Der Orthopäde

, Volume 37, Issue 10, pp 953–958 | Cite as

Neue und evidenzbasierte Aspekte in der postoperativen Schmerztherapie

  • T. Volk
Leitthema
First Online:

Zusammenfassung

Die postoperative Akutschmerztherapie ist ein wichtiges Thema für die tägliche Praxis in der Unfallchirurgie und Orthopädie. Umfragen gehen davon aus, dass höchstens in etwa der Hälfte der Kliniken interdisziplinäre Konzepte vorhanden sind oder Schmerzen regulär gemessen und dokumentiert werden. Eine Verbesserung der Akutschmerztherapie kann in den zunehmend konkurrierenden Einrichtungen des Gesundheitsmarktes nicht nur einen Wettbewerbsvorteil darstellen, es kann unter den Zwängen der Verweildauerreduktion erlösrelevant werden. Daher lohnt es sich, evidenzbasierte Verfahren im Alltag gemeinsam umzusetzen.

Schlüsselwörter

Akutschmerztherapie Evidenzbasierte Medizin Patientenkotrollierte Analgesie Regionalanalgesie Opioide 

New and evidence-based aspects of postoperative pain therapy

Abstract

Poorly managed postoperative pain has been recognised to delay patient recovery and hospital discharge. Recent metaanalyses support a multimodal approach with combinations of analgesics from different classes. The pharmacological options of commonly used opioids, nonsteroidal anti-inflammatory drugs, and other nonopioid analgesics in combination have been shown to provide effective pain relief and to reduce opioid consumption. Local, intraarticular, epidural, and, more importantly, modern peripheral regional techniques can be used successfully to enhance perioperative analgesia. The use of continuous perineural techniques with local anaesthetic infusion has been extended beyond hospital discharge in many European countries.

Keywords

Acute pain Evidence-based medicine Nerve block Patient-controlled analgesia Opioid 
This is a preview of subscription content, log in to check access.

Notes

Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehungen hin: Der Autor hat Referentenhonorare und Studienunterstützung der Firmen Abbott, Janssen Cilag, Arrow, Lilly, Astra Zeneca, Mundipharma, Baxter, Pharmacia & Upjohn, Pfizer und Glaxo Smith Kline erhalten. Trotz des möglichen Interessenkonflikts ist der Beitrag unabhängig und produktneutral.

