Systematic Review on Pain-Related Outcome Domains After Sternotomy: A First Step Toward the Development of a Core Outcome Set.

OBJECTIVES: Pain after surgery has a major impact on acute and long-term recovery and quality of life, but its management is often insufficient. To enhance the quality of research and to allow for better comparability between studies, it is important to harmonize outcomes for assessing the efficacy and effectiveness of pain management interventions after surgery. As a first step in developing a core outcome set, this study aimed to systematically search for outcome domains assessed in research regarding acute pain management after sternotomy as an example of a typically painful surgical procedure. METHODS: A systematic literature review was performed using MEDLINE, Embase, and CENTRAL. Eligibility criteria consisted of randomized controlled trials and observational trials targeting pain management after sternotomy in adults in the acute postoperative setting (≤2 weeks). After duplicate removal and title and abstract screening by 2 independent reviewers, study characteristics and outcome domains were identified, which were extracted from full texts and summarized qualitatively. RESULTS: Of 1350 studies retrieved by database searching, 156 studies were included for full-text extraction. A total of 80 different outcome domains were identified: pain intensity, analgesic consumption, physiological function, and adverse events were the most frequent ones. Outcome domains were often not explicitly reported, and the combination of domains and assessment tools was heterogeneous. The choice of outcomes is commonly made within clinicians; patients' perspectives are not considered. CONCLUSIONS: The wide variety of commonly applied outcome domains, the nonexplicit wording, and the heterogeneous combination of the domains indicating treatment benefit demonstrate the need for harmonization of outcomes assessing perioperative pain management after surgery.

PROSPECT guideline for tonsillectomy: systematic review and procedure-specific postoperative pain management recommendations.

Tonsillectomy is one of the most frequently performed surgical procedures; however, pain management remains challenging. Procedure-specific efficacy as well as specific risks of treatment options should guide selection of pain management protocols based on evidence and should optimise analgesia without harm. The aims of this systematic review were to evaluate the available literature and develop recommendations for optimal pain management after tonsillectomy. A systematic review utilising preferred reporting items for systematic reviews and meta-analysis guidelines with procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language up to November 2019 assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Out of the 719 potentially eligible studies identified, 226 randomised controlled trials met the inclusion criteria, excluding the studies examining surgical techniques. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol; non-steroidal anti-inflammatory drugs; intravenous dexamethasone; ketamine (only assessed in children); gabapentinoids; dexmedetomidine; honey; and acupuncture. Inconsistent evidence was found for local anaesthetic infiltration; antibiotics; and magnesium sulphate. Limited evidence was found for clonidine. The analgesic regimen for tonsillectomy should include paracetamol; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone, with opioids as rescue analgesics. Analgesic adjuncts such as intra-operative and postoperative acupuncture as well as postoperative honey are also recommended. Ketamine (only for children); dexmedetomidine; or gabapentinoids may be considered when some of the first-line analgesics are contra-indicated. Further randomised controlled trials are required to define risk and combination of drugs most effective for postoperative pain relief after tonsillectomy.

Staff and organizational requirements for pain services in hospitals : A recommendation from the German Society for Anaesthesiology and Intensive Care Medicine.

Although pain services have been established in many hospitals, there is considerable heterogeneity among them with respect to organization of service, staff and qualifications of staff, and treatment approaches.With this recommendation, the German Society for Anesthesiology and Intensive Care Medicine defines requirements for pain services in hospitals with respect to organizational standards and staff qualifications. The therapy offered by pain services supplements the treatment provided by the other departments involved, ensuring the high quality of specialized pain management in all areas of the hospital. Pain services shall oversee treatment with specialized analgesia techniques as well as the involvement of consultants, bringing together in-hospital pain medicine expertise in one service with availability 24 h and 7 days per week via a single contact. The medical head of the pain service shall be a qualified provider of pain medicine as defined by the German Medical Association and as a minimum should also have undergone additional training in basic psychosomatic medicine. Further members of the medical staff should possess the credentials of a medical specialist: non-medical staff should have completed continuing education in the treatment of pain. Minimal guidelines for personnel resources were defined: these included a specific time frame for first contacts (20 min) and follow-up (10 min) for specific analgesic techniques and for the involvement of consultants (first contact 45 min, follow-up 20 min), with additional time for travel, set-up, training and quality management. In addition to definition of the space and equipment needed, each service should draft its own budget, and this should be adequate and plannable. Written agreements between the disciplines and transparent documentation, including patient-reported outcomes, are recommended to ensure quality. The provision of specialized pain therapy should have high priority over all disciplines or departments.

