Schmerztherapie auf der Intensivstation

Kernaussagen

• Viele Patienten auf der Intensivstation klagen über starke bis stärkste Schmerzen.

• Eine gute Schmerztherapie kann postoperative Komplikationen reduzieren.

• Die Schmerztherapie auf der Intensivstation sollte in ein kombiniertes Analgosedierungs- und Delirkonzept integriert sein.

• Kontaktfähige Patienten sollte man mit der NRS-Skala untersuchen. Für analgosedierte und beatmete Patienten eignet sich die BPH-Skala, für bewusstseinsgetrübte, nicht intubierte Patienten die BPS-NI-Skala.

• Eine basale Schmerztherapie mit Bedarfsmedikation und eine tägliche Unterbrechung der Analgosedierung ist die Grundlage der medikamentösen Schmerztherapie.

• Besonders geeignet sind gut steuerbare Analgetika (Sufentanil, Remifentanil) oder die intermittierende Bolusgabe von Piritramid, ggf. sind adjuvante Medikamente sinnvoll. Man sollte möglichst auch eine Regionalanästhesie einsetzen. Zusätzlich sollte man nichtmedikamentöse Verfahren verwenden.

• Die Schmerztherapie sollte klinikinternen Standards folgen. Außerdem ist ein Qualitätssicherungsverfahren empfehlenswert (Peer Review, Zertifizierung).

