Effects of controlled ovarian stimulation on vascular barrier and endothelial glycocalyx: a pilot study.

PURPOSE: Controlled ovarian stimulation significantly amplifies the number of maturing and ovulated follicles as well as ovarian steroid production. The ovarian hyperstimulation syndrome (OHSS) increases capillary permeability and fluid extravasation. Vascular integrity intensely is regulated by an endothelial glycocalyx (EGX) and we have shown that ovulatory cycles are associated with shedding of EGX components. This study investigates if controlled ovarian stimulation impacts on the integrity of the endothelial glycocalyx as this might explain key pathomechanisms of the OHSS. METHODS: Serum levels of endothelial glycocalyx components of infertility patients (n=18) undergoing controlled ovarian stimulation were compared to a control group of healthy women with regular ovulatory cycles (n=17). RESULTS: Patients during luteal phases of controlled ovarian stimulation cycles as compared to normal ovulatory cycles showed significantly increased Syndecan-1 serum concentrations (12.6 ng/ml 6.1125th-19.1375th to 13.9 ng/ml 9.625th-28.975th; p=0.026), indicating shedding and degradation of the EGX. CONCLUSION: A shedding of EGX components during ovarian stimulation has not yet been described. Our study suggests that ovarian stimulation may affect the integrity of the endothelial surface layer and increasing vascular permeability. This could explain key features of the OHSS and provide new ways of prevention of this serious condition of assisted reproduction.

[Cardiorespiratory effects of perioperative positioning techniques]. / Kardiorespiratorische Effekte perioperativer Positionierungsmaßnahmen.

The supine position is still the most frequently used type of positioning during surgical procedures. Positions other than the supine position lead to physiological alterations that have a relevant influence on the course of anesthesia and surgery. As a matter of principle, hemodynamic stability is at risk because venous blood is pooled in the lower positioned body parts. In addition, head down positions (Trendelenburg position) may lead to an impairment of respiratory function by reducing lung volumes as well as lung compliance. Upright positions (beach chair position) are characterized by a relative hypovolemia accompanied by a reduction of mean arterial pressure, cardiac output and stroke volume, whereas pulmonary functions remain unchanged. Some severe adverse events have been described in the literature (e.g. intraoperative apoplexy, postoperative blindness). The pathophysiological principles and effects of hemodynamic alterations as well as potential strategies to avoid complications are presented and discussed in this lead article. Head down positions, especially the Trendelenburg position, cause a relative (intrathoracic) hypervolemia and an increase in cardiac preload that is usually well-tolerated in patients without heart problems; however, the Trendelenburg position, especially if combined with a capnoperitoneum, significantly impairs pulmonary function, can have a negative effect on intracerebral pressure and may reduce blood flow of intra-abdominal organs. The pathophysiological intraoperative changes caused by Trendelenburg positioning are described and approaches suitable for risk reduction are discussed. The prone position and lateral decubitus position have little influence on the intraoperative homeostasis. Nevertheless, there is an ongoing discussion concerning the efficacy of a 15° left lateral position during caesarean section, which is also discussed in a separate section of this review.

Screening for delirium after surgery: validation of the 4 A's test (4AT) in the post-anaesthesia care unit.

Postoperative delirium is common and has multiple adverse consequences. Guidelines recommend routine screening for postoperative delirium beginning in the post-anaesthesia care unit. The 4 A's test (4AT) is a widely used assessment tool for delirium but there are no studies evaluating its use in the post-anaesthesia care unit. We evaluated the performance of the 4AT in the post-anaesthesia care unit in a tertiary German medical centre. Adults who were able to provide informed consent, were not scheduled for postoperative intensive care, and who did not have dementia or severe neuropsychiatric disorders underwent screening by trained research staff with the Nurse Delirium Screening Scale and a new German translation of the 4AT in a random order at the point of discharge from the post-anaesthesia care unit. Reference standard assessment of delirium was psychiatric evaluation by experienced clinicians. Five hundred and forty-three patients (mean age (SD) 52 (18) years) were analysed; 22 (4.1%) patients developed delirium. The sensitivity and specificity of the 4AT were 95.5% (95%CI 77.2-99.9) and 99.2% (95%CI 98.1-99.8), respectively. The area under the receiver operator characteristic curve was 0.998 (95%CI 0.995-1.000). The Nursing Delirium Screening Scale had a sensitivity of 27.3% (95%CI 10.7-50.2) and specificity of 99.4% (95%CI 98.3-99.9), with an area under the curve of 0.761 (95%CI 0.629-0.894). These findings suggest that the 4AT is an effective and robust instrument for delirium detection in the post-anaesthesia care unit.

