Die Therapie möglicher ursächlicher, prozedurenspezifischer und/oder -begleitender Akutschmerzen ist ein essenzielles Qualitätsmerkmal in jedem chirurgischen Fachgebiet. Ziele einer interdisziplinären und interprofessionellen Schmerztherapie sind unmittelbar eine Verbesserung der Lebensqualität durch Schmerzfreiheit, mittelfristig eine Reduktion des postoperativen Morbiditäts- und Mortalitätsrisikos, langfristig eine Verhinderung der Chronifizierung von Schmerzen und stets begleitend eine Reduktion der Krankenhausverweildauer und des Krankenstands. Seit 1992 existiert die „Vereinbarung des Berufsverbandes Deutscher Anästhesisten und des Berufsverbandes der Deutschen Chirurgen zur Organisation der postoperativen Schmerztherapie“. Vor dem Hintergrund fortentwickelter Evidenz, aktualisierter Leitlinienempfehlungen und interprofessionell gestalteter Behandlungsprozesse wurden diese Vereinbarungen den aktuellen Erfordernissen und Strukturgegebenheiten unseres Gesundheitswesens angepasst. Somit geben beide Berufsverbände in der nun aktualisierten Version dieser „Vereinbarung zur Organisation der Schmerztherapie chirurgischer Patienten“ den agierenden Partnern eine klare Empfehlung und ein Manual zur Umsetzung der genannten Ziele an die Hand.

Background:High intensity of acute postsurgical pain is one of the strongest predictors of chronic postsurgical pain (CPSP). We investigated if different types of patients with distinct combinations of initial pain intensity and rate of pain resolution exhibit different risks for increased pain intensity six months after surgery.Methods:Data from 174 patients were examined using growth mixture analysis by means of structural equation modeling.Results:Three types of patients were distinguished on the basis of acute pain trajectories. The majority of patients (57%) showed an unproblematic pattern of little initial pain on the first postoperative day, combined with further pain resolution over the four subsequent days. There also was a substantial group of patients (30%) who started out with severe pain but exhibited a high rate of pain resolution. Finally, we found a problematic group of patients (13%) who reported high pain intensities throughout all five postoperative measurements, with no signs of pain resolution. Even after controlling for preoperative pain intensity, these patients exhibited significantly higher pain intensities six months after surgery than the remaining patient groups.Conclusions:In this study, we demonstrated that there is substantial variation in postsurgical pain trajectories, not only with regard to postsurgical initial pain intensity, but also with regard to individual rates of pain resolution. Successful pain resolution appeared to be a better predictor of absence of increased pain intensities six months after surgery than initial pain immediately after surgery. Hence, attention should be given to appropriate pain treatment in order to minimize the risk of CPSP.

Tapentadol prolonged release (PR) for the treatment of moderate to severe chronic pain combines 2 modes of action. These are -opioid receptor agonism and noradrenaline reuptake inhibition in a single molecule that allow higher analgesic potency through modulation of different pharmacological targets within the pain transmitting systems. At the same time, this can also serve as a clue for modulation of different pain-generating mechanisms according to nociceptive, neuropathic, or mixed pain conditions. Tapentadol PR has now been on the market for 5 years, with over 4.6 million people treated worldwide. A panel of pain specialists convened in Germany to review the clinical program and to discuss the role of tapentadol PR in the management of chronic pain. The clinical study program demonstrated effective and generally well-tolerated treatment for up to 2 years in a broad range of chronic pain conditions, including those with neuropathic pain components. This was confirmed in routine clinical practice observations. Head-to-head studies with World Health Organization (WHO) III opioids such as oxycodone controlled release and oxycodone/naloxone PR showed at least comparable pain relief in the treatment of moderate-to-severe musculoskeletal pain. Rotation from poorly tolerated WHO III opioids to tapentadol PR provided effective pain relief and better symptom control for musculoskeletal pain compared to previous medication. Functionality, health status and quality of life also improved under tapentadol PR treatment. The gastrointestinal tolerability profile was more favorable compared to other tested WHO III opioids. Tapentadol PR has a good safety profile and no evidence of acquired tolerance from the long-term data so far collected. Overall, tapentadol PR represents an effective and generally well-tolerated alternative to classical opioidergic drugs.

