This review provides an overview of the basic knowledge of drug pain therapy in the palliative situation. Pain is one of the main symptoms in 60 to 90% of cancer patients. Pain also develops with neurological and other diseases that occur in end-of-life situations. To address this symptom, a holistic strategy is required that encompasses all physical, psychological, social, and spiritual aspects of the multi-dimensional pain experience ("total pain" concept).Drug treatment for cancer pain has been based on a stepwise approach for many years, starting with non-opioid analgesics, followed by moderate and strong opioids. In contrast, today's pain management is determined more by the actual intensity of this aversive event.The pain assessment should be tailored to identify a nociceptive vs. a neuropathic pain component that needs to be challenged by the most appropriate drug therapies. Non-opioid analgesics are ideal substances for relieving nociceptive pain. Antidepressants and anticonvulsants reduce the intensity of new neuropathic pain. Opioids are suitable for all types of pain, but are restricted to a second-line choice. Among all opioids are Tilidine and Tramadol prodrugs, which only relieve pain after activation in the liver. Drug-drug interactions may also block this activation. Rapid release opioids should be used for break-through cancer pain. Transdermal opioid applications are recommended in case of swallowing disorders, but usually not to initiate pain control. An opioid change can be performed if side effects such as hallucinations for the selected opioid are more pronounced than the pain reduction.

ZusammenfassungDieser Beitrag bietet einen Überblick zu Basiswissen in medikamentöser Schmerztherapie in der Palliativsituation. Schmerz ist eines der führenden Symptome bei 60–90 % aller Krebspatienten. Schmerzen entstehen auch bei neurologischen oder anderen Krankheiten, die am Lebensende auftreten. Um dieses Symptom zu behandeln, ist eine ganzheitliche Strategie vonnöten, die alle körperlichen, psychologischen, sozialen und spirituellen Aspekte der multidimensionalen Schmerzerfahrung („Total Pain“-Konzept) umfasst.Die Behandlung von Krebsschmerzen basierte viele Jahre auf einem Stufenschema, beginnend mit nichtopioiden Analgetika, gefolgt von mittelstarken und starken Opioiden. Im Gegensatz dazu wird die heutige Schmerzbehandlung mehr von der tatsächlichen Intensität dieses aversiven Ereignisses bestimmt.Die Schmerzbeurteilung sollte darauf zugeschnitten sein, eine nozizeptive vs. neuropathische Schmerzkomponente zu identifizieren, die durch die geeignete Arzneimitteltherapie gelindert werden muss. Nichtopioid-Analgetika sind ideale Substanzen zur Linderung nozizeptiver Schmerzen. Antidepressiva und Antikonvulsiva reduzieren die Intensität neuer neuropathischer Schmerzen. Opioide sind für alle Arten von Schmerzen geeignet, sollten jedoch als zweite Wahl eingesetzt werden. Tilidin und Tramadol sind Prodrugs, die erst nach Aktivierung in der Leber schmerzlindernd wirken. Arzneimittelwechselwirkungen können diese Aktivierung blockieren. Schnellwirksame Opioide sollten bei Tumor-Durchbruchschmerzen eingesetzt werden. Transdermale Opioid-Anwendungen werden bei Schluckstörungen empfohlen, normalerweise jedoch nicht, um die Schmerzkontrolle einzuleiten. Wenn Nebenwirkungen wie Halluzinationen für das ausgewählte Opioid auftreten, kann ein Opioid-Wechsel durchgeführt werden.

