal in acute coronary syndrome. Epidural hematoma versus stent thrombosis

Perioperative pain therapy using an epidural catheter is the standard operating procedure for numerous surgical interventions. The necessity of initiating anticoagulant therapy in a patient with an epidural catheter requires a careful weighing up between thromboembolic complications and epidural hematoma. The case presented here of a 47-year-old female patient who was operated on for mastectomy with a latissimus dorsi myocutaneous flap demonstrates a possible solution to this dilemma. The patient sustained a perioperative ST elevation myocardial infarction treated with drug-eluting stents while undergoing epidural pain therapy. By using the short-acting antiplatelet drug tirofiban over a time period of 7 days the gap for dual antiplatelet therapy was reduced with the help of specific platelet aggregation assays to a time frame of a few hours to minimize the risk of stent thrombosis. The epidural catheter was removed without complications under consideration of the current recommendations for regional anesthesia and antithrombotic agents.

Fragen-Identifikationsliste für das Prämedikationsgespräch@@@Question prompt list for premedication consultation: Patientenorientiertes Informieren in der Anästhesie@@@Patient-oriented information on anesthesia

BACKGROUND The anesthesia premedication consultation is an obligatory procedure prior to any upcoming surgery. It is the anesthesiologists responsibility to collect all necessary information regarding the patients medical condition to decide on the appropriate narcosis and to ensure that the patient comprehends the anesthesia procedure and its effects. AIM Information needs of patients regarding anesthesia are often not adequately fulfilled. This study was carried out to develop a structured questionnaire containing questions that patients may wish to ask the anesthesiologist (question prompt list anesthesiology QPL-A) to support information transfer from the anesthesiologist to the patient in the premedication consultation. The questionnaire should measure the information needs of the patient regarding different aspects of the anesthesia process with good psychometric qualities. MATERIAL AND METHODS Based on a literature review and interviews with experts a list of anesthesia-related questions was developed and distributed to patients receiving premedication consultation at the University Medical Center in Mainz, Germany (n = 202). In addition, patients were also asked to complete the state trait operation anxiety inventory (STOA). RESULTS Using principal component analysis and subsequent varimax rotation (declaration of total variance 68 %), four reliable information needs scales were extrapolated: (1) anesthesia procedure and effects (QPL-A-E, α = 0.92), (2) anesthesia safety (QPL-A-S, α = 0.86), (3) advice concerning preanesthesia behavior (QPL-A-B, α = 0.85) and (4) anesthetists actions (QPL-A-A, α = 0.79). In order to obtain sufficient information regarding the QPL-A-S, the procedure itself and its effects (QPL-A-E) were found to be of greatest importance for the patients and behavioral changes (QPL-A-B), e. g. stopping smoking, were judged to be less important by the patients. Women scored higher on the QPL-A-E (U-test p ≤ 0.001) and QPL-A-A (U-test p ≤ 0.05) than men. Elderly patients (≥ 70) showed significantly more interest in safety information (QPL-A-S) than younger patients (≤ 39, U-test p ≤ 0.05). All scales showed a significant positive correlation with STOA trait anxiety (r = 0.29-0.50) but only the QPL-A-E and the QPL-A-S scales were associated with STOA state anxiety (QPL-A-E: affective r = 30, cognitive r = 0.36, both p ≤ 0.001; QPL-A-S: affective r = 19, p ≤ 0.05, cognitive r = 0.23, p ≤ 0.01). Self-assessed knowledge on narcosis correlated only weakly with the QPL-A-E (r = 0.21 p ≤ 0.01) but not with the other information areas. Information needs were not associated with the education level of the patient, American Society of Anesthesiologists (ASA) classification and malignancy of the disease. Most of the participants (77 %) evaluated the QPL-A to be very or fairly helpful for the expression of their information needs. CONCLUSION The QPL-A is a useful tool for meeting the subjective information needs of patients which could improve the patient orientation of the anesthesia premedication consultation.

Medikamente zur postoperativen Schmerztherapie: Bewährtes und Neues@@@Drugs for postoperative analgesia: routine and new aspects: Teil 1: Nichtopioide@@@Part 1: Non-opioids

In part 1 of this review the perioperative aspects of the use of non-opioids (acetaminophen, dipyrone, traditional NSAR, coxibs) and in part 2 of opioids (weak opioids: tramadol, tilidine with naloxone, strong opioids: morphine, piritramide, oxycodone, hydromorphone, fentanyl, methadone, buprenorphine) and coanalgesics (gabapentinoids, ketamine) will be discussed. The main aim is to describe the relationship between analgesic efficacy and side effects to make clinical decisions easier in patients with preoperative renal, gastrointestinal, cardiovascular and other diseases. Some new aspects concerning perioperative administration of gabapentinoids and ketamine in patients with perioperative neuropathic pain are discussed.