BACKGROUND AND OBJECTIVES:Trauma patients often suffer from persisting pain even years after injury, and data on long-term pain management is lacking. The aim of this study was to evaluate the frequency of persisting pain and health-related quality of life (HrQoL) among trauma victims 2 years after injury. Furthermore, the frequency of pain specialist consultation and the quality of outpatient pain management, including phamacological management, was assessed. MATERIALS AND METHODS:We analyzed prospectively collected data on severely injured adult patients treated between 2008-2011 at the Cologne Merheim Medical Center (CMMC)/Germany.  Data included the 'Polytrauma Outcome Profile' and a standardized questionnaire on outpatient pain management. Exclusion criteria were death, inability to answer the questionnaire due to cognitive disabilities and lack of language knowledge. RESULTS AND CONCLUSIONS:207/391 (53 %) data sets were available for analysis, presenting a typical trauma collective with injury severity of ISS 19, predominantly male and a mean age of 44 years. 2 years after trauma 59 % still reported that they suffered from severe persisting pain; 53 % of these patients were under pharmacological pain medication. Only 1/5 of the patients with severe persisting pain was treated by a pain specialist. Successful treatment options do exist; improvement of treatment is required.

Noch Jahre nach einem Trauma berichten schwerverletzte Patienten regelhaft über fortbestehende Schmerzen. Jedoch gibt es keine Daten zur Situation der ambulanten Schmerzmitteleinnahme und Mitbehandlung durch spezielle Schmerztherapeuten. Ziel der vorliegenden Studie ist es, die gesundheitsbezogene Lebensqualität von Traumapatienten mit bzw. ohne starke Schmerzen, die Schmerzmitteleinnahmerate und die Anzahl der Patienten, die von einem Schmerztherapeuten behandelt werden innerhalb von zwei Jahren nach Trauma zu evaluieren.

The significance of postoperative pain management for patients in the hospital is well known and has been a focus of research for several years. The ambulatory care after hospital discharge, however, is not well investigated. A prospective observational study was therefore conducted to study the transfer management from in-hospital patients to ambulatory care. A patient questionnaire was developed and patients were asked to fill it out at different time points after the operation: during the time in the hospital, then at 2 weeks and 6 months after hospital discharge. In addition, the responsible family doctor was approached and interviewed. The main focus of the questionnaire was the measurement of post-surgical pain (numeric rating scale NRS), patient satisfaction (Cologne patient questionnaire), and quality of life (SF 12). Of a total of 128 patients 72.9% described moderate to severe pain after the orthopaedic operations in the hospital. 90.8% of the patients had pain directly after discharge from the hospital; in 67.4% of the cases pain was ≥3 and in 23.4% of the cases pain was ≥6. Six months after discharge pain was significant in 29.4% of the patients, 60.8% of the patients were satisfied with the transfer to the home setting. 16% were not satisfied at all and 23.2% were neutral. Important factors for dissatisfaction with the transfer management were, according to stepwise logistic regeression analysis, sex (female patients), young age, a poor bodily constitution at the hospital and thereafter, and the pain management in the hospital and after discharge. The study shows the significance of the acute pain therapy not only during the hospital stay but also after discharge. There are very few data on pain therapy after discharge from the hospital. Based on the significance of the chronification of acute pain it is of the utmost importance to close this gap.

OBJECTIVE This study investigated the incidence and determinants of chronic postsurgical pain (CPSP) in a general surgical patient population. DESIGN This is a prospective cross-sectional study at a university-affiliated clinic/level 1 trauma center. Patients were followed at least 1 year postoperatively. By surgical discipline, procedures were 50% orthopedic/trauma, 33% general (abdominal/visceral), and 17% vascular. SETTING All patients admitted during one year (N = 3020) were eligible. Exclusion criteria were cognitive impairment, communication/language barrier, nonoperative treatment, and refusal to participate. A CPSP questionnaire was completed. Step-by-step analysis followed with a 2(nd) questionnaire to detect CPSP with numeric rating scale (NRS) pain intensity ≥3. Finally, individual follow-up examinations were performed. RESULTS 911 patients responded (30.2%). 522 complained of pain intensity ≥3 on NRS (scale 0-10). The second step identified 214 patients with chronic pain (NRS ≥3, mean 29 months postoperatively). On final examination, 83 CPSP patients (14.8%) were identified. By surgical discipline, 28% were general, 15% vascular, and 57% trauma/orthopedic surgery. Most oftenly cited pain sites were joint (49.4%), incisional/scar (37.7%), and nerve pain (33.7%). By procedure, patients underwent pelvic surgery, colon surgery, laparoscopies, inguinal herniorrhaphies, arthroscopies, and hardware extractions. All patients in the "laborer" and "unemployed" categories reported chronic pain. CONCLUSION Bias due to study design and/or heterogeneity of patients is possible, but there was a high CPSP rate after 2 years both generally and particularly in orthopedic/trauma (57%) patients. Both "major" and "minor" surgical procedures led to CPSP.