[Safety and monitoring of patient-controlled intravenous analgesia : Clinical practice in German hospitals]. / Sicherheit und Monitoring der patientenkontrollierten intravenösen Analgesie : Anwendungspraxis in deutschen Krankenhäusern.

BACKGROUND: Patient-controlled intravenous analgesia (PCIA) is a well-established technique in acute pain management and available in most German hospitals. Despite its widespread use, information on current clinical practice is limited. This investigation evaluated clinical practice and monitoring as well as PCIA-associated adverse events and critical incidents in German hospitals. METHODS: An invitation to participate in this online-survey was sent to 995 heads of anesthesiology departments belonging to the "German Society of Anaesthesiology and Intensive Care Medicine". RESULTS: Of the departments receiving the link, 244 took part (response rate 25%). PCIA was used in 193 of these hospitals (79%). All the following statements relate to the hospitals in which PCIA was used. Piritramide was the most frequently used opioid. In parallel with PCIA, additional nonopioid analgesics were used in 94% of the hospitals, and in 38%, additional slow-release oral opioids were used. Parenteral opioids were administered by the ward staff in 4% of the hospitals. In 75% of hospitals, there were standardized indications for PCIA therapy, with almost two thirds of respondents stating that PCIA was the technique of second choice if regional procedures were contraindicated or failed. In all, 76% of the hospitals had an acute pain service. Twenty-four percent of the hospitals regularly used PCIA in non-surgical patients. In pediatric patients, PCIA was used in 62 hospitals (32%). Only 31% of the hospitals reported the use of standardized protocols for the specific monitoring of patients' vital signs on general wards, exceeding general care. Of the department, 158 (82%) reported adverse events in connection with the use of PCIA within the six-month period preceding the survey (most frequently due to patients' noncompliance [52%], dislocated intravenous lines [41%], communication errors [16%], administration of additional analgesics [16%] and/ or sedatives [14%], problems with the pump [16%], programming errors [9%], incorrect opioid concentration in the reservoir [8%], non-observance of contraindications [7%], incorrect dosing [6%] and self-dosing by the patient [4%] or by third parties [3%], filling the reservoir with thewrong medication [2%]; and other problems [5%]). Only 35 of the hospitals (18%) reported no problems associated with PCIA therapy. Seventy-five of the 193 respondents (39%) stated that at least one critical incident had occurred in the context of the use of PCIA. This resulted in a total of 335 cases out of an estimate of 50.000 patients treated with PCIA. The respondents classified these as follows: I) 273 incidents requiring a prolonged stay in the recovery room, but without further complications, II) 58 requiring transfer to the intensive care unit, but without further complications, III) three resulting in permanent harm to the patient and IV) one resulting in the death of the patient. A comparison of the monitoring standards for PCIA showed that critical incidents were reported less frequently in hospitals with less intensive monitoring, and more frequently in hospitals with higher monitoring standards. CONCLUSION: PCIA is a frequently used analgesic technique in German hospitals. There were many differences in how PCIA therapy was applied and monitored on general wards. Adverse events occurred to a significant extent, with a considerable part of them, which might be preventable. Critical incidents were perceived more often when standards for monitoring on general wards were higher. Consented current recommendations regarding treatment and monitoring standards as well as the systematic recording of complications when using PCIA are pending.

PROSPECT guideline for rotator cuff repair surgery: systematic review and procedure-specific postoperative pain management recommendations.

