Der Schmerz
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Beside the procedures to ensure adequate ventilatory and circulatory support, analgesia, sedation and even anesthesia are essential parts of the preclinical treatment of patients with multiple injuries. The measures for extrication and positioning must be adjusted to minimize pain and excitation. ⋯ The therapy must take into account the special conditions concerning the patient, material and assisting personnel by choosing suitable techniques. The best results can be obtained if all kinds of measures can be administered from the site of the accident on up to the definitive care in the operating room.
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Postoperative pain can intensify the sympathoadrenergic reaction, which is commonly seen after surgery, and thus possibly pave the way for certain complications, such as coronary ischemia, bronchopneumonia, intestinal stasis, thromboembolism, infection, sepsis, and metabolic disturbances. Investigations of cardiovascular, respiratory, gastrointestinal, metabolic, and immunologic function indicate that high-quality pain relief can diminish postoperative organ impairment and failure. Some aspects of the improvements attributed to the quality of analgesia, such as prevention of tachycardia and hypertension, attenuation of hyperglycemia and catabolism, improvement of gastrointestinal motility and cellular immunity cannot be definitely distinguished from the effects of sympathetic blockade due to epidural analgesia with local anesthetics, however. ⋯ Some studies indicate that better analgesia is advantageous for the patient, especially with respect to postoperative complications, hospital stay, long-term well being, and costs. In other clinical trials incorporating more patients, however, this hypothesis had to be rejected. At present, therefore, we cannot state that effective pain relief influences postoperative morbidity and mortality.
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At present, intramuscular application of opioids given on request is the most widespread form of postoperative analgesia. This method is widely recognized as often being inadequate, however. As advanced techniques of pain management, such as patient-controlled analgesia, are not generally available, the question arises as to whether non-opioid analgesics should routinely be used in order to improve this situation. ⋯ Despite these results, it must be borne in mind that most studies have been carried out on patients of ASA groups I and II and that conclusions drawn from the literature are not necessarily representative for the elderly and for patients with organ failure. Alternative substances have received relatively little attention. Of these, the pyrazolone derivative, metamizol, may well prove to be of value for patients in whom the use of NSAIDS is contraindicated or relatively ineffective such as after biliary tract surgery.