Palliative care was established as the fifth pillar of the German Society for Anaesthesiology and Intensive Care Me dicine e. V. (DGAI). However, which role anaesthetists may play regarding the care of patients with palliative care needs, is not clear yet. Method An ad hoc email survey among mem bers of the scientific working group "palliative me dicine" of the Association of German Anaesthetists e.V. (BDA) and DGAI on Aug. 22, 2022, about the role of anaesthesiology in palliative medicine. The response to the single question "Is there a matter close to your heart that in your view should be mentioned here?" were analysed qualitatively according to Mayring [1]. Results Eleven of 39 registered addressees re sponded. The three main categories were (1) self perception of the professional task regarding palliative care (2) pallia tive care qualifications or palliative care training and continuing education, and (3) the effectiveness of anaesthesiology activities with regard to palliative care. Numerous aspects of anaesthesiological competence concerning palliative care were reported. The need for further training and qualification of anaesthe siologists as well as the creation of ne cessary political structures were pointed out. Conclusion Future initiatives should include speci fic recommendations on the role of anaes thesiologists concerning palliative care in everyday clinical practice and interdis ciplinary collaboration. Further training and qualification concepts should be examined.

Background: The transition of patients from the intensive care unit (ICU) to the palliative care (PC) ward often implies changes including establishing a palliative concept. Adaptation of therapeutic goals can be challenging for medical staff, patients and relatives; however, descriptions of these transition trajectories are rare.Objective: The aim of this retrospective study was to characterize the consultation requests of the ICU to the PC consultation team as well as the patients by a description of trajectories and interventions.Methods: Retrospective analysis of all patients receiving intensive care at RWTH Aachen University Hospital in 2019 for whom a PC consultation was requested. The patient population transferred from the ICU to the PC ward was compared with the non-transferred population. In each case, the primary consultation was evaluated regarding the following factors: question, vigilance, length of time from consultation request to its performance, and primary focus of the question. The question focus was categorized into "symptom control", "counselling" and "transfer" (tick options). In addition, a free text field was available for further notes. Exploration of diagnoses was complemented by accessing the electronic health records.Results: A total of 102 consultation requests from the ICU to the PC ward were evaluated. The morbidity of patients was high, and most patients had at least one of the following diagnoses: pulmonary (62%), cardiovascular (61%), and/or neurological disease (55%). Of the patients 32 (31%) were transferred to the PC ward, among whom weakness (94%), fatigue (77%), anxiety (55%), pain (53%), and dyspnea (48%) were the most frequently noted symptoms. Of the transferred patients 5 (16%) could be discharged to home, nursing home, hospice or other. In total, 35 (34%) of all patients who were seen by palliative care specialists on ICUs in 2019 could be discharged alive. The most frequent reasons for nonadmission were lack of capacity of the PC ward (33%), dying while being on the waiting list (20%), and refusal by the patient (20%). Of the patients, 7 (26%) died within 48 h after they had been transferred to the PC ward. Performed consultation services "symptom control" (?(2) = 10.17; p < 0.05) and "counselling" (?(2) = 12.82; p < 0.001), which were requested by the intensive care physicians, showed a significant linkage with the respective intervention performed by the palliative care team. On the other hand, no statistically significant difference was found for requested and performed "transfer" of patients from ICUs to PC ward. Comparing the transferred versus non-transferred patient population, a significantly more frequent transfer of patients with malignant tumors (p = 0.00) was observed.Conclusion: The need for palliative care support in the ICUs exceeded the admission capacity of the PC ward. Future studies should further examine palliative care models in intensive care medicine.