State of the art in fluid and volume therapy : A user-friendly staged concept. English version.

Adequate intraoperative infusion therapy is essential for the perioperative outcome of a patient. Both hypo- and hypervolemia can lead to an increased rate of perioperative complications and to a worse outcome. Perioperative infusion therapy should therefore be needs-based. The primary objective is the maintenance of preoperative normovolemia using a rational infusion strategy. Perioperative fluid losses should be differentiated from volume losses due to surgical bleeding or protein losses into the interstitial space. Fluid loss via urine excretion or insensible perspiration (0.5-1.0 ml/kg/h) should be replaced with balanced, isooncotic, crystalloid infusion solutions in a ratio of 1:1. Volume therapy stage 1: intraoperative volume losses up to a blood loss corresponding to 20% of the patient's total blood volume are compensated for by balanced crystalloids in a ratio of 4-5:1. Stage 2: blood losses exceeding this level are to be treated with isooncotic colloids (preferably balanced) in a 1:1 ratio. In this regard taking into consideration the contraindications, e. g., sepsis, burns, critical illness (usually patients in the intensive care unit), impaired renal function or renal replacement therapy, intracranial hemorrhage, or severe coagulopathy, artificial colloids such as hydroxyethyl starch (HES) can be used perioperatively for volume replacement. Stage 3: if an allogeneic blood transfusion is indicated, blood and blood products are applied in a differentiated manner.

[Physiological changes during pregnancy]. / Physiologische Veränderungen in der Schwangerschaft.

The physiological state of a woman experiences multiple changes in the body during pregnancy. These alterations could be of particular importance in the medical care of pregnant women. This review article highlights the physiological developments of various organ systems throughout gestation with a focus on endocrinology, the cardiovascular system, hematology, the respiratory system and water balance.

[State of the art in fluid and volume therapy : A user-friendly staged concept]. / Stand der Wissenschaft in der Flüssigkeits- und Volumentherapie : Ein anwenderfreundliches Stufenkonzept.

Adequate fluid therapy is highly important for the perioperative outcome of our patients. Both, hypovolemia and hypervolemia can lead to an increase in perioperative complications and can impair the outcome. Therefore, perioperative infusion therapy should be target-oriented. The main target is to maintain the patient's preoperative normovolemia by using a sophisticated, rational infusion strategy.Perioperative fluid losses should be discriminated from volume losses (surgical blood loss or interstitial volume losses containing protein). Fluid losses as urine or perspiratio insensibilis (0.5-1.0 ml/kg/h) should be replaced by balanced crystalloids in a ratio of 1:1. Volume therapy step 1: Blood loss up to a maximum value of 20% of the patient's blood volume should be replaced by balanced crystalloids in a ratio of 4(-5):1. Volume therapy step 2: Higher blood losses should be treated by using iso-oncotic, preferential balanced colloids in a ratio of 1:1. For this purpose hydroxyethyl starch can also be used perioperatively if there is no respective contraindication, such as sepsis, burn injuries, critically ill patients, renal impairment or renal replacement therapy, and severe coagulopathy. Volume therapy step 3: If there is an indication for red cell concentrates or coagulation factors, a differentiated application of blood and blood products should be performed.

[Knowledge and implementation of the S3 guideline on delirium management in Germany]. / Kenntnis und Umsetzung der S3-Leitlinie zum Delirmanagement in Deutschland.