BACKGROUND:To detect whether external factors (time of day, day of week, month and season, lunar phases) influence incidence and outcome of severely injured trauma patients. PATIENTS AND METHODS:A retrospective cohort analysis of the TraumaRegister DGU(®) (TR-DGU) was carried out over a period of 10 years (January 2002-December 2011). Data of 35,432 primary admitted patients from Germany with a severe trauma (Injury Severity Score (ISS) >15) were analysed in this study. For the outcome evaluation transferred patients were excluded as well as those who did not have a valid Revised Injury Severity Classification (RISC) prognostic score. The outcome analysis could be performed in 31,596 (89.2%) patients. Incidence, demographics and injury pattern were analysed. For outcome analysis the observed hospital mortality was compared with the expected prognosis. RESULTS:Time of day was the factor that showed the highest variation in trauma incidence due to rush hours. Saturday was the day with the highest accident rate. Most accidents in the night happened on weekends. June and July were the months with the highest trauma rate with a large portion of two-wheel drivers. The days of year with the lowest trauma incidence rate were those between Christmas and New Year, and the highest rate was observed on May 1st. The outcome of the trauma patients was close to the prognosis in all investigated subgroups. CONCLUSION:There are clear differences in incidence but not in outcome of the patients due to external factors.

Systems for and methods of quality management are increasingly being implemented in public health services. The aim of our study was to analyze the current state of the integrated quality management concept "quality management acute pain therapy" of the TV RheinlandA (R) (TV) after a 5-year project period. General characteristics of the participating hospitals, number of departments certified by the TV and implementation of structures and processes according to the TV guidelines were evaluated by a mail questionnaire. Furthermore, positive and negative aspects concerning the effects of certification were evaluated by the hospitals' representatives of certification. A total of 36 questionnaires were returned. Since 2006 the number of certified hospitals (2011: n = 48) and surgical departments (2011: n = 202) has increased continuously. The number of certified medical departments is low (2011: n = 39); however, in the last 3 years, it has increased by about 200-300% annually. Standard operative procedures for pain therapy and measurement of pain intensity at regular intervals were implemented in all certified clinics (100%). Although 41% take part in the benchmarking project QUIPS (Quality Improvement in Postoperative Pain Therapy), 24% do not systematically check the quality of the outcome of pain management. Acceptance of the new pain therapy concepts among nursing staff was rated positively (ratio positive:negative 16:1); however, acceptance among physicians was rated negatively (1:15). Certification by the TV leads to sustainable implementation of quality management principles. Future efforts should focus on better integration of physicians in acute pain therapy and the development of an integrated tool to measure patients' outcome.

In der Medizin werden zunehmend Qualitätsmanagement(QM)-Systeme mit dem Ziel eingeführt, die Qualität der Patientenversorgung zu verbessern. Ziel der vorliegenden Untersuchung war die Analyse des aktuellen Stands des Zertifizierungsprojekts QM Akutschmerztherapie des TÜV Rheinland® und die Evaluation nach einer Projektdauer von 5 Jahren.

The incidence of chronic post-surgical pain (CPSP) after various common operations is 10% to 50%. Identification of patients at risk of developing chronic pain, and the management and prevention of CPSP remains inadequate. The aim of this study was to develop an easily applicable risk index for the detection of high-risk patients that takes into account the multifactorial aetiology of CPSP. A comprehensive item pool was derived from a systematic literature search. Items that turned out significant in bivariate analyses were then analysed multivariately, using logistic regression analyses. The items that yielded significant predictors in the multivariate analyses were compiled into an index. The cut-off score for a high risk of developing CPSP with an optimal trade-off between sensitivity and specificity was identified. The data of 150 patients who underwent different types of surgery were included in the analyses. Six months after surgery, 43.3% of the patients reported CPSP. Five predictors multivariately contributed to the prediction of CPSP: capacity overload, preoperative pain in the operating field, other chronic preoperative pain, post-surgical acute pain and co-morbid stress symptoms. These results suggest that several easily assessable preoperative and perioperative patient characteristics can predict a patient's risk of developing CPSP. The risk index may help caregivers to tailor individual pain management and to assist high-risk patients with pain coping.