Rotator cuff repair can be associated with significant and difficult to treat postoperative pain. We aimed to evaluate the available literature and develop recommendations for optimal pain management after rotator cuff repair. A systematic review using procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in English from 1 January 2006 to 15 April 2019 assessing postoperative pain after rotator cuff repair using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. Out of 322 eligible studies identified, 59 randomised controlled trials and one systematic review met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, cyclo-oxygenase-2 inhibitors, intravenous dexamethasone, regional analgesia techniques including interscalene block or suprascapular nerve block (with or without axillary nerve block) and arthroscopic surgical technique. Limited evidence was found for pre-operative gabapentin, perineural adjuncts (opioids, glucocorticoids, or α-2-adrenoceptor agonists added to the local anaesthetic solution) or postoperative transcutaneous electrical nerve stimulation. Inconsistent evidence was found for subacromial/intra-articular injection, and for surgical technique-linked interventions, such as platelet-rich plasma. No evidence was found for stellate ganglion block, cervical epidural block, specific postoperative rehabilitation protocols or postoperative compressive cryotherapy. The analgesic regimen for rotator cuff repair should include an arthroscopic approach, paracetamol, non-steroidal anti-inflammatory drugs, dexamethasone and a regional analgesic technique (either interscalene block or suprascapular nerve block with or without axillary nerve block), with opioids as rescue analgesics. Further randomised controlled trials are required to confirm the influence of the recommended analgesic regimen on postoperative pain relief.

[Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy for Surgical Patients (revised version 2019)]. / Vereinbarung zur Organisation der Schmerztherapie chirurgischer Patienten des Berufsverbandes Deutscher Anästhesisten und des Berufsverbandes der Deutschen Chirurgen (Neufassung 2019).

The treatment of any causal, procedure-specific and/or concomitant acute pain is an essential quality feature in any surgical subspecialty. An interdisciplinary and interprofessional pain therapy aims for an immediate improvement of the patients' quality of life, a reduction of the risk of postoperative morbidity and mortality in the medium term, prevention of any pain chronification in the long run as well as a reduction of hospitalization and sick leave. The "Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy" exists since 1992. In view of the continuously developing scientific evidence, updated guideline recommendations and interprofessionally designed treatment pathways, these agreements have been adapted to the current requirements and structural conditions of the German healthcare system. Thus, both aforementioned professional associations promote an up to date version of an "Agreement for the Organization of Pain Therapy for Surgical Patients", a precise recommendation and a manual for the acting partners in order to realize the abovementioned goals.

[Recommendations for the perioperative use of dipyrone : Expert recommendation of the working group on acute pain of the German Pain Society, the scientific working group on pain medicine of the German Society for Anesthesiology and Intensive Care Medicine and the surgical working group on acute pain of the German Society for Surgery with participation of representatives of the Drug Commission of the German Medical Association]. / Empfehlungen zur perioperativen Anwendung von Metamizol : Expertenempfehlung des Arbeitskreises Akutschmerz der Deutschen Schmerzgesellschaft, des Wissenschaftlichen Arbeitskreises Schmerzmedizin der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin und der Chirurgischen Arbeitsgemeinschaft Akutschmerz der Deutschen Gesellschaft für Chirurgie unter Beteiligung von Vertretern der Arzneimittelkommission der deutschen Ärzteschaft.

BACKGROUND: Dipyrone (metamizole) is widely used for perioperative pain management in countries where it is marketed; however, uncertainty exists concerning the safe use of this drug, specifically considering the rare adverse event of an agranulocytosis. METHODS: As evidence from published studies was lacking, an expert panel developed recommendations for the perioperative use of dipyrone. After a formal, structured consensus process, the recommendations were approved by the involved medical societies. RESULTS: The panel agreed that blood cell counts shall not be standard for short-term perioperative use in patients unless they are at risk for neutropenia. The medical staff shall be aware of the symptoms and course of action when agranulocytosis is suspected. Patients shall be informed about the risks and benefits of dipyrone and about potential alternatives. The expert group concluded that dipyrone has a relatively positive risk-benefit ratio compared to other nonopioid analgesics. The group strongly recommended educating patients about the symptoms of agranulocytosis if they have received dipyrone over several days and/or treatment is to be continued after discharge, because agranulocytosis can occur several days after discontinuation of metamizole. Further recommendations refer to the information of the physician taking over the patient's care after discharge and the avoidance of re-exposure in patients having previously suffered from dipyrone-induced agranulocytosis. CONCLUSION: The group's recommendations shall be communicated in order to raise medical staff's and patients' awareness of the appropriate use of dipyrone in the perioperative period.

[Staff and organizational requirements for pain services in hospitals : A recommendation from the German Society for Anaesthesiology and Intensive Care Medicine]. / Personelle und organisatorische Voraussetzungen für Schmerzdienste in Krankenhäusern : Empfehlung der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin e. V.

