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Background Standard protocols or algorithms are considered essential to ensure adequate analgesia. Germany has widely adopted postoperative protocols for pain management including oral opioids for rescue medication, but the effectiveness of such protocols has only been evaluated longitudinally in a before and after setting. The aim of this cohort analysis was to compare the effectiveness of an oral opioid rescue medication algorithm for postoperative management of pain to the gold standard of patient-controlled intravenous analgesia (PCIA). Material and methods This study compared cohorts of patients of two prospective observational studies undergoing elective total hip replacement. After surgery patients received piritramide to achieve a pain score of ≤3 on the numeric rating scale (NRS 0–10). A protocol was started consisting of oral long-acting oxycodone and ibuprofen (basic analgesia). Cohort 1 (C1, 126 patients) additionally received an oral opioid rescue medication (hydromorphone) when reporting pain >3 on the NRS. Cohort 2 (C2, 88 patients) was provided with an opioid by PCIA (piritramide) for opioid rescue medication. Primary endpoints were pain intensity at rest, during movement, and maximum pain intensity within the first 24 h postoperative. Secondary endpoints were opioid consumption, functional outcome and patient satisfaction with pain management. Results Pain during movement and maximum pain intensity were higher in C1 compared to C2: pain on movement median 1st–3rd quartile: 6 (3.75–8) vs. 5 (3–7), p = 0.023; maximum pain intensity: 7 (5–9) vs. 5 (3–8), p = 0.008. There were no differences in pain intensity at rest or between women and men in either group. The mean opioid consumption in all patients (combined PACU, baseline, and rescue medication; mean ± SD mg ME) was 126.6 ± 51.8 mg oral ME (median 120 (87.47–154.25) mg ME). Total opioid consumption was lower in C1 than C2 (117 ± 46 mg vs 140 ± 56 mg, p = 0.002) due to differences in rescue opioids (C1: 57 ± 37 mg ME, C2: 73 ± 43 mg ME, p = 0.006, Z = −2.730). Basic analgesia opioid use was comparable (C1: 54 ± 31 mg ME, C2: 60 ± 36 mg ME, p = 0.288, Z = −1.063). There were no differences in respect to the addition of non-opioids and reported quality of mobilization, sleep, frequency of nausea and vomiting, or general satisfaction with pain management. Conclusion In this study PCIA provided a better reduction of pain intensity, when compared to a standardized protocol with oral opioid rescue medication. This effect was associated with increased opioid consumption. There were no differences in frequencies of opioid side effects. This study was a retrospective analysis of two cohorts of a major project. As with all retrospective studies, our analysis has several limitations to consider. Data can only represent the observation of clinical practice. It cannot reflect the quality of a statement of a randomized controlled trial. Observational studies do not permit conclusions on causal relationships.

