Der Schmerz
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From all symptoms in palliative medicine those concerning respiration are most excruciating and most difficult to treat. No other symptom is more dependent on psychosocial circumstances and on the atmosphere around the patient. ⋯ A team present twenty-four hours a day, the training of relatives and friends, the frank dealing with the patient's anxiety of suffocation are the basis of all therapeutic measures. Dyspnea often is the reason for a longer stay in a palliative care unit.
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Within their psychosocial problems, badly ill patients and their families often feel left alone by caregivers, as there are physicians and nurses. It is the caregiver's task to allow patients to communicate all their feelings, not seeking to mollify, or banish them by attempting to cheer up or distract the patient. ⋯ Both of them, caregiver and patient have to find out their primary goals and challenges in the process of dying and come to an agreement. Communicating with a dying patient and being with him in the last period of his life presupposes a deepened communication with oneself and the own hopes and fears.
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We report 8 in-patients with nonmalignant chronic pain (main diagnosis: 7 somatoform pain disorders, 1 eating disorder) and with abuse of opioid therapy, which we have treated within 2 years in an tertiary centre. In all patients the inefficacy of opioids with regard to pain symptomatology could be demonstrated. Because the ICD-10 criteria of addiction cannot be fully applied to patients under opioid therapy because of chronic pain we suggest as criteria the intake of opioids because of positive psychotropic effects, the demand of high dosage of short acting opioids with inefficacy of similar long acting opioids dosage, the uncontrolled raising of dosage with illegal procurement and reluctance of the patient to stop opioid therapy because of proved inefficacy of pain control. ⋯ Therefore a qualified psychotherapeutic evaluation before starting an opioid therapy for nonmalignant pain in order to exclude a somatoform pain disorder or to assess a substance dependency is mandatory. Patients with somatoform pain disorder should be treated with opioids only in clinical studies. A prior or present history of substance abuse given chronic opioid therapy for nonmalignant pain should only be performed in close cooperation of addiction- and pain therapists.
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Randomized Controlled Trial Clinical Trial
[Lack of pre-emptive analgesic effect of low-dose ketamine in postoperative patients. A prospective, randomised double-blind study].
NMDA receptors are assumed to play an important role for neuronal plasticity. In vitro and animal experiments confirmed that NMDA antagonistic drugs can prevent hyperexitability of dorsal root neurons after strong pain stimuli. Clinical data, however, are more or less controversial in this respect. ⋯ Cumulative PCA piritramide consumption after 24 hours was 25.0+/-16.2 mg in the ketamine group and 29.5+/-20.4 mg in the placebo group. Ketamine-specific side effects such as hallucinations or bad dreams were not observed. It is concluded that under the study conditions used, low dose ketamine, contrary to previously reported results [30], does not provide a clinically relevant pre-emptive analgesic effect in postoperative patients.