The role of acute coagulopathy after traumatic brain injury (TBI) on outcome has gained increasing appreciation over the recent years. This study was conducted to assess the frequency, outcome, and risk factors associated with this complication.

Background Venous thromboembolic events (VTEs) are common life-threatening complications after trauma, but epidemiology and reported risk factors still vary. The purpose of this investigation was to determine the incidence of VTEs among hospitalised trauma patients, to identify potential risk factors and to assess whether their presence was associated with: (a) the magnitude and pattern of injury, (b) therapeutic interventions and (c) outcome, all by using a large population-based registry. Patients and methods Patient data from the Trauma Registry of the German Society for Trauma Surgery (TR-DGU) including datasets from more than 35,000 trauma patients were screened for all clinically relevant VTEs, i.e. deep vein thrombosis (DVT) and pulmonary embolism (PE). A total of 7937 patients were identified for further investigation and multivariate logistic regression analyses were performed to assess potential risk factors for VTEs and to evaluate the effect of VTEs on outcome. Results One hundred forty-six of 7937 patients developed clinically relevant VTEs during post-traumatic hospitalisation corresponding to an overall incidence rate of 1.8%. Two-thirds (97/146) of all VTEs occurred during the first 3 weeks after admission. At the time point of the event 118/146 (80.8%) patients were under either mechanical or chemical prophylaxis. Multivariate analysis with VTE as dependent variable identified injury severity score, the number of operative procedures, pelvic injury (abbreviated injury scale ≥ 2) and concomitant diseases (i.e. diabetes, renal failure, malignancies and congenital or acquired coagulation disorders) as independent risk factors. The presence of VTEs was associated with higher frequencies of sepsis (25% vs. 9.1%), single (63.6% vs. 41.3%) and multiple organ failure (49% vs. 25%) and prolonged in-hospital length of stay (52 ± 34 days vs. 29 ± 30 days; all p < 0.001). The mortality in the VTE group totaled 13.7% vs. 7.4% in the non-VTE group (p = 0.004). The presence of PE was associated with a mortality rate of 25.7%. The adjusted odds ratio of post-traumatic VTEs for hospital mortality was 2.08 (CI95 1.15–3.78; p = 0.016). Conclusion The occurrence of clinically apparent VTEs during post-traumatic hospitalisation is low but associated with increased morbidity and mortality. Conclusions about the effectiveness of different thromboprophylactic measures could not be drawn, since detailed information was not recorded. However, 80.8% of VTE patients had received thromboprophylaxis at the time point of the event.

Die Chronifizierung postoperativer Akutschmerzen ist eine wesentliche Morbidität von Operationen. Sie wurde bisher nur anhand von einzelnen Operationsarten unersucht. Ziel dieser Studie war, das Problem für eine chirugische Klinik der Maximalversorgung für die Gesamtpopulation der Patienten zu erfassen. Alle Patienten der chirurgischen Klinik Köln-Merheim eines Jahres (n=3020) wurden mindestens 1 Jahr nach Operation zu Ihrer Schmerzsituation befragt. Einschlusskriterium war Schmerz in den letzten 4 Wochen VAS⩾3. Danach wurden über Erhebung der perioperativen Daten und ein Telephoninterview die potentiellen Chronifizierungspatienten weiter eingegrenzt. Die Verbliebenen wurden zu einem Follow-up mit physischer Untersuchung, freien Fragen und standardisierten Fragebögen (psychosozial, Schmerzart und -qualität) eingeladen. Als Kernaussage zeigte sich eine Chronifizierungsrate von 14,8%. Ausserdem zeigten sich relevante Einschränkungen in den Scores der o.g. Fragebögen. Zudem wurde eine offensichtliche Unterversorgung im medikamentösen und ärztlichen Bereich deutlich. Die Schmerzchronifizierung von postoperativen Akutschmerzen ist ein ernst zu nehmendes Problem. Die Chronifizierungspatienten sind v.a. psychisch und physisch deutlich eingeschränkt. Ihre medizinische Versorgung muss dringend verbessert werden