Although pain services have been established in many hospitals, there is considerable heterogeneity among them with respect to organization of service, staff and qualifications of staff, and treatment approaches.With this recommendation, the German Society for Anesthesiology and Intensive Care Medicine defines requirements for pain services in hospitals with respect to organizational standards and staff qualifications. The therapy offered by pain services supplements the treatment provided by the other departments involved, ensuring the high quality of specialized pain management in all areas of the hospital. Pain services shall oversee treatment with specialized analgesia techniques as well as the involvement of consultants, bringing together in-hospital pain medicine expertise in one service with availability 24 h and 7 days per week via a single contact. The medical head of the pain service shall be a qualified provider of pain medicine as defined by the German Medical Association and as a minimum should also have undergone additional training in basic psychosomatic medicine. Further members of the medical staff should possess the credentials of a medical specialist: non-medical staff should have completed continuing education in the treatment of pain. Minimal guidelines for personnel resources were defined: these included a specific time frame for first contacts (20 min) and follow-up (10 min) for specific analgesic techniques and for the involvement of consultants (first contact 45 min, follow-up 20 min), with additional time for travel, set-up, training and quality management. In addition to definition of the space and equipment needed, each service should draft its own budget, and this should be adequate and plannable. Written agreements between the disciplines and transparent documentation, including patient-reported outcomes, are recommended to ensure quality. The provision of specialized pain therapy should have high priority over all disciplines or departments.

[Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy for Surgical Patients (revised version 2019)]. / Vereinbarung zur Organisation der Schmerztherapie chirurgischer Patienten des Berufsverbandes Deutscher Anästhesisten und des Berufsverbandes der Deutschen Chirurgen (Neufassung 2019).

The treatment of any causal, procedure-specific and/or concomitant acute pain is an essential quality feature in any surgical subspecialty. An interdisciplinary and interprofessional pain therapy aims for an immediate improvement of the patients' quality of life, a reduction of the risk of postoperative morbidity and mortality in the medium term, prevention of any pain chronification in the long run as well as a reduction of hospitalization and sick leave. The "Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy" exists since 1992. In view of the continuously developing scientific evidence, updated guideline recommendations and interprofessionally designed treatment pathways, these agreements have been adapted to the current requirements and structural conditions of the German healthcare system. Thus, both aforementioned professional associations promote an up to date version of an "Agreement for the Organization of Pain Therapy for Surgical Patients", a precise recommendation and a manual for the acting partners in order to realize the abovementioned goals.

[Recommendations for the perioperative use of dipyrone : Expert recommendation of the working group on acute pain of the German Pain Society, the scientific working group on pain medicine of the German Society for Anesthesiology and Intensive Care Medicine and the surgical working group on acute pain of the German Society for Surgery with participation of representatives of the Drug Commission of the German Medical Association]. / Empfehlungen zur perioperativen Anwendung von Metamizol : Expertenempfehlung des Arbeitskreises Akutschmerz der Deutschen Schmerzgesellschaft, des Wissenschaftlichen Arbeitskreises Schmerzmedizin der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin und der Chirurgischen Arbeitsgemeinschaft Akutschmerz der Deutschen Gesellschaft für Chirurgie unter Beteiligung von Vertretern der Arzneimittelkommission der deutschen Ärzteschaft.

BACKGROUND: Dipyrone (metamizole) is widely used for perioperative pain management in countries where it is marketed; however, uncertainty exists concerning the safe use of this drug, specifically considering the rare adverse event of an agranulocytosis. METHODS: As evidence from published studies was lacking, an expert panel developed recommendations for the perioperative use of dipyrone. After a formal, structured consensus process, the recommendations were approved by the involved medical societies. RESULTS: The panel agreed that blood cell counts shall not be standard for short-term perioperative use in patients unless they are at risk for neutropenia. The medical staff shall be aware of the symptoms and course of action when agranulocytosis is suspected. Patients shall be informed about the risks and benefits of dipyrone and about potential alternatives. The expert group concluded that dipyrone has a relatively positive risk-benefit ratio compared to other nonopioid analgesics. The group strongly recommended educating patients about the symptoms of agranulocytosis if they have received dipyrone over several days and/or treatment is to be continued after discharge, because agranulocytosis can occur several days after discontinuation of metamizole. Further recommendations refer to the information of the physician taking over the patient's care after discharge and the avoidance of re-exposure in patients having previously suffered from dipyrone-induced agranulocytosis. CONCLUSION: The group's recommendations shall be communicated in order to raise medical staff's and patients' awareness of the appropriate use of dipyrone in the perioperative period.

[Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy for Surgical Patients (revised version 2019)]. / Vereinbarung zur Organisation der Schmerztherapie chirurgischer Patienten des Berufsverbandes Deutscher Anästhesisten und des Berufsverbandes der Deutschen Chirurgen (Neufassung 2019).

The treatment of any causal, procedure-specific and/or concomitant acute pain is an essential quality feature in any surgical subspecialty. An interdisciplinary and interprofessional pain therapy aims for an immediate improvement of the patients' quality of life, a reduction of the risk of postoperative morbidity and mortality in the medium term, prevention of any pain chronification in the long run as well as a reduction of hospitalization and sick leave. The "Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy" exists since 1992. In view of the continuously developing scientific evidence, updated guideline recommendations and interprofessionally designed treatment pathways, these agreements have been adapted to the current requirements and structural conditions of the German healthcare system. Thus, both aforementioned professional associations promote an up to date version of an "Agreement for the Organization of Pain Therapy for Surgical Patients", a precise recommendation and a manual for the acting partners in order to realize the abovementioned goals.

[Nursing pain experts in German hospitals : A compilation of activity profiles and tasks]. / Pflegerische Schmerzexperten an deutschen Kliniken : Eine Erfassung zu Tätigkeitsprofilen und Aufgaben.

BACKGROUND: In recent years nurses have come to play a professional role in pain management. In Germany, the publication of the national expert standards on pain management in nursing resulted in nurses being educated to be pain resource nurses; however, since education has started the continuance and commitments of specialized pain nurses in clinical practice is basically unclear. The goal of this evaluation was to identify how pain resource nurses are involved in pain management and organizational aspects in German hospitals. METHOD: Online survey of 374 directors of nursing services of different types of hospitals on the assignment of nursing pain experts. RESULTS: Pain resource nurses are involved in pain management in 70.6% of the hospitals responding to the questionnaire. Their task profile depends on the hospital size and 42.2% of the hospitals have documented task profiles. Pain resource nurses are primarily involved in invasive pain management processes (37.1%) and in the management of pain in patients with complex pain problems after surgery (33.2%). Educative tasks are training of colleagues and implementation and conversion of the national expert standards. Of the hospitals 36.1% implemented the national expert standards for acute pain and 57% of the medium-sized hospitals have at least also implemented the national expert standards for chronic pain. DISCUSSION: The study shows a first insight into the task profiles of pain resource nurses. The implementation of this special qualification is meaningful and seems to be well-recognized in the hospitals. The tasks of patient care are orientated to the spectrum of patients treated in the hospital. The tasks of education also show the importance for the education of colleagues.

[Delegation of medical activities in acute pain therapy]. / Delegation ärztlicher Tätigkeiten in der Akutschmerztherapie.

Acute pain management is an interprofessional and interdisciplinary task and requires a good and trustful cooperation between stakeholders. Despite provisions in Germany according to which medical treatment can only be rendered by a formally qualified physician ("Arztvorbehalt"), a physician does not have to carry out every medical activity in person. Under certain conditions, some medical activities can be delegated to medical auxiliary personnel but they need to be (1) instructed, (2) supervised and (3) checked by the physician himself; however, medical history, diagnostic assessment and evaluation, indications, therapy planning (e.g. selection, dosage), therapeutic decisions (e. g. modification or termination of therapy) and obtaining informed consent cannot be delegated. With respect to drug therapy, monitoring of the therapy remains the personal responsibility of the physician, while the actual application of medication can be delegated. From a legal perspective, the current practice needs to be stressed about what is within the mandatory requirements and what is not when medical activities are delegated to non-medical staff. The use of standards of care improves treatment quality but like any medical treatment it must be based on the physician's individual assessment and indications for each patient and requires personal contact between physician and patient. Delegation on the ward and in acute pain therapy requires the authorization of the delegator to give instructions in the respective setting. The transfer of non-delegable duties to non-medical personnel is regarded as medical malpractice.

