Praxisorientierte Schmerztherapie in der Dermatologie

Perioperative pain management in dermatosurgery - current practice in Germany: Data analysis of a Germany-wide online survey among dermatosurgeons

BACKGROUND

Adequate pain management should be part of the standard of care in surgical procedures. However, there is a paucity of data in the field of dermatosurgery. In a standardized online survey among dermatosurgeons working in Germany, the current practice of perioperative pain management was investigated.

METHODS

Members of the German Society for Dermatosurgery (DGDC) and heads of dermatosurgical departments were asked to participate. Questions were related to practical implementation of perioperative pain management, pain documentation and personal sources of information on the topic.

RESULTS

116 questionnaires were analyzed. While prophylactic analgesia is rarely used, the vast majority (86%) reported the use of postoperative on-demand medication. The majority of surgeons do not have a fixed regimen. Mostly NSAIDs and occasionally low potency opioids are used. Pain is documented by the majority (59.1%) as free text. Personal experience (69%) and in-house standards (51%) are the most important factors in pain management. The use of guidelines (25%) plays a minor role.

CONCLUSIONS

Perioperative pain management in dermatosurgery is strongly influenced by personal experience and may vary depending on the surgery performed. Consensus-based standardized recommendations are lacking. For adequate perioperative analgesia, the development of demand-oriented pain concepts is desirable. This requires prospective studies that address the specific patient population and surgical procedures in dermatology.

Perioperative Schmerztherapie bei dermatochirurgischen Eingriffen - aktuelle Praxis in Deutschland: Datenauswertung einer deutschlandweiten Online-Umfrage unter Dermatochirurgen

Hintergrund

Adäquate Schmerztherapie sollte bei operativen Eingriffen zum regelhaften Behandlungskonzept gehören. In der Dermatochirurgie gibt es hierzu jedoch kaum Daten, wie am besten vorgegangen werden sollte. In einer standardisierten Online‐Umfrage unter in Deutschland tätigen Dermatochirurgen wurde die gängige Praxis der perioperativen Schmerztherapie bei dermotochirurgischen Eingriffen erhoben.

Methodik

Mitglieder der Deutschen Gesellschaft für Dermatochirurgie (DGDC) sowie Leiter dermatochirurgischer Abteilungen wurden um Teilnahme gebeten. Fragen bezogen sich auf praktische Umsetzung des perioperativen Schmerzmanagements, Schmerzdokumentation und persönliche Informationsquellen zum Themenkomplex.

Ergebnisse

116 Fragebögen konnten ausgewertet werden. Während prophylaktische Analgesie kaum angewandt wird, berichtet die überwiegende Mehrzahl (86%), eine postoperative Bedarfsmedikation einzusetzen. Feste Therapieregime existieren mehrheitlich nicht. Zumeist werden NSAR und gelegentlich niedrigpotente Opioide verwendet. Schmerzen werden von der Mehrzahl (59,1%) als Freitext dokumentiert. Die größte Bedeutung beim schmerztherapeutischen Management besitzen persönliche Erfahrungswerte (69%) und hausinterne Standards (51%). Die Nutzung von Leitlinien (25%) spielt eine untergeordnete Rolle.

Schlussfolgerungen

Perioperatives Schmerzmanagement in der Dermatochirurgie ist stark von persönlichen Erfahrungswerten geprägt und kann je nach durchgeführtem Eingriff unterschiedlich ausfallen. Konsensbasierte standardisierte Empfehlungen hierfür fehlen. Für eine suffiziente perioperative Analgesie ist die Entwicklung bedarfsorientierter Schmerzkonzepte wünschenswert. Dafür bedarf es prospektiver Studien, die das spezielle Patientenklientel und operative Vorgehen in der Dermatologie berücksichtigen.

Herpes-zoster-Update – was gibt es Neues?

Shingles are triggered by the reactivation of an infection with the varicella zoster virus (VZV) and are characterized by specific vesicular skin lesions. Mostly, elderly patients are affected. Depending on the affected dermatome, some serious complications can be observed. The introduction of a vaccine against shingles in Germany offers a great potential for reducing the frequency and severity of this disease. There are both a live vaccine, which is no longer recommended, and an inactivated vaccine, which, however, is still not sufficiently recommended to the authorized patient groups and is also only available to a limited extent due to delivery bottlenecks. HZ neuralgia is a serious complication of the disease that requires rapid and effective therapy and should be handed over to experienced pain therapists rather too early than too late. Unfortunately, in everyday clinical practice only a few people are familiar with VZV vasculopathy, which is associated with a significantly increased risk of cerebral insults.

[Current aspects of pain management during and after dermatologic surgery]

The project "Pain-free Hospital" was the first attempt to improve the level of postoperative care by standardizing pain therapy standards (concepts) in the individual surgical disciplines. Dermatosurgery is no exception. In addition to drug therapy, it is also important to consider biopsychosocial aspects of the symptom pain, as this is the only way to prevent chronification of acute pain in the further course of a disease. Drug therapy should not only be adapted to the classic WHO system (only considering pain intensity), but should also address aspects of pain quality. In this article, we discuss these aspects in more detail and present our treatment concept for dermatosurgery.

[Therapy of herpes zoster and postherpetic neuralgia]

Herpes zoster (HZ) is caused by the reactivation of varicella zoster virus. The incidence of herpes zoster and associated problems increases with age. With a life-long prevalence of 30%, every second 85-year-old person experiences HZ once in his lifetime. Three therapeutic columns are based on antiviral, topical and analgetic therapies. An extreme handicap is acute and persistent pain which can develop into postherpetic neuralgia (PHN). Those pain symptoms are predominantly neuropathic. The management of acute and chronic manifestation of pain may be challenging. HZ vaccination represents a substantial improvement in terms of prevention of herpes zoster and reduction of long-term complications, such as PHN. The permanent vaccination commission of the Robert Koch Institute recommends vaccination with dead virus for all persons over the age of 60 years. Risk groups like immunosuppressed patients are advised to be vaccinated starting at the age of 50 years.