Postoperative Schmerzen stellen ein relevantes Problem dar; die in der Literatur beschriebene Inzidenz chronischer postoperativer Schmerzen liegt je nach Studie und operativer Prozedur bei bis zu 70%. Die Identifikation von Risikopatienten ist eine erste, notwendige Maßnahme zur Prävention postoperativer Schmerzchronifizierung, um betroffenen Patienten gezielt frühzeitig Unterstützung zukommen zu lassen. Auf Basis von Literaturarbeiten wurden Prädiktoren und Korrelate chronisch postoperativer Schmerzen gesichtet und die Items einer CPPS-Vorversion formuliert und zusammengestellt. Diese Vorversion des CPPS wurde an einer Stichprobe von 250 chirurgischen Patienten validiert: Zunächst wurden die Items bivariat mit dem Outcome-Parameter Schmerzchronifizierung in Bezug gesetzt, gewichtet, und schließlich wurde mittels binär-logistischer Regressionen ein Cut-off Score zur Identifikation von Risikopatienten bestimmt. Es konnte ein valides Indexinstrument zur Identifizierung von Risikopatienten für Schmerzchronifizierung erstellt werden. Aufgrund seiner Praktikabilität lässt sich das CPPS gut in den klinischen Alltag integrieren, und wird so zu einer frühzeitigen schmerzfokussierten Behandlung von Risikopatienten beitragen.

Klinische Akutschmerztherapiestandards helfen Schnittstellenproblematiken bei der regionalen und systemischen Schmerztherapie vermeiden, um so die überwiegende Zahl der Patienten schmerztherapeutisch optimal zu versorgen, mit einer geringstmöglichen Nebenwirkungsrate [3,6]. Dabei werden Patienten mit Routineeingriffen unter Berücksichtigung ihrer Begleiterkrankungen pharmakokinetisch bestmöglichst eingestellt, durch Kombination einzelner analgetischer Substanzklassen (sog. multimodales Therapieprinzip) [4,5,8]. Allen Anstrengungen zum Trotz ist es nahezu unmöglich ein Krankenhaus „schmerzfrei“ zu gestalten, trotzdem sind Anstrengungen zur optimalen Schmerztherapie sinnvoll. Im Juli 2007 wurde unsere Klinik als erste Klinik in Deutschland bezüglich ihres „Qualitätsmanagements Akutschmerztherapie“ von der TÜV Rheinland Group zertifiziert. Seitdem jährlich, d.h. in drei Rezertifizierungsaudits bezüglich ihrer schmerztherapeutischen Effizienz überprüft. Umfangreiche organisatorische und strukturelle Maßnahmen waren notwendig, um die interdisziplinäre Schmerztherapie in allen Kliniken zu synchronisieren und eine Aufrechterhaltung über die einzelnen Schnittstellen (OP > Aufwachraum > Station > Physiotherapie) zu gewährleisten. Auf der Seite der Pflegenden wurde ein Schmerzmentorensystem entwickelt, welches eine kontinuierliche Schmerztherapieverabreichung auf den Stationen ermöglicht und Neuerungen umsetzen läßt. Schriftliche Vereinbarungen der Klinikchefs und der Pflegedienstleitung wurden getroffen, in denen die Schmerztherapiemaßnahmen als Verfahrensanweisungen für alle am Patienten tätigen Mitarbeiter niedergelegt wurden. Qualitätsberichte wurden nach Auswertung von Benchmarkfragebögen durch den kliniksinternen Qualitätszirkel Akutschmerztherapie erstellt und anhand dieser Ergebnisse neue Ziele im Rezertifizierungsverfahren überprüft. Mittlerweile sind neben den initialen Kliniken für Unfallchirurgie, Orthopädie und Sporttraumatologie, Viszeralchirurgie, Gefäß- und Transplantationschirurgie, Anästhesiologie und operative Intensivmedizin und der plastischen Chirurgie, nun die Kliniken für Neurochirurgie und Thoraxchirurgie hinzugekommen, in diesem Jahr konnte erweiternd die komplette „Schwesterklinik“ in Köln-Holweide zertifiziert werden. Die Studienergebnisse, in denen eine bessere Schmerzreduktion durch Schmerztherapiestandards gegen eine Kontrollgruppe ohne Standards oder den Ausgangszustand getestet wurden, sind allesamt erfolgversprechend [1,2,7], unsere eigenen klinischen Erfahrungen bestätigen dieses. Jedoch ist ein permanenter Entwicklungsprozess und interdisziplinärer Erfahrungsaustausch notwendig, um die Qualität der Akutschmerztherapie hochzuhalten und auch den sich ständig ändernden Kliniksbedingungen adäquat anzupassen.