[Role of anesthesiology in pain medicine and palliative care treatment in German hospitals : Survey of department heads of anesthesiology on treatment structures]. / Rolle der Anästhesiologie in der schmerzmedizinischen und palliativmedizinischen Versorgung in deutschen Krankenhäusern : Befragung von Chefärzten der Anästhesiologie zu Versorgungsstrukturen.

BACKGROUND: The aim of this analysis was to describe the role of anesthesiology departments in pain medicine and palliative care services in German hospitals. METHOD: In the year 2012, all heads of departments of anesthesiology registered with the German Society of Anesthesiology and Intensive Care Medicine were surveyed about structures of pain medicine and palliative care services in their hospitals using a standardized postal questionnaire. RESULTS: Out of 408 returned questionnaires (response rate 47%) 403 could be evaluated. Of the hospitals 58% had a designated pain medicine service, in 36 (9%) of the hospitals this was organized as an independent department and in 195 (57%) as part of another department, mostly the department of anesthesiology. The "pain clinic" as an outpatient service was the most common form of structure for pain medicine services (41%). Inpatient pain medicine units were available in 77 (19%) of the hospitals and a partial inpatient unit in the form of a day hospital in 26 (7%) of the hospitals. For the care of inpatients from other departments, there was an intrahospital pain consultation service in 166 of the hospitals, which was the only structure for pain medicine in 32 of the 231 hospitals that reported having a designated pain medicine service. In 160 pain medicine services anesthesiologists were the only medical practitioners and in a further 18 both anesthesiologists and other specialists were available (orthopedist/orthopedic surgeons n = 6, internal medicine n = 4, psychiatrist n = 2, general practitioner = 1 and neurologist n = 1). Only two hospitals had no anesthesiologist in the pain medicine team and for the remaining 51 hospitals no information was provided. In 189 of the 231 hospitals with pain medicine services, there was at least 1 physician with special qualifications in pain management. In 97 (44%) of the hospitals psychologists were part of the team with 53 having at least 1 psychologist with a special qualification in chronic pain management. Of the hospitals, 16% had a specialized department for palliative care, in 32% a specialized palliative care service was part of another department, which was the department of anesthesiology in 30%. Of the hospitals 56% had a palliative care consultation service, 41% had a specialized inpatient palliative care unit, 6% an outpatient clinic, 4% a day hospital and in 16% a specialized outpatient palliative care (SOPC) serving the community was incorporated. Inpatient consultation services and the SOPC were more common when the department of anesthesiology was involved in the palliative care services. CONCLUSION: In German hospitals, the departments of anesthesiology make a significant contribution to the provision of both pain medicine and palliative care services. Nevertheless, the respective structures of care are often incomplete or even lacking. There were shortcomings in terms of organization and qualification of the team in pain medicine services (e.g. no doctor with special qualifications in pain management or no psychologist). Palliative care services are more often organized as independent departments than as pain medicine services. Engagement of the anesthesiology department in palliative care is linked to a broader scope of the services provided, which might reflect the capacity of many anesthesiologists to work in an interdisciplinary manner and across interfaces.

[Survey of pain after ambulatory surgery: An internet-based instrument]. / Erhebung von Schmerzen nach ambulanten Operationen : Ein internetbasiertes Instrument.

BACKGROUND AND AIM: Pain after surgery continues to be undermanaged. Studies and initiatives aiming to improve the management of postoperative pain are growing; however, most studies focus on inpatients and pain on the first day after surgery. The management of postoperative pain after ambulatory surgery and for several days thereafter is not yet a major focus. One reason is the low return rate of the questionnaires in the ambulatory sector. This article reports the development and feasibility of a web-based electronic data collection system to examine pain and pain-related outcome on predefined postoperative days after ambulatory surgery. MATERIAL AND METHODS: In this prospective pilot study 127 patients scheduled for ambulatory surgery were asked to participate in a survey to evaluate aspects related to pain after ambulatory surgery. The data survey was divided in (1) a preoperative, intraoperative and postoperative part and (2) a postoperative internet-based electronic questionnaire which was sent via e-mail link to the patient on days 1, 3 and 7 after surgery. A software was developed using a PHP-based platform to send e-mails and retrieve the data after web-based entries via a local browser. Feasibility, internet-based hitches and compliance were assessed by an additional telephone call after day 7. RESULTS: A total of 100 patients (50 female) between 18 and 71 years (mean 39.1 ± 12.7 years) were included in the pilot study. Return rates of the electronic questionnaires were 86% (days 3 and 7) and 91% (day 1 after surgery). All 3 electronic questionnaires were answered by 82% of patients. Aspects influencing the return rate of questionnaires were work status but not age, gender, education level and preoperative pain. Telephone interviews were performed with 81 patients and revealed high operability of the internet-based survey without any major problems. CONCLUSION: The user-friendly feasibility and operability of this internet-based electronic data survey system explain the high compliance and return rate of electronic questionnaires by patients at home after ambulatory surgery. This survey tool therefore provides unique opportunities to evaluate and improve postoperative pain management after ambulatory surgery.