Zusammenfassung Hintergrund Die Verlegung von Patient:innen der Intensivstation (ITS) auf die Palliativstation (PTS) geht meist mit der Festlegung eines palliativen Konzeptes einher. Die Anpassung der Therapieziele mit primärem Fokus auf Lebensqualität und Symptomkontrolle kann für medizinisches Personal, Patient:innen und Angehörige herausfordernd sein. Beschreibungen dieser Transition sind jedoch rar. Fragestellung Ziel der Studie war die Charakterisierung der von den intensivmedizinischen Stationen gestellten Konsile an die Palliativmedizin sowie der Patient:innen durch Beschreibung der Versorgungspfade und Interventionen. Methode Retrospektive, quantitative Analyse aller im Jahr 2019 intensivmedizinisch betreuten Patient:innen der Uniklinik RWTH Aachen, für die ein palliativmedizinisches Konsil angefordert worden war. Ergebnisse Es wurden n = 102 Konsilanfragen der ITS an die Palliativmedizin ausgewertet. Fünf von 32 (16 %) auf die PTS übernommenen Konsilpatient:innen bzw. 35 (34 %) aller 102 Patient:innen konnten in das häusliche Umfeld oder eine stationäre Einrichtung (Pflegeheim, Hospiz, andere) entlassen werden. Die häufigsten Gründe einer Nichtübernahme waren: fehlende Kapazität der PTS (33 %), Versterben auf der Warteliste (20 %) und Ablehnung durch die Patient:innen (20 %). Die durch die Intensivmediziner:innen angefragten konsiliarischen Leistungen „Symptomkontrolle“ (χ 2 = 10,17; p < 0,05) und „Beratung“ (χ 2 = 12,82; p < 0,001) zeigten einen signifikanten Zusammenhang mit der jeweils durch die Palliativmediziner:innen durchgeführten Intervention. Schlussfolgerung Der Bedarf palliativmedizinischer Unterstützung der ITS überstieg die Aufnahmekapazität der PTS. Zukünftige Studien sollten Versorgungsmodelle palliativmedizinischer Unterstützung in der Intensivmedizin näher untersuchen.

Zusammenfassung Hintergrund Opioide gehören zum Klinikalltag in Anästhesiologie, Intensivmedizin und Palliativmedizin. Hinsichtlich der Behandlung von Dyspnoe mit Opioiden finden sich in Leitlinien jedoch unterschiedliche Gewichtungen. Dies kann zu Unsicherheiten bezüglich Indikationsstellung und ethischer Implikationen im Umgang mit Opioiden – auch bei COVID-19 – führen. Ziel der Arbeit Erfassung der Wahrnehmung bezüglich Umgang mit Morphin/Opioiden (M/O) zur Symptomkontrolle inner - und außerhalb der Palliativmedizin, auch bei COVID-19-Erkrankten. Material und Methoden Mittels SurveyMonkey® (Momentive Inc., San Mateo, CA, USA) wurden Mitglieder der Deutschen Gesellschaft für Anästhesiologie (DGAI) und des Berufsverbands Deutscher Anästhesisten (BDA) im Oktober 2020 anonymisiert nach ihrer eigenen Wahrnehmung zum Umgang mit M/O zur Symptomkontrolle befragt. Ergebnisse und Diskussion Von N = 1365 teilnehmenden Anästhesist:innen beschrieben 88 % den Umgang mit M/O innerhalb der Palliativmedizin als „sicher und vertraut“ bzw. 85 % als „klar geregelt“, während dies für die Bereiche außerhalb der Palliativmedizin deutlich seltener angegeben wurde (77 %/63 %). Bei der Betreuung COVID-19-Erkrankter wurde der Umgang mit M/O außerhalb der Palliativmedizin noch seltener als „sicher und vertraut“ (40 %) oder „klar geregelt“ (29 %) wahrgenommen. Dyspnoe (95 %/75 %), Erleichterung des Sterbeprozesses (84 %/51 %), Unruhe (59 %/27 %) und Angst/Panik (61 %/33 %) wurden häufiger innerhalb als außerhalb der Palliativmedizin als allgemeine Indikationen genannt. Von den Befragten wünschten sich 85 % die Einbindung eines palliativmedizinischen Konsilteams. Fazit Anästhesist:innen nahmen deutliche Unsicherheiten im Umgang mit M/O wahr, insbesondere außerhalb der Palliativmedizin. Einheitliche, interdisziplinäre Leitlinien zur Symptomkontrolle etwa bei Dyspnoe, mehr Lehre und die Einbindung eines palliativmedizinischen Konsilteams sollten zukünftig intensiver bedacht werden.

Background and PurposeOxycodone is a potent semi-synthetic opioid that is commonly used for the treatment of severe acute and chronic pain. However, treatment with oxycodone can lead to cardiac electrical changes, such as long QT syndrome, potentially inducing sudden cardiac arrest. Here, we investigate whether the cardiac side effects of oxycodone can be explained by modulation of the cardiac Na(v)1.5 sodium channel. Experimental ApproachHeterologously expressed human Na(v)1.5, Na(v)1.7 (HEK293 cells) or Na(v)1.8 channels (mouse N1E-115 cells) were used for whole-cell patch-clamp electrophysiology. A variety of voltage-clamp protocols were used to test the effect of oxycodone on different channel gating modalities. Human stem cell-derived cardiomyocytes were used to measure the effect of oxycodone on cardiomyocyte beating. Key ResultsOxycodone inhibited Na(v)1.5 channels, concentration and use-dependently, with an IC50 of 483M. In addition, oxycodone slows recovery of Na(v)1.5 channels from fast inactivation and increases slow inactivation. At high concentrations, these effects lead to a reduced beat rate in cardiomyocytes and to arrhythmia. In contrast, no such effects could be observed on Na(v)1.7 or Na(v)1.8 channels. Conclusions and ImplicationsOxycodone leads to an accumulation of Na(v)1.5 channels in inactivated states, with a slow time course. Although the concentrations needed to elicit cardiac arrhythmias in vitro are relatively high, some patients under long-term treatment with oxycodone as well as drug abusers and addicts might suffer from severe cardiac side effects induced by the slowly developing effects of oxycodone on Na(v)1.5 channels.

Background In palliative care patients, fatigue can be severely debilitating and is often not counteracted with rest, thereby impacting daily activity and quality of life. Further complicating issues are the multidimensionality, subjective nature and lack of a consensus definition of fatigue. The review aimed to evaluate the efficacy of pharmacological treatments for fatigue in palliative care, with a focus on patients at an advanced stage of disease, including patients with cancer and other chronic diseases. Methods We considered randomized controlled trials concerning adult palliative care with a focus on pharmacological treatment of fatigue compared with placebo, application of two drugs, usual care or a non-pharmacological intervention. The primary outcome had to be non-specific fatigue (or related terms such as asthenia). We searched the CENTRAL, MEDLINE, PsycINFO and EMBASE, and a selection of cancer journals up to 28 April 2014. Two review authors independently assessed trial quality and extracted the data. Results We screened 1645 publications of which 45 met the inclusion criteria. In total, we analysed data from 18 drugs and 4696 participants. There was a very high degree of statistical and clinical heterogeneity in the trials. Meta-analysis of data was possible for modafinil, pemoline, and methylphenidate. Conclusions Due to the limited evidence, we cannot recommend a specific drug for the treatment of fatigue in palliative care patients. Some drugs, which may be beneficial for the treatment of fatigue associated with palliative care such as amantadine, methylphenidate, and modafinil, should be further researched.

Patients with chronic non-cancer pain not only show reduced quality of life, but also chronic morbidity and increased mortality. However, little is known about prevalence and type of abnormal electrocardiogram (ECG) recordings in these individuals.A total of 100 consecutive patients (a parts per thousand yenaEuro parts per thousand 18 years) with chronic (a parts per thousand yenaEuro parts per thousand 3 months) non-cancer pain were examined prospectively using ECG recordings and a questionnaire [German Pain Society (DGSS); further questions]. Data were collected at the first and next two follow-up outpatients' clinic appointments.Participation rate was 98%. Of all patients, 26% had an abnormal ECG, while 5% of these patients had an abnormal ECG first at the follow-up when consuming a different analgesic regimen. Findings were QTc prolongation (16%), ventricular block (7%), artrioventricular block (6%), and atrial fibrillation (4%).The prevalence of abnormal ECG recordings should be considered in the pain management of these patients. General ECG screening in this population should be discussed. Future studies should examine a larger population to identify potential risk factors (e.g., medication).

Patienten mit chronischen Nichttumorschmerzen haben nicht nur eine reduzierte Lebensqualität, sondern auch eine erhöhte Komorbidität und Mortalität. Häufigkeit und Art abnormer Elektrokardiogramme (EKG) sind jedoch unklar.