BACKGROUND: Delirium is a common complication in critical care. The syndrome is often underestimated due to its potentially no less dangerous course as a hypoactive delirium. Therefore, current guidelines ask for a structured, regular and routine screening in all intensive care units. If delirium is diagnosed, symptomatic therapy should be initiated promptly. OBJECTIVES: The aim of the current study was to evaluate recent German anesthetists' strategies regarding delirium care compared to the German guidelines for sedation and delirium in intensive care. METHODS: In an online survey German hospitals' senior anesthetists (n = 922) were interviewed anonymously between May and June 2015 regarding guideline use in delirium management in German intensive care units. In 33 direct questions the anesthetists were invited to answer items regarding the structure of their hospitals, intensive care and delirium therapy in order to review their knowledge of the German delirium guidelines that expired in 2014. RESULTS: The 249 senior anesthetists who responded to the survey, can be associated with (or represent) a quarter of German intensive care beds and cases, respectively. In every tenth clinic that runs an intensive care unit the guideline was unknown. In three of four intensive care units physicians specified a preferred delirium score, the CAM-ICU (49.4 %) is used most frequently. With knowledge of the guidelines more often a recommended delirium score is used (p = 0.017). However, only 53.6 % of the respondents ascertain a score every eight hours and 36 % have no facility for standardized documentation in the records. At intensive care rounds, a possible diagnosis of delirium is an inherent part in only 34.9 % of the responders even with guideline knowledge. The particular gold standard for the therapy of delirium (alphaagonists for vegetative symptoms; 89.6 %, benzodiazepines for anxiety, 77.5 %; antipsychotics in 86.7 % for psychotic symptoms) is implemented more often with growing knowledge of the guidelines. The latter applies to the implementation of structured programs for delirium prophylaxis, cognition and therapy. CONCLUSION: For the first time, this study documents knowledge and implementation of the German S3 guidelines for delirium in intensive care. Overall, the guidelines for delirium care are less well executed than those for sedation. With growing knowledge of the guidelines, diagnosis and treatment of delirium fits the guidelines more frequently. The facility to document a delirium score in intensive records is insufficient. Especially a nursing-based delirium strategy could possibly improve implementation of the guidelines, claiming an eight-hour screening and documentation. However, the small number of hospitals that have integrated the guidelines into in-house standard operating procedures (40 %) shows urgent need for optimization. A re-evaluation involving all relevant caretakers could probably improve the implementation of guidelines in intensive care and perioperative medicine.

[Acute perioperative hemodilution without using hydroxyethyl starch : hemodynamic alterations under "controlled" hypovolemia]. / Akute perioperative Hämodilution ohne Verwendung von Hydroxyethylstärke : Hämodynamische Veränderungen unter "kontrollierter" Hypovolämie.

BACKGROUND: Up to now hydroxyethyl starch preparations have frequently been used to compensate for volume deficits accompanying blood withdrawal during acute normovolemic hemodilution. This approach was questioned with respect to the current limitations for use of hydroxyethyl starch solutions imposed by the European Medicines Agency. Because crystalloids distribute evenly across the whole extracellular compartment, 80 % of the infused solution will be "lost" to the interstitial space. Thus, a physiological adjustment of blood loss caused by hemodilution with crystalloids alone (1:5 ratio) seems hardly feasible and according to current data perhaps not even desirable. A 3:1 ratio (crystalloids versus blood loss) as applied in the current study can be regarded as a practical compromise between physiological needs and recommendations according to the literature (1.4:1) but will lead to moderate hypovolemia the hemodynamic consequences of which are not well described. AIM: The current study investigates the hemodynamic impact of a hemodilution with crystalloids under the precondition of a 3:1 substitution ratio compared to withdrawn blood. METHODS: In the context of acute perioperative hemodilution 10 otherwise healthy women graded I and II on the American Society of Anesthesiologists (ASA) classification scheduled for open gynecological cancer surgery underwent an average blood withdrawal of 1097 ± 285 ml which was substituted by an average of 3430 ± 806 ml of Ringer's lactate. The resulting deficit in blood volume was exactly quantified by a double tracer technique. Hemodynamic changes were evaluated by a combination of thermodilution and pulse contour analysis (PiCCO system®). Subsequently, the remaining volume deficit was compensated by 245 ± 64 ml of a 20 % albumin solution and hemodynamic parameters were again evaluated. RESULTS: When infusing Ringer's lactate in a 3:1 ratio compared to the actual blood loss, the blood volume decreased by 12 %. The volume effect of Ringer's lactate proved to be 17 %. While mean arterial pressure and heart rate remained constant, key hemodynamic parameters changed relevantly during the time course. A significant rise in cardiac output and myocardial contractility could be observed which was accompanied by a decrease in systemic vascular resistance. In contrast, cardiac preload and the parameters representing pulmonary vascular permeability remained unaltered. The infusion of 245 ± 64 ml of a 20 % albumin solution nearly completely restituted blood volume and led to an insignificant rise in systemic vascular resistance but did not normalize cardiac output or myocardial contractility. CONCLUSION: In the study population, the loss of intravascular fluid during perioperative haemodilution could be compensated by an increase in cardiac performance. However, whether patients with a reduced cardiac capacity (i.e. older patients) are capable to improve their cardiac output sufficiently in order to compensate hypovolemia accompanying perioperative haemodilution with crystalloids remains questionable.