Literatur

  1. 1.
    Bell RF, Dahl JB, Moore RA, Kalso E (2006) Perioperative ketamine for acute postoperative pain. Cochrane Database Syst Rev 25: CD004603Google Scholar
  2. 2.
    Birnbaum J, Klotz E, Bogusch G, Volk T (2007) Electrical nerve stimulation for plexus and nerve blocks Anaesthesist 56: 1155–1162Google Scholar
  3. 3.
    Block BM, Liu SS, Rowlingson AJ et al. (2003) Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA 290: 2455–2463PubMedCrossRefGoogle Scholar
  4. 4.
    Carroll IR, Angst MS, Clark JD (2004) Management of perioperative pain in patients chronically consuming opioids. Reg Anesth Pain Med 29: 576–591PubMedCrossRefGoogle Scholar
  5. 5.
    Cheville A, Chen A, Oster G et al. (2001) A randomized trial controlled-release oxycodone during inpatient rehabilitation following unilateral total knee arthroplasty. J Bone Joint Surg Am 83: 572–576PubMedCrossRefGoogle Scholar
  6. 6.
    Clifton R, Haleem S, McKee A, Parker MJ (2007) Closed suction surgical wound drainage after anterior cruciate ligament reconstruction: a systematic review of randomised controlled trials. Knee 14: 348–351PubMedCrossRefGoogle Scholar
  7. 7.
    Clifton R, Haleem S, McKee A, Parker MJ (2007) Closed suction surgical wound drainage after hip fracture surgery: a systematic review and meta-analysis of randomised controlled trials. Int Orthop. DOI 10.1007/s00264-007-0420-zGoogle Scholar
  8. 8.
    Elia N, Tramer MR (2005) Ketamine and postoperative pain–a quantitative systematic review of randomised trials. Pain 113: 61–70PubMedCrossRefGoogle Scholar
  9. 9.
    Elia N, Lysakowski C, Tramèr MR (2005) Does multimodal analgesia with acetaminophen, nonsteroidal antiinflammatory drugs, or selective cyclooxygenase-2 inhibitors and patient-controlled analgesia morphine offer advantages over morphine alone? Meta-analyses of randomized trials Anesthesiology 103: 1296–1304Google Scholar
  10. 10.
    Engelhardt L et al. (2008) Ein Netzwerk zur Sicherheit in der Regionalanästhesie in Deutschland – Eine Initiative der DGAI und des BDA. Anästh Intensivmed 1: 55–61Google Scholar
  11. 11.
    Ettrich U, Seifert J, Scharnagel R, Günther KP (2007) Multimodales und interdisciplinäres postoperatives Schmerztherapiekonzept. Orthopäde 36: 544–551PubMedCrossRefGoogle Scholar
  12. 12.
    Foss NB, Kristensen BB, Bundgaard M et al. (2007) Fascia iliaca compartment blockade for acute pain control in hip fracture patients: a randomized, placebo-controlled trial. Anesthesiology 106: 773–778PubMedCrossRefGoogle Scholar
  13. 13.
    Fowler SJ, Symons J, Sabato S, Myles PS (2008) Epidural analgesia compared with peripheral nerve blockade after major knee surgery: a systematic review and meta-analysis of randomized trials. Br J Anaesth 100: 154–164PubMedCrossRefGoogle Scholar
  14. 14.
    Grond S, Hall J, Spacek A et al. (2007) Iontophoretic transdermal system using fentanyl compared with patient-controlled intravenous analgesia using morphine for postoperative pain management. Br J Anaesth 98: 806–815PubMedCrossRefGoogle Scholar
  15. 15.
    Hartrick CT, Bourne MH, Gargiulo K et al. (2006) Fentanyl iontophoretic transdermal system for acute-pain management after orthopedic surgery: a comparative study with morphine intravenous patient-controlled analgesia. Reg Anesth Pain Med 31: 546–54PubMedCrossRefGoogle Scholar
  16. 16.
    Hensel M, Schwenk W, Bloch A et al. (2006) The role of anesthesiology in fast track concepts in colonic surgery. Anaesthesist 55: 80–926PubMedCrossRefGoogle Scholar
  17. 17.
    Huang HT, Su JY, Chang JK et al. (2007) The early clinical outcome of minimally invasive quadriceps-sparing total knee arthroplasty: report of a 2-year follow-up. J Arthroplasty 22: 1007–1012PubMedCrossRefGoogle Scholar
  18. 18.
    Hudcova J, McNicol E, Quah C et al. (2006) Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain. Cochrane Database Syst Rev 18:CD003348Google Scholar
  19. 19.
    Ilfeld BM, Mariano ER, Williams BA et al. (2007) Hospitalization costs of total knee arthroplasty with a continuous femoral nerve block provided only in the hospital versus on an ambulatory basis: a retrospective, case-control, cost-minimization analysis. Reg Anesth Pain Med 32: 46–54PubMedCrossRefGoogle Scholar
  20. 20.
    Kehlet H (2007) Glucocorticoids for peri-operative analgesia: how far are we from general recommendations? Acta Anaesthesiol Scand 51: 1133–1135PubMedGoogle Scholar
  21. 21.