[Pain medicine from intercultural and gender-related perspectives]. / Schmerzmedizin aus einer interkulturellen und geschlechterspezifischen Perspektive.

Cultural setting and sex and gender of the patient are important factors affecting the occurrence, severity, clinical course and prognosis of pain and pain-related diseases. Intercultural differences in the perception and verbal expression of symptoms and emotional function are fundamental and it is important to realize these differences in order to understand patients with a migration background. A trusting doctor-patient relationship is generally very sensitive and it is even more difficult to establish when differences in the cultural background impair mutual understanding. Regarding sex and gender there is evidence that females are more susceptible to developing chronic pain conditions, experience more severe pain and respond differently to pain therapy; however, results of recent studies indicate that females are not that different to males when comparing several modalities of experimental pain (although some differences exist). Similarly, sex and gender differences in postoperative pain seem to exist but the differences are relatively small when pain scores are compared. Other aspects, such as the response to analgesics and role of psychosocial factors should be addressed when sex and gender aspects are studied. Similarly, sex and gender differences in the prevalence of chronic pain exist but the results of some studies, e.g. those controlling for confounders, are not very clear. Research is needed to delineate the role of specific aspects affecting sex and gender differences and the underlying mechanisms (e.g. reduced inhibitory control, hormones, psychological aspects and social factors). Altogether, we need to open our minds to some intercultural and sex and gender aspects in the clinical setting. For sex and gender differences we may need a more biopsychosocial approach to understand the underlying differences and differentiate between sex and gender and sex and gender-associated aspects for acute and chronic pain.

[Postoperative pain therapy in Germany. Status quo]. / Therapie postoperativer Schmerzen in Deutschland. Aktueller Stand.

A great deal of progress has been made in the field of postoperative pain therapy in the last 20 years. Beginning from clinical trials on the effectiveness of individual procedures, such as epidural anesthesia and patient-controlled analgesia, a wide range of healthcare services research as well as basic research with human and animal experiments has been established. Whereas health services research in the 1980s and 1990s focused more on the implementation of acute pain services, outcome-oriented research approaches are nowadays the center of attention. Acute pain registries and pain certification projects initiated in Germany have to be mentioned particularly in this respect. Basic research papers from recent years increasingly address specific aspects of acute postoperative pain and have provided translational approaches that are applied around the world for studying neurobiological mechanisms of postoperative pain. At the same time, interdisciplinary cooperation in research projects has led to a better understanding of complex correlations regarding predictors and mechanisms (including psychosocial aspects) of acute and in recent times also chronic pain after surgery. In parallel, evidence-based medicine has found its way into acute pain medicine in Germany. In 2007, clinical acute pain therapy in Germany was enhanced by S3 level guidelines for the first time; however, the implementation is still incomplete. In future, questions concerning mechanism-based therapy of acute pain need to be equally in the center of attention of research, such as prevention of persisting pain after surgery and acute pain of different origins.

[Perioperative pain management for abdominal and thoracic surgery]. / Perioperative Schmerztherapie bei abdominellen und thorakalen Operationen.

