[Pain assessment and pain treatment in the geriatric patient. Part II: pain treatment]. / Schmerzdiagnostik und -therapie in der Geriatrie. Teil II: Schmerztherapie.

A primary goal of pain treatment in geriatric patients consists of maintaining physical and mental function, which is a precondition of activity and participation. In patients with chronic pain, multidisciplinary treatment without excluding invasive procedures is the most effective approach. The medication ladder, suggested by the WHO initially for cancer pain, provides a guideline for pharmacological treatment. Due to age-dependent alterations in the kinetics and dynamics of pharmaceuticals, the titration of the medication follows the rule "start low and go slow." The same principle holds true for the maintenance or augmentation of physical activity in order to escape from the activity-deconditioning cycle. The training should be based on learning theories, include pain management strategies, and incorporate psychological approaches to facilitate the active participation of the patient in the treatment program. In hospitals and nursing homes, nurses play an important role in defining the need for pain treatment and in supervising the patient in the treatment process. Despite all these endeavors, a significant number of patients remains whose pain cannot be controlled sufficiently. Euthanasia on demand of the patient with untreatable pain is not admitted in Germany.

[Differentiation of peripheral and central hyperalgesic effects of systemic procaine]. / Differenzierung peripherer und zentraler antihyperalgetischer Effekte einer systemischen Procaindauerinfusion.

OBJECTIVE: The aim of this study was to differentiate between the peripheral and central analgesic and antihyperalgesic properties of systemic procaine hydrochloride in standardized human pain models. METHOD: Subcutaneous injections of either 150 mg procaine hydrochloride or saline solution were administered at intervals of 2 weeks on a randomized and double blind basis. During the 90-min infusion and subsequent 60-min monitoring periods, touch sensitivity was determined and in addition two experimental hyperalgesic models were analyzed. RESULTS: While touch sensitivity was not affected by procaine hydrochloride, development of primary mechanical hyperalgesia was significantly reduced. CONCLUSION: The concentration of procaine hydrochloride used in our experiment elicited peripheral antihyperalgesic effects without central venous side effects. These results can account for the clinical effect of low-dose procaine hydrochloride in pain conditions exhibiting pronounced hyperalgesia.

[Pain treatment in geriatric patients]. / Schmerztherapie in der Geriatrie.

A primary goal of pain treatment in geriatric patients is the maintenance of physical and mental functions. This is a precondition for activity and participation. In patients with chronic pain, multidisciplinary treatment, without excluding invasive procedures, is the most effective approach. The medication ladder, initially suggested by the WHO for cancer pain, provides a guideline for pharmacological treatment. Due to age-dependent alterations in the kinetics and dynamics of pharmaceuticals, the titration of the medication follows the rule "start low-go slow". The same principle holds true for the maintenance or augmentation of physical activity in order to escape from the activity-deconditioning cycle. Training should be based on learning theories, include pain management strategies, and incorporate psychological approaches to facilitate the active participation of the patient in the treatment program. In hospitals and nursing homes, nurses play an important role in defining the need for pain treatment and in supervising the patient in the treatment process. Despite these endeavours, a significant number of patients remain whose pain cannot be controlled sufficiently. Euthanasia on demand for a patient with untreatable pain is not admitted in Germany.

[Monitoring of patient-controlled analgesia by the nursing staff]. / Uberwachung der patientenkontrollierten Analgesie (PCA) durch den Pflegedienst auf Allgemeinstationen.

OBJECTIVE: Patient-controlled analgesia (PCA) is employed successfully on surgical wards. Continuous monitoring is important for the safety of the patient and the efficiency of this form of pain therapy. In the study we evaluated the regularity and completeness of monitoring data which had been collected by the nursing staff on the surgical wards. METHODS: Data on pain intensity, vital signs, and side effects were collected. Additionally, in the case of epidural analgesia, sensory and motor function were tested. In the first four hours after starting the PCA-pump, the nursing staff was instructed to document this data hourly (phase I), followed by a two hour interval until 8 am the next day (phase II). In general, monitoring was continued every four hours up to the discontinuation of the PCA; whereas in our study only forty hours (10 measurements) were included (phase III). Documentation protocols of 637 patients were evaluated and tested for the completeness of the data. RESULTS: In phase I, the data of 128 patients (20%) were complete. In 173 patients (27%) less than 50% of the data were documented. During phase II, only in 98 patients (15%) the data collection was complete. In 237 patients (37%) less than 50% of the measurements were determined. In phase III, in 205 patients (32%) all measurements, and in 104 patients (16%) less than 50% of the measurements were documented. CONCLUSION: Complications during PCA become manifest mainly during the first hours after starting the PCA-pump. Especially during these phases, documentation was found to be quite poor. This underlines the importance of an intense cooperation between acute-pain service and nursing staff with periodical training of the staff.

Budd-Chiari syndrome resulting from intrahepatic IVC compression secondary to blunt hepatic trauma.

Hepatic venous outflow obstruction (Budd-Chiari syndrome)is a rare sequel of abdominal trauma. Three cases of Budd-Chiari syndrome resulting from obstruction to the intrahepatic IVC by liver injury are reported. The CT findings include extrinsic compression of the intrahepatic inferior vena cava (IVC) by intraparenchymal and/or subcapsular hepatic haematoma, non-visualization or narrowing of one or more main hepatic veins with intravenous contrast-enhanced CT, and accumulation of low attenuation ascites. This entity should be distinguished from intraperitoneal bile leak or hemoperitoneum associated with major liver injury with which it could be confused. Decompression of the IVC and hepatic veins by surgical or percutaneous drainage of intrahepatic or subcapsular hematoma was curative in two of the three patients.

Effect of computerized requisition of radiology examinations on the transmission of clinical information.

RATIONALE AND OBJECTIVES: The authors developed a method to evaluate the availability and accuracy of clinical data proffered by clinicians when ordering radiologic examinations with a computer order-entry system. METHODS: Two thousand consecutive clinical indications for a spectrum of pediatric imaging studies were scrutinized for accuracy by means of computerized chart review, verbal communication with clinical attending staff, and reference to surgical and laboratory results. The indications were classified as appropriate, incorrect, misleading, or incomplete. RESULTS: Of the 2,000 stated indications, 1,464 (73%) provided a reasonable, if minimal, amount of clinical information; however, in 376 (19%) cases the diagnosis or proximate indication was incorrect, in 108 (5%) cases the data were incomplete, and in 52 (3%) cases the information was misleading. CONCLUSION: Computer order-entry systems can improve the transmission of clinical information but they allow misinformation to be provided.