[Hypernatremic alkalosis. Possible counterpart of hyperchloremic acidosis in intensive care patients?]. / Hypernatriämische Alkalose. Pendant zur hyperchlorämischen Acidose in der Intensivmedizin?

BACKGROUND: With broad acceptance of Stewart's acid-base model "hyperchloremic acidosis" is regarded as an independent form of metabolic disorder. It is unknown whether hypernatremia plays a corresponding role with respect to the development of alkalosis. METHODS: A total of 201 artificially ventilated, critically ill patients were monitored for hypernatremic episodes. Inclusion criterion was a serum sodium concentration above 145 mmol/l. RESULTS: In 20 patients a total of 78 periods of elevated plasma sodium levels lasting at least 24 h were observed. In 86% of these cases sodium and chloride concentrations were simultaneously increased. The development of alkalosis correlated with the strong ion difference (r=0.80, p<0.01) but not with the serum sodium concentration (r=-0.031, p=0.78). In cases without accompanying hyperchloremia (13%) metabolic alkalosis regularly occurred and a correlation between serum sodium concentration and base excess could be verified (r=0.66, p=0.03). Alkalosis occurred in 84.8% of cases where the strong on difference exceeded 39 mmol/l. CONCLUSION: From the available data hypernatremic alkalosis could not be defined as an independent metabolic disorder. In would seem more appropriate to use the term "strong ion alkalosis" in this context.

[Analgesia as an important component of emergency care]. / Analgesie in der Notfallmedizin.

Besides protection of vital functions, pain treatment is one of the fundamental tasks in emergency care. However, in emergency situations patients frequently do not receive any pain treatment at all or, despite high pain intensities, treatment remains insufficient. There are various reasons for inadequate prehospital analgesia: fear of side effects, underestimation of the duration of emergency care, and concern about impeding diagnostic analysis are the most frequently stated motives. Thereby one should not disregard that pain has several negative effects on the patient that should be avoided. In this article the basics of preclinical analgesia are shown and concepts presented that should help the emergency physician to accomplish adequate analgesia in an emergency situation.

[Expedition glycocalyx. A newly discovered "Great Barrier Reef"]. / Expedition Glykokalyx. Ein neu entdecktes "Great Barrier Reef."

Healthy vascular endothelium is luminally coated by an endothelial glycocalyx, which interacts with the bloodstream and assumes a filter function on the vascular wall. Although this structure was discovered nearly 70 years ago, its physiological importance has been underestimated for a long time. Recent findings indicate that the glycocalyx is, in addition to the endothelial cells themselves, a main constituent part of the vascular barrier. The existence of different colloid osmotic gradients within and beneath this structure has now led to a modification of the Starling equation. In many vascular beds the interstitial space features a protein concentration similar to that of the plasma. The inwardly directed gradient, which retains water and proteins in the vascular system, is generated beneath the glycocalyx by selective protein filtration over this structure. The endothelial glycocalyx, as an additional competent vascular permeability barrier has, therefore, not only a key role for perioperative fluid and protein shifts into the interstitial space, but it seems to be intimately involved in the pathophysiology of diabetes, arteriosclerosis, sepsis and ischemia/reperfusion, especially with respect to associated vascular dysfunctions. The fragile glycocalyx can be destroyed in the course of surgery, trauma, ischemia/reperfusion and sepsis and by inflammatory mediators such as TNF-alpha, causing leukocyte adhesion, platelet aggregation and edema formation. Recent studies have shown that protecting this structure not only maintains the vascular barrier, but constitutes an important component of a rational perioperative fluid therapy.

[Metabolic alkalosis despite hyperlactatemia and hypercapnia. Interpretation and therapy with help of the Stewart concept]. / Metabolische Alkalose trotz ausgeprägter Hyperlaktatämie and Hyperkapnie. Interpretation und Therapie mithilfe des Stewart-Modells.

Acid-base disturbances are commonly found in critically ill patients and are often associated with fatal complications. The basis of a successful treatment is a thorough understanding of the causes of these disorders. The "classical methods" to explain acid-base disorders--pH, base excess and bicarbonate concentration--mostly do not provide a causal correlation to the underlying pathology. An unusual case of a combined respiratory-metabolic disorder with hyperlactatemia and hypercapnia is presented. An acidosis masked by hypochloremic and hypoalbuminemic alkalosis was identified with the help of Stewart's concept and finally permitted a successful therapy. The modern Stewart concept provides enhanced information, enabling an exact diagnosis and causal therapy even in complex cases.