Zusammenfassung Obwohl Schmerzdienste als Versorgungsmodell etabliert sind, besteht eine erhebliche Heterogenit��t bez��glich Organisation, personeller Besetzung und Qualifikation sowie zum Behandlungsspektrum. Mit der vorliegenden Empfehlung definiert die Deutsche Gesellschaft f��r An��sthesiologie und Intensivmedizin personelle und organisatorische Voraussetzungen f��r Schmerzdienste, um in Erg��nzung zur allgemeinen Schmerzbehandlung der prim��r bettenf��hrenden Abteilungen eine qualitativ hochwertige, spezialisierte, innerklinische schmerzmedizinische Versorgung in allen Versorgungseinheiten des Krankenhauses zu gew��hrleisten. Schmerzdienste sollen die Betreuung spezieller an��sthesiologischer Analgesieverfahren sowie die Konsil- und Liaison-Betreuung fachlich und organisatorisch in einer Dienststruktur abdecken. Sie sollen 24 h/7 Tage die Woche ��ber einen einheitlichen Kontakt erreichbar sein. Der ��rztliche Leiter soll die Zusatzbezeichnung Spezielle Schmerztherapie innehaben, zus��tzlichm��glichst eine Weiterbildung in psychosomatischer Grundversorgung. Weitere ��rztliche Mitarbeiter sollen den Facharztstandard erf��llen, nicht��rztliche Mitarbeiter schmerzspezifische Weiterbildungen nachweisen. Als zeitliche Richtwerte f��r die Personalkalkulation wurden Mindestzeiten definiert f��r die Betreuung spezieller Analgesieverfahren (Erstkontakt 20 min, Folgekontakte 10min) und f��r Konsil- und Liaison-Betreuung (Erstkontakt 45 min, Folgekontakt 20 min), zuz��glichWege- und R��stzeiten, Schulung und Qualit��tssicherung.Neben der Definition der r��umlichen Ressourcen und Ausstattung wird betont, dass die Sicherstellung der spezialisierten Versorgung fach- und abteilungs��bergeordnet eine hohe Priorit��t hat und ein ausreichendes und planbares eigenes Budget zur Verf��gung stehen soll. Klinikinterne schriftliche Vereinbarungen zwischen den beteiligten Fachabteilungen werden zur Sicherung der Versorgungsqualit��t empfohlen, ebenso eine f��r alle Beteiligten transparente Dokumentation und die regelm����ige Erfassung der Ergebnisqualit��t aus Patientensicht. Schl��sselw��rter Akutschmerzdienst �� Schmerzmanagement �� Konsildienst �� Regionalan��sthesie �� Analgesieverfahren

BACKGROUND Dipyrone (metamizole) is widely used for perioperative pain management in countries where it is marketed; however, uncertainty exists concerning the safe use of this drug, specifically considering the rare adverse event of an agranulocytosis. METHODS As evidence from published studies was lacking, an expert panel developed recommendations for the perioperative use of dipyrone. After a formal, structured consensus process, the recommendations were approved by the involved medical societies. RESULTS The panel agreed that blood cell counts shall not be standard for short-term perioperative use in patients unless they are at risk for neutropenia. The medical staff shall be aware of the symptoms and course of action when agranulocytosis is suspected. Patients shall be informed about the risks and benefits of dipyrone and about potential alternatives. The expert group concluded that dipyrone has a relatively positive risk-benefit ratio compared to other nonopioid analgesics. The group strongly recommended educating patients about the symptoms of agranulocytosis if they have received dipyrone over several days and/or treatment is to be continued after discharge, because agranulocytosis can occur several days after discontinuation of metamizole. Further recommendations refer to the information of the physician taking over the patient's care after discharge and the avoidance of re-exposure in patients having previously suffered from dipyrone-induced agranulocytosis. CONCLUSION The group's recommendations shall be communicated in order to raise medical staff's and patients' awareness of the appropriate use of dipyrone in the perioperative period.

BACKGROUND Dipyrone (metamizole) is a non-opioid analgesic commonly used in Germany, which can, in very rare cases, cause life-threatening agranulocytosis. The prescribing information calls for regular monitoring of the differential blood count in cases of long-term treatment. However, there is uncertainty about how this testing should be handled in practice. OBJECTIVES Which recommendations can be derived from the published literature for evaluating blood cell counts during treatment with metamizole and which other options for monitoring exist? METHODS Data from recent epidemiological studies, reviews, and spontaneously reported cases were evaluated. RESULTS Agranulocytosis can emerge at highly variable intervals ranging from the first day of metamizole treatment to months after treatment has begun. As a result, there is no conclusive, evidence-based recommendation for the time intervals at which blood cell counts should be tested. Therefore, the onset of clinical symptoms should be used as trigger for monitoring blood cell counts to enable early diagnosis and avoid agranulocytosis-related complications. In addition to general symptoms like fever, sore throat, fatigue, and muscle pain, mucosal ulcerations, severe angina, and systemic infections leading to sepsis are typical of agranulocytosis. CONCLUSIONS Providing patients and medical staff with better information about early symptoms of agranulocytosis could be a sensible way to prevent complications. Any suspicion of agranulocytosis should immediately lead to a differential blood count and to the withdrawal of all drugs possibly associated with agranulocytosis. Patients should be monitored and treated according to the severity of their symptoms.