Patientenkontrollierte Analgesie zur Behandlung postoperativer Schmerzen :Herausforderungen und Innovationen

Patient-controlled analgesia is a common principle in postoperative pain management. Since its early beginnings in the late seventies of the last century the main principle of patient-controlled analgesia has stayed the same: The patient controls his own pain therapy and determines frequency and time of application. Nevertheless, the methods of application of patient-controlled analgesia have changed a lot. There are many new and competing methods of patient-controlled analgesia. To decide for one or another PCA-method in a given individual postoperative situation is challenging. Each method has its advantages and disadvantages, which are examined in this doctoral thesis. To begin with, this work elaborates on requirements to guaranty an “ideal” postoperative patient-controlled therapy. Afterwards a broad overview of different established and new PCA-methods is given in order to present the advantages and disadvantages of the different methods. As one requirement, the economics of patient-controlled analgesia are further analyzed, as they will become even more important in the future, due to increasing costs and cut budgets. Therefore a cost-analysis of the process with iPATS (iontophoretic patient-activated transdermal system) was conducted as an example of a new and innovative PCA-method. Using qualitative expert interviews with expert staff of the department of Anesthesia and Intensive care of the University Hospital Marburg, a profile of the standards of patient-controlled analgesia was defined. Employing an informal interview technique, corresponding requirements to PCA were deduced, evaluated, and clustered. In a second step, a detailed literature review was conducted regarding the subject: “Patient-controlled Analgesia”. The literature review aimed to identify all the established methods of patient-controlled Analgesia, comprising new and not well established methods. Aspects of the review included a description, mechanisms of action and presenting evidence of effectiveness and side-effects. Altogether 13 different requirements of patient-controlled analgesia were identified. Based on the literature review 3 invasive and 5 non-invasive methods of PCA were found. These were evaluated regarding the identified requirements and presented in a synopsis. As none of the evaluated PCA-methods met all requirements, it was not possible to identify an “ideal” method. Evaluating the economics of patient controlled analgesia was conducted via 22 sequence data entry forms to document the duration of each execution step with the iPATS. As the execution steps were related to the work processes of medical and nursing staff, the costs of relevant work processes could be evaluated via the collected work duration times and the particular personnel expenses. Further on, the overall process costs consists of work process costs and the material costs for the iPATS. The duration of a single working process with the iPATS lasted 32 minutes, with employing medical staff for 30 minutes and nursing staff only 2 minutes. In summary cost staff labour costed 36 € per day of therapy. With material costs of 135 € per day, the overall process costs amounted to 171 € per day of treatment with the iPATS. As a conclusion, a trend towards developing non invasive PCA-methods, e.g. iPATS, was observed. These can help to minimize side-effects that are due to the actual application method. Moreover, they are comfortable to apply by the patient and assist in postoperative mobility and rehabilitation, as no cables or other infrastructure is required. Nevertheless invasive, well established PCA-methods, like the epidural PCA, are still indispensable in certain situations due to their superior analgetic efficacy. Regarding PCA methods it was shown, that innovative PCA methods, e.g. iPATS, reduced labour time and consequently personnel costs regarding postoperative pain management; contrary to intravenous PCA. Yet the overall process costs were even higher with the iPATS, as material costs of the iPATS treatment are comparatively high; counterbalancing the savings of labour time. Besides comfortable and reliable pain therapy and other application related factors, the future challenge for developing new PCA treatments is posed by optimising treatment processes. Such optimisations aim to reduce treatment costs, conditioned upon economisation of hospital routines.