Abdominal and thoracic surgical procedures can result in significant acute postoperative pain. Present evidence shows that postoperative pain management remains inadequate especially after "minor" surgical procedures. Various therapeutic options including regional anesthesia techniques and systemic pharmacotherapy are available for effective treatment of postoperative pain. This work summarizes the pathophysiological background of postoperative pain after abdominal and thoracic surgery and discusses the indication, effectiveness, risks, and benefits of the different therapeutic options. Special focus is given to the controversial debate about the indication for epidural analgesia, as well as various alternative therapeutic options, including transversus abdominis plane (TAP) block, paravertebral block (PVB), wound infiltration with local anesthetics, and intravenous lidocaine. In additional, indications and contraindications of nonopioid analgesics after abdominal and thoracic surgery are discussed and recommendations based on scientific evidence and individual risk and benefit analysis are made. All therapeutic options discussed are eligible for clinical use and may contribute to improve postoperative pain outcome after abdominal and thoracic surgical procedures.

[Differences of analgesic efficacy and complication rates between ultrasound and nervestimulator guided peripheral nerve catheters : Database analysis on patient-relevant target parameters]. / Vergleich der Analgesiequalität und Komplikationen von ultraschall- und nervenstimulatorgesteuerten peripheren Nervenkathetern : Datenbankanalyse zu patientenrelevanten Zielparametern.

BACKGROUND: Peripheral nerve catheters (PNC) play an important role in postoperative pain treatment following major extremity surgery. There are several trials reported in the literature which investigated the efficacy and safety of ultrasound (US) and nerve stimulator (NS) guided PNC placement; however, most of these trials were only small and focused mainly on anesthesiologist-related indicators of block success (e.g. block onset time and procedure time) but not primarily on patient-related outcome data including postoperative pain during movement. AIM: This retrospective analysis compared the analgesic efficacy and safety of US versus NS guided peripheral nerve catheters (PNC) for postoperative pain therapy in a large cohort of patients. MATERIAL AND METHODS: Data of patients (June 2006-December 2010) treated with US (nus = 368 June 2008-December 2010) and NS (nns = 574, June 2006-May 2008) guided PNC were systematically analyzed. Apart from demographic data, postoperative pain scores [numeric rating scale (NRS): 0-10] on each treatment day, the number of patients with need for additional opioids, cumulative local anesthetic consumption and catheter-related complications were compared. RESULTS: On the day of surgery patients treated with US-guided PNC reported lower NRS at rest (p = 0.034) and during movement (p < 0.001). Additionally, the number of patients requiring additional opioids on the day of surgery was lower in the US group (absolute difference 12.4 %, p = 0.001). Furthermore, the number of multiple puncture attempts (absolute difference 5.6 %, p < 0.001) and failed catheter placements (absolute difference 3.4 %, p = 0.06) were lower in the US group. There were no patients in both groups with long-lasting neurological impairment. CONCLUSION: This database analysis demonstrated that patients treated with US-guided PNC reported significantly lower postoperative pain scores and the number of patients requiring additional opioids was significantly lower on the day of surgery. The numbers of multiple punctures and failed catheter placements were reduced in the US group, which might be seen as an advantage of US-guided regional anaesthesia.

Objectively measured activity is not associated with average pain intensity 1 week after surgery: A cross-sectional study.

BACKGROUND: Measures of physical activity and pain-related patient-reported outcomes are important components of patient recovery after surgery. However, little is known about their association in the early post-operative period. This study aims to increase this knowledge. Our primary objective was to determine the association between average pain intensity and activity (in steps) 1 week after surgery. Secondary objectives were the association of activity with other patient-reported outcomes, age, sex, comorbidities and body mass index. METHODS: Data were obtained from the PROMPT sub-project of IMI-PainCare. Patients after breast and endometriosis-related surgery, sternotomy and total knee arthroplasty completed pain-related outcomes questionnaires and wore an ActiGraph activity-tracking device. We correlated steps with average pain intensity on post-operative days 6 and 7. Secondary analyses were done using correlations and t-tests. RESULTS: In 284 cases, there was no statistically significant correlation between steps and average pain intensity. In addition, none of the 28 secondary analyses showed a statistically significant result. CONCLUSIONS: Pain-related patient-reported outcome measures and physical activity are separate entities. Both should be measured after surgery to assess patient recovery and to identify treatment deficiencies. SIGNIFICANCE STATEMENT: Measuring recovery is a multi-dimensional challenge. After surgery, clinicians need to be aware that neither pain intensity nor activity levels tell the whole story. Each can hint to problems and treatment requirements.