    Liu SS, Strodtbeck WM, Richman JM, Wu CL (2005) A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials. Anesth Analg 101: 1634–1642PubMedCrossRefGoogle Scholar
  22. 22.
    Marret E, Kurdi O, Zufferey P, Bonnet F (2005) Effects of nonsteroidal antiinflammatory drugs on patient-controlled analgesia morphine side effects: meta-analysis of randomized controlled trials. Anesthesiology 102: 1249–1260PubMedCrossRefGoogle Scholar
  23. 23.
    Møiniche S, Mikkelsen S, Wetterslev J, Dahl JB (1999) A systematic review of intra-articular local anesthesia for postoperative pain relief after arthroscopic knee surgery. Reg Anesth Pain Med 24: 430–437PubMedCrossRefGoogle Scholar
  24. 24.
    Myles PS, Power I (2007) Clinical update: postoperative analgesia. Lancet 369: 810–812PubMedCrossRefGoogle Scholar
  25. 25.
    Parker MJ, Livingstone V, Clifton R, McKee A (2007) Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database Syst Rev 8: CD001825Google Scholar
  26. 26.
    Pogatzki-Zahn EM, Zahn PK. (2007) Postoperative Akutschmerztherapie - Neue Möglichkeiten der systemischen Analgesie. Anasthesiol Intensivmed Notfallmed Schmerzther 42: 22–31PubMedCrossRefGoogle Scholar
  27. 27.
    Poolman RW, Abouali JA, Conter HJ, Bhandari M (2007) Overlapping systematic reviews of anterior cruciate ligament reconstruction comparing hamstring autograft with bone-patellar tendon-bone autograft: why are they different? J Bone Joint Surg Am 89: 1542–1552PubMedCrossRefGoogle Scholar
  28. 28.
    Remy C, Marret E, Bonnet F (2005) Effects of acetaminophen on morphine side-effects and consumption after major surgery: meta-analysis of randomized controlled trials. Br J Anaesth 94: 505–513PubMedCrossRefGoogle Scholar
  29. 29.
    Reuben SS, Buvanendran A (2007) Preventing the development of chronic pain after orthopaedic surgery with preventive multimodal analgesic techniques. J Bone Joint Surg Am 89: 1343–1358PubMedCrossRefGoogle Scholar
  30. 30.
    Richman JM, Liu SS, Courpas G et al. (2006) Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesth Analg 102: 248–257PubMedCrossRefGoogle Scholar
  31. 31.
    Röstlund T, Kehlet H (2007) High-dose local infiltration analgesia after hip and knee replacement--what is it, why does it work, and what are the future challenges? Acta Orthop 78: 159–161PubMedCrossRefGoogle Scholar
  32. 32.
    Rosseland LA (2005) No evidence for analgesic effect of intra-articular morphine after knee arthroscopy: a qualitative systematic review. Reg Anesth Pain Med 30: 83–98PubMedCrossRefGoogle Scholar
  33. 33.
    Russon K, Sardesai AM, Ridgway S et al. (2006) Postoperative shoulder surgery initiative (POSSI): an interim report of major shoulder surgery as a day case procedure. Br J Anaesth 97: 869–873PubMedCrossRefGoogle Scholar
  34. 34.
    Schenk Schenk MR, Putzier M, Kügler B et al. (2006) Postoperative analgesia after major spine surgery: patient-controlled epidural analgesia versus patient-controlled intravenous analgesia. Anesth Analg 103: 1311–1317PubMedCrossRefGoogle Scholar
  35. 35.
    S3 Leitlinie: Behandlung akuter perioperativer und posttraumatischer Schmerzen. AWMF-Leitlinien-Register Nr. 041/001. Entwicklungsstufe 3,5/2007Google Scholar
  36. 36.
    Tiippana EM, Hamunen K, Kontinen VK, Kalso E (2007) Do surgical patients benefit from perioperative gabapentin/pregabalin? A systematic review of efficacy and safety. Anesth Analg 104: 1545–1556PubMedCrossRefGoogle Scholar
  37. 37.
    Viscusi ER, Reynolds L, Chung F et al. (2004) Patient-controlled transdermal fentanyl hydrochloride vs intravenous morphine pump for postoperative pain: a randomized controlled trial. JAMA 291: 1333–1341PubMedCrossRefGoogle Scholar
  38. 38.
    Wathen JE, Gao D, Merritt G et al. (2007) A randomized controlled trial comparing a fascia iliaca compartment nerve block to a traditional systemic analgesic for femur fractures in a pediatric emergency department. Ann Emerg Med 50: 162–171PubMedCrossRefGoogle Scholar
  39. 39.
    Wu CL, Cohen SR, Richman JM et al. (2005) Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis. Anesthesiology 103: 1079–1088PubMedCrossRefGoogle Scholar

Copyright information

© Springer Medizin Verlag 2008

Authors and Affiliations

  • T. Volk
    • 1
  1. 1.Universitätsklinik für Anästhesiologie und Operative IntensivmedizinCharité-Universitätsmedizin Berlin, Campus Virchow-Klinikum und Campus MitteBerlinDeutschland

Personalised recommendations