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Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
To the Editor:
We read with interest the article by Kampe et al. (1) on the current practice of postoperative epidural analgesia in Germany. As this survey was conducted about 1 year after another German survey that included 446 responding hospitals, a comparison of the data might be of interest (2,3).
The availability of a 24-h acute pain services (APS) in German hospitals was 36% in the 1999 investigation and 41% in the 2000 survey. Kampe et al. emphasized that there is no generally accepted definition of an APS, and this is in accordance with previous investigations (4,5). However, several national guidelines for postoperative pain management provide recommendations and indicate the main components of an APS. The 1999 survey revealed that only half of the German APS fulfilled five basic quality criteria, such as designated personnel for pain treatment, organization of patients’ care at nights and weekends, written protocols for pain management, and regular assessment and documentation of pain scores. These data question