[Determinants of insensible fluid loss. Perspiration, protein shift and endothelial glycocalyx]. / Determinanten des insensiblen Flüssigkeitsverlustes. Perspiratio, Proteinshift und endotheliale Glykokalyx.

Accurate perioperative fluid balance is the basis of a targeted infusion regimen. However, neither the initial status nor perioperative changes of the fluid compartments can be reliably measured in daily routine. In particular, insensible losses are not consistently assessed, so that substitution therapy is generally empirical. The object of this paper is to communicate the scientific data on this topic. Preoperative fasting (10 h) does not per se cause intravascular hypovolemia. In adults, total basal evaporation by way of the skin and airways and of any wounds during major abdominal interventions is usually less than 1 ml/kg/h. An inconstant fluid and protein shift towards the interstitial space perioperatively seems to be associated with hypervolemia, which suggests it should be preventable. The decisive factor in this context seems to be deterioration of the endothelial glycocalyx, whose further patho-physiological impact is currently only partially known. Clinical studies have revealed a link between fluid restriction and improved outcome after major abdominal surgery.

CSF tau protein phosphorylated at threonine 231 correlates with cognitive decline in MCI subjects.

In this longitudinal study of 77 patients with mild cognitive impairment (MCI), the authors analyzed whether levels of tau protein phosphorylated at threonine 231 (p-tau(231)) in CSF correlate with progression of cognitive decline. High CSF p-tau(231) levels at baseline, but not total tau protein levels, correlated with cognitive decline and conversion from MCI to AD. Independently, old age and APOE-epsilon 4 carrier status were predictive as well. Our data indicate that an increased p-tau(231) level is a potential risk factor for cognitive decline in patients with MCI.

Ropivacaine 7.5 mg/ml versus bupivacaine 5 mg/ml for interscalene brachial plexus block--a comparative study.

We investigated ropivacaine 75 mg/ml in comparison with bupivacaine 5 mg/ml in patients receiving interscalene brachial plexus block (ISB) and general anaesthesia. In this randomized, double-blind, prospective clinical trial, each patient received an ISB block according to the technique originally described by Winnie and a catheter technique as per Meier. The rapidity of onset and the quality of sensory and motor block were determined. After general anaesthesia had been induced further parameters evaluated were consumption of local anaesthetic, opioid and neuromuscular blocking drug. After arrival in the recovery room, the patients were assessed for intensity of pain using a visual analog scale (VAS). One hundred and twenty patients were included in the study. The onset and development of sensory block was similar in both groups. Development and quality of motor block was also nearly identical for both local anaesthetics. Consumption of neuromuscular blocking drug and opioid did not differ between ropivacaine and bupivacaine. In the recovery room the mean pain score was less than 25 in both groups. There were no significant differences in terms of onset and quality of sensory or motor block during the intraoperative and early postoperative period. In addition we did not identify any side-effects related to the administration of the local anaesthetics. Ropivacaine 7.5 mg/ml and bupivacaine 5mg/ml proved to be nearly indistinguishable when administered for interscalene brachial plexus block.

Ropivacaine 2 mg/mL vs. bupivacaine 1.25 mg/mL with sufentanil using patient-controlled epidural analgesia in labour.

BACKGROUND: In recent studies, minimum local analgesic concentrations have been defined as 0.93 mg/mL for bupivacaine and 1.56 mg/mL for ropivacaine for epidural analgesia for the first stage of labour, resulting in an analgesic potency ratio of 1 : 0.6. In the current study we compared ropivacaine and bupivacaine in a PCEA system (combined with sufentanil) taking this potency ratio into account but administering drug doses providing sufficient analgesia for all stages of labour. METHODS: In a prospective, double-blinded study 114 parturients were randomised to receive either ropivacaine 2 mg/mL with sufentanil 0.75 microg/mL or bupivacaine 1.25 mg/with sufentanil 0.75 microg/mL. After epidural catheter placement, PCEA was available with boluses of 4 mL, a lock-out time of 20 min and no basal infusion rate. We evaluated pain intensity during contractions, sensory and motor function, duration of labour, mode of delivery and neonatal outcome. Consumption of local anaesthetic and opioid drugs and PCEA system variables were recorded. RESULTS: Mean total consumption as well as mean hourly drug consumption was significantly increased in the ropivacaine-sufentanil group. No differences in analgesic quality, sensory or motor blocking potencies or neonatal outcome variables between groups were detected. Frequency of instrumental deliveries was significantly increased in the ropivacaine-sufentanil group. CONCLUSIONS: The results support the findings of previously published studies postulating ropivacaine to be 40-50% less potent for labour epidural analgesia compared to bupivacaine. However, we observed an increased frequency of instrumental deliveries with ropivacaine. To evaluate the clinical relevance of these findings, further investigations are warranted.