• Literatur

• 1 Myhren H, Toien K, Ekeberg O et al. Patient’s memory and psychological distress after ICU stay compared with expectations of the relatives. Intensive Care Med 2009; 35: 2078-2086
• 2 Martin J, Parasch A, Franck M et al. Practice of sedation and analgesia in German intensive care units: results of a national survey. Critical Care 2005; 9: R117-R123
• 3 Whipple JK, Lewis KS, Quebbeman EJ et al. Analysis of pain management in critical ill patients. Pharmacotherapy 1995; 15: 592-599
• 4 Kehlet H. Editorial. Postoperative pain relief – what is the issue?. Br J Anaesth 1995; 72: 375-378
• 5 Chanques G, Jaber S, Barbotte E et al. Impact of systemic evaluation of pain and agitation in an intensive care unit. Crit Care Med 2006; 34: 1691-1699
• 6 Puntillo K, Nelson JE, Wiessmann D et al. Palliative care in the ICU: relief of pain, dyspnea, an thirst - a report from the IPAL-ICU Advisory. Intensive Care Med 2014; 40: 235-248
• 7 Barr J, Fraser GL, Puntillo K et al. Clinical practice guidelines for the management of pain, agitation and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41: 263-306
• 8 Kastup M, Dossow V, Seeling M et al. Key Performance Indicators in Intensive Care Med. A Retrospective Matched Cohort Study. Journal of International Medical Research 2009; 37: 1267-1284
• 9 Laubenthal H et al. S3-Leitlinie „Behandlung akuter perioperativer und posttraumatischer Schmerzen“. AWMF-Leitlinien-Register Nr. 041/001. 2009
• 10 Spies C, Waydhas C, Martin J. Leitlinie „Analgesie, Sedierung und Delirmanagement in der Intensivmedizin“. AWMF-Leitlinien-Register Nr. 001/012; 2009
• 11 Chanques G, Viel E et al. The measurement of pain in intensive care unit: Comparison of 5 self-report intensity scales. Pain 2010; 151: 711-721
• 12 Payen JF, Bosson JL, Chanques G et al. Pain assessment is associated with decreased duration of mechanical ventilation in the intensive care unit: a post Hoc analysis of the DOLOREA study. Anesthesiology 2009; 6: 1308-1316
• 13 American Geriatrics Society Panel on Persistent Pain in Older Adults. The management of persistent pain in older persons. J Am Geriatr Soc 2002; 50: 205-224
• 14 Chanques G, Payen JF et al. Assessing pain in non-intubated critically ill patients unable to self report: an adaptation of the Behavioral Pain Scale. Intensive Care Med 2009; 35: 2060-2067
• 15 Handel E. Praxishandbuch ZOPA. Bern: Huber; 2009
• 16 Chanques G, Sebbane M, Constantin JM et al. Analgesic efficacy and haemodynamic effects of nefopam in critically ill patients. Br J Anaesth 2011; 106: 336-343
• 17 Gélinas C, Tousignant-Laflamme Y, Tanguay A et al. Exploring the validity of the bispectral index, the Critical-Care Pain Observation Tool and vital signs for the detection of pain in sedated and mechanically ventilated critically ill adults: a pilot study. Intensive Crit Care Nurs 2011; 27: 46-52
• 18 Herr K, Coyne PJ et al. Pain assessment in the patient unable to self-report: position statement with clinical practice recommendations. Pain Management Nursing 2011; 12: 230-250
• 19 Jeitziner MM, Schwendimann R, Hamers JP et al. Assessment of pain in sedated and mechanically ventilated patients: an observational study. Acta Anaesthesiol Scand 2012; 56: 645-654
• 20 Kress JP, Pohlmann AS, O’Connor MF et al. Daily interruption of sedative infusions in critically patients undergoing mechanical ventilation. N Engl J Med 2000; 342: 1471-1477
• 21 Bell RF, Dahl JB, Moore RA et al. Perioperative ketamine for acute postoperative pain. Cochrane Database Syst Rev 2006; 25: CD004603
• 22 Martin J, Franck M, Sigel S et al. Changes in sedation management in German intensive care units between 2002 and 2006: a national follow-up survey. Crit Care 2007; 11: R124
• 23 Hudcova J, McNicol E, Quah C et al. Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain. Cochrane Database Syst Rev 2006; 18: CD 003348
• 24 Cupitt JM, Kasipandian V. Pain and intramuscular injections. Anesthesia 2004; 59: 93
• 25 Mueller-Vahl H. Adverse reactions after intramuscular injections. Lancet 1983; 1: 1050
• 26 Bone HG, Freyhoff J. Opioide in der Akutschmerztherapie. In: Aktuelle Schmerztherapie, Standards und Entwicklungen. 16. Ergänzungslieferung 9/12. Landsberg: Ecomed; 2012
• 27 Zahn PK, Sabatowski R, Schug SA et al. Paracetamol für die perioperative Analgesie. Anaesthesist 2010; 10: 940-952
• 28 Lee WM. Acute liver failure. Semin Respir Crit Care Med 2012; 33: 36-45
• 29 Hedenmalm K, Spigset O. Agranulocytosis and other blood dyscrasias associated with dipyrone. Eur Pharmacol 2002; 58: 265-274
• 30 Edwards JE, McQuay HJ. Dipyrone and agranulocytosis: what is the risk?. Lancet 2002; 360: 1438
• 31 Gosch M, Böhmdorfer B, Benvenuti-Falger U. Polypharmacy and pain treatment. Wien Med Wochenschr 2010; 160: 286-292
• 32 Cruz P, Garutti I, Díaz S et al. Metamizol versus propacetamol: comparative and antipyretic effects in critically ill patients. Rev Esp Anestesiol Reanim 2002; 49: 391-396
• 33 Subramaniam K, Subramaniam B, Steinbrook RA. Ketamine as adjuvant analgetic to opioids: a quantitative and qualitative systematic review. Anesth Analg 2004; 99: 482-495
• 34 Dahi-Taleghani M, Fazl B, Ghasemi M et al. Effect of intravenous patient controlled ketamine analgesiaon pain in opium abusers. Anesth pain Med 2014; 4: e14129
• 35 Tawfic QA. A review of the use of ketamine in pain management. J Opioid Manag 2013; 9: 379-388
• 36 Pandharipande PP, Pun BT, Herr DL et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MEDOS randomizes controlled trail. JAMA 2007; 298: 2644-2653
• 37 Pöpping DM, Elia N, Marret E et al. Protective effects of epidural analgesia on pulmonary comlications after abdominal and thoracic surgery: a meta-analysis. Arch Surg 2008; 143: 990-999
• 38 Block BM, Liu SS, Rowlingson AJ et al. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA 2003; 290: 2455-2463
• 39 Wijeysundera DN, Beattie WS, Austin PC et al. Epidural anesthesia and survival after intermediate-to-high risk non-cardiac surgery: a population-based cohort study. Lancet 2008; 372: 562-569
• 40 Engelbrecht JS, Pogatzki-Zahn EM. Perioperative Schmerztherapie bei abdominellen und thorakalen Schmerzen. Schmerz 2014; 28: 265-281
• 41 Manion SC, Brennan TJ. Thoracic epidural analgesia and pain management. Anesthesiology 2001; 115: 181-188
• 42 Bromage PR, Benumof JL. Paraplegia following intracord injection during attempted epidural anesthesia under general anesthesia. Reg Anesth Pain Med 1998; 23: 104-107
• 43 Horlocker TT et al. Small risk of serious neurologic complications related to lumbar epidural catheter placement in anesthetized patients. Anesth Analg 2003; 96: 1547-1552
• 44 Pogatzki-Zahn EM, Wenk M, Wassmann H et al. Complications of regional anesthesia: diagnostic and management. Anasthesiol Intensivmed Notfallmed Schmerzther 2007; 42: 42-52
• 45 Gogarten W, Van Aken H, Büttner J et al. Rückenmarknahe Regionalanästhesie und Thrombembolieprophylaxe/antithrombotische Medikation. 2. überarbeitete Empfehlung der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin. 2007 48. S109-124
• 46 Burton AW, Eappen S. Regional anesthesia techniques for pain control in the intensive care unit. Crit Care Clin 1999; 15: 77-88
• 47 Schulz-Stübner S. The critically ill patient and regional anesthesia. Curr Opin Anaesthesiol 2006; 19: 538-544
• 48 Good M, Anderson GC, Ahn S et al. Relaxation and music reduce pain following intestinal surgery. Res Nurs Health 2005; 28: 240-251
• 49 Koc M, Tez M, Yoldas O et al. Cooling for the reduction of postoperative pain: prospective randomized study. Hernia 2006; 10: 184-186
• 50 Erstad BL, Puntillo K, Gilbert HC et al. Pain management principles in the critically ill. Chest 2009; 135: 1075-1086
• 51 Cepeda MS, Carr DB, Lau J et al. Music for pain relief. Cochrane Database Syst Rev 2006; CD004843
• 52 Vance CG, Dailey DL, Rakel BA et al. Using TENS for pain control: the state of the evidence. Pain Manag 2014; 4: 197-209
• 53 Johnson M. Transcutaneous electrical nerve stimulation: a review of effectiveness. Nurs Stand 2014; 28: 44-53
• 54 Ewers A, Nestler N, Pogatzki-Zahn E et al. Nichtmedikamentöse Maßnahmen in der Schmerztherapie. Anwendung in 25 deutschen Krankenhäusern. Schmerz 2011; 25: 516-521
• 55 Braun JP, Mende P et al. The German quality indicators in intensive Care Med 2013. Düsseldorf: German Medical Science; 2013
• 56 Quernot JP et al. Effect of nursing-implemented sedation on the protocol of ventilator-associated pneumonia. Crit Care Med 2007; 35: 2031-2036
• 57 Maier C, Nestler N, Hansel N et al. Zertifizierung für „Qualifizierte Schmerztherapie“. Klinikarzt 2013; 42: 80-87