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Oraler Therapiealgorithmus bei akuten postoperativen Schmerzen

Eine prospektive Beobachtungsstudie

Oral therapy algorithm for the treatment of postoperative pain

A prospective observational study

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Zusammenfassung

Hintergrund

Untersuchungen zeigen, dass Patienten ohne Regionalanalgesieverfahren oder patientenkontrolliertes i.v.-Analgesieverfahren (PCIA) nach Operationen oft unter zu starken Schmerzen leiden. Ziel dieser prospektiven Observationsstudie war es, die Wirksamkeit und Durchführbarkeit eines einfachen und an den Bedarf des Patienten anpassbaren oralen Therapiealgorithmus für diese Patienten zu evaluieren.

Material und Methoden

Patienten, die routinemäßig nach elektiven unfall- (UCH) oder allgemeinchirurgischen (ACH) und Hals-Nasen-Ohrenheilkunde(HNO)-Eingriffen nach einem Therapiealgorithmus behandelt wurden, der eine Basisanalgesie (orales retardiertes Opioid plus Nichtopioidanalgetikum) und ein Bedarfsanalgetikum (nichtretardiertes orales Opioid) umfasste, wurden nach Einwilligung in die Studie eingeschlossen. Sowohl präoperativ als auch für 4 Tage postoperativ wurden standardisiert demografische Daten einschließlich der präoperativen Schmerzen und des Analgetikaverbrauchs sowie ergebnisbezogene Daten wie Schmerzintensität, Übelkeit, Erbrechen, Zufriedenheit mit der Schmerztherapie und Gründe für Unzufriedenheit erhoben. Sechs und 12 Monate nach Operation wurden die aktuellen Schmerzen und die Lebensqualität evaluiert.

Ergebnisse

Insgesamt wurden 275 Patienten in die Studie eingeschlossen (HNO: n = 163; UCH: n = 82; ACH: n = 30). Die Schmerzintensität in Ruhe lag bei ≤ 3 (median) für alle Patienten; Belastungsschmerzen lagen bei ≤ 4 in der HNO- und bei ≤ 5 in der ACH- bzw. UCH-Gruppe. In der HNO und ACH war der Basisanalgetikaverbrauch (retardiertes Opioid) signifikant geringer als in der UCH (p < 0,001). Die häufigsten Nebenwirkungen waren Übelkeit, Erbrechen und Obstipation; während Obstipation deutlich häufiger bei Patienten in der ACH und in der UCH auftrat als in der HNO, konnte kein Unterschied hinsichtlich Übelkeit und Erbrechen gefunden werden. Es wurden keine schwerwiegenden unerwünschten Nebenwirkungen beobachtet. Depressive Patienten litten unter stärkeren akuten postoperativen Schmerzen. Von den Patienten, die Rückmeldung gaben, berichteten 11 (15,7%) bzw. 7 (14,9%) über persistierende postoperative Schmerzen 6 bzw. 12 Monate nach Operation.

Schlussfolgerung

Mit dieser Studie konnten wir zeigen, dass die Implementierung und Anwendung eines opioidbasierten Therapiealgorithmus für Patienten ohne PCIA effektiv in der Behandlung postoperativer Schmerzen ist. Patienten nach UCH-Eingriffen benötigten signifikant mehr Basisanalgetika als Patienten der HNO oder ACH bei gleicher Inzidenz potenzieller opioidassoziierter Nebenwirkungen, ausgenommen Obstipation.

Abstract

Background

Postoperative pain continues to be undermanaged, at least in part, due to inadequate organization and lack of use of opioids. Especially patients who do not receive consultation from an acute pain service and are therefore not eligible to receive regional anesthesia techniques or patient-controlled devices suffer from severe pain after surgery. The aim of the present prospective observational study was to assess the efficacy and feasibility of an analgesia algorithm for this subgroup of patients.

Methods

An oral opioid concept including controlled-release (cr) oxycodone, immediate-release (ir) hydromorphone and a non-opioid analgesic was implemented at three different departments at the University Clinic of Muenster, Germany. Briefly, cr-oxycodon was administered preoperatively to patients undergoing ear nose and throat (ENT), general or elective trauma surgery on the day of surgery and every 12 h for a maximum of 4 days postoperatively. Inadequately managed pain above 3 on a visual analog scale (VAS 0–10) at rest and above 5 during movement was treated with ir-hydromorphone on patient request. After written informed consent, patients were assessed prospectively for up to 5 days perioperatively using a standardized questionnaire preoperatively, for 4 days postoperatively as well as 6 and 12 months after surgery.

Results

A total of 275 patients were included in the present prospective observational study: (ENT surgery: 163, trauma surgery 82 and general surgery 30). Median resting and evoked numeric rating scale (NRS) pain scores were equal or less than 3 and 5, respectively. Less patients received cr-oxycodone after ENT and general surgery compared to trauma surgery (p < 0.001). Constipation was more frequent after general and trauma surgery compared to ENT surgery. Vomiting decreased from 20 %-30 % on the day of surgery to 10 % or less regardless of the type of operation. No severe adverse events were observed. Additionally, patients with an increased depression score before surgery reported greater immediate postoperative pain than non-depressed patients. Of the patients 11 (15.7 %) and 7 (14.9 %) complained about persistent postoperative pain 6 and 12 months after surgery, respectively and these patients had increased acute pain ratings during the first postoperative days.

Conclusions

The present study has demonstrated that the implementation of an oral opioid algorithm for patients without patient-controlled intravenous or regional analgesia is effective and feasible on surgical wards. Patients who underwent trauma surgery needed more cr-oxycodone. Side effects were similar regardless of the operation with the exception of obstipation which was more frequent after trauma and general surgery compared to ENT surgery.

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Interessenkonflikt

Die korrespondierende Autorin weist für sich und ihre Koautoren auf folgende Beziehungen hin: E.M. Pogatzki-Zahn: Beratungs- und Vortragstätigkeiten für B. Braun, Mundipharma, MSD, Pfizer, Janssen-Cilag und Grünenthal; P. Zahn: Vortragstätigkeiten für Mundipharma und Mitsubishi Pharma. Die Datenerhebung wurde finanziell z. T. unterstützt durch Mundipharma. Die Firma nahm weder Einfluss auf die Auswertung noch auf die Publikation der Daten.

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Authors and Affiliations

  1. Klinik und Poliklinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland

    E.M. Pogatzki-Zahn, J.S. Englbrecht, D. Pöpping & R. Boche

  2. Klinik für Anästhesiologie, Intensiv-, Palliativ- und Schmerzmedizin, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Deutschland

    P.K. Zahn

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  1. E.M. Pogatzki-Zahn
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  2. J.S. Englbrecht
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  3. D. Pöpping
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Correspondence to E.M. Pogatzki-Zahn.

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Pogatzki-Zahn, E., Englbrecht, J., Pöpping, D. et al. Oraler Therapiealgorithmus bei akuten postoperativen Schmerzen. Schmerz 27, 26–37 (2013). https://doi.org/10.1007/s00482-012-1279-5

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