[Induction of anesthesia for a patient with sleep apnea syndrome]. / Narkoseeinleitung bei einem Patienten mit Schlaf-Apnoe-Syndrom.

Based on a case report, we offer brief guidelines on the perioperative management of patients with Sleep-Apnea-Syndrome (SAS) who present with a high incidence of a difficult airway and a high risk of respiratory depression during the perioperative period. A 39 year old male patient with a body mass index of 34.22 kg/m2 and receiving continuous-positive-airway-pressure-(CPAP) therapy for known SAS was scheduled for elective plastic surgery. After induction of anaesthesia and direct laryngoscopy no adequate airway could be established and the patient became hypoxic, hypercapnic and developed hypotension and bradycardia. With the use of a laryngeal mask airway the patient was stabilized and did not show neurologic sequale after immediate awakening. The following fiberoptic intubation of the awake patient, still showing tendency of upper airway obstruction, confirmed the difficult anatomical structures. The subsequent general anesthesia was uneventful. The patient received CPAP therapy and was monitored during the first postoperative night in the Intensive Care Unit. He made an uneventful recovery. He was advised to have regional anaesthesia or planned fiberoptic intubation, where possible, in the case of further anesthetic intervention. SAS has major implications for the anaesthesiologist and whenever patients exhibiting the high risk factors (obesity, male sex, history of intense snoring, impaired daytime performance, nonrefreshing daytime naps) are presented for surgery this condition should be considered. Elective surgery should be postponed until after adequate examination and treatment when necessary. Patients with SAS should always be suspected of having cardiopulmonary dysfunctions such as hypertension, cardiac dysrhythmia or cor pulmonale. It is most important to avoid sedative premedication, to initiate CPAP therapy preoperatively, to encourage regional anaesthesia if possible and to ensure close monitoring over the complete perioperative period. Planned fiberoptic intubation, preferably with surgical personnel available for an emergency airway, is a safe method for the induction of anaesthesia. Postoperatively, patients are at high risk from respiratory depression, even in the awake state. Postoperative opioid analgesia, no matter what route, should only be given under close monitoring. Independently of regional or general anaesthesia there is an increased risk of respiratory depression in the middle of the first postoperative week, suspected to be caused by the catching up on lost REM-sleep, due to shifts in the normal sleep pattern during the first postoperative days.

[Quality of pain management in preclinical care of acutely ill patients]. / Qualität schmerztherapeutischer Massnahmen bei der präklinischen Versorgung akut kranker Patienten.

UNLABELLED: The aim of this study was to evaluate the quality of pain management in prehospital emergency care and to get more information about the administration of analgesics in prehospital patients. METHODS: Patients with painful diseases or injuries who had been brought to Munich hospital's were included in the study. Immediately after having reached the hospitals' emergency department, they were evaluated using a 101-point visual analogue scale for the severity of pain at four predefined periods. Information about the patient, the diagnosis, and the analgesic treatment used by the emergency teams were drawn from the patient's chart. RESULTS: A total of 462 patients were included in the study. The mean pain score on arrival of the emergency team was 64 points; 36.5% of the patients were treated with analgesics. In 28.1% the emergency team tried to reduce pain through external measures (i.e., setting of fractures). In 35.3% there was no therapeutic intervention. In cases in which analgesic therapy was initiated, a definite reduction in pain was achieved during emergency care. Visual analogue scores decreased from 70 points at the beginning to 29 points at arrival to the hospital's emergency department. Analgesics were most frequently used for patients with cardiopulmonary diseases (47.2%), followed by patients with traumatic accidents (35.5%) and patients with acute abdominal pain (25.2%). Of the analgesics, opioids were given most frequently (87.0%). Nonopioid analgesic agents were used in 32.1%. The results of our investigation demonstrate that in many cases the administration of analgesics is not individualized to the patients needs. CONCLUSION: During the prehospital period of emergency care many patients suffer from severe pain. The development of patient-oriented concepts concerning pain management could contribute to improvement of pain therapy in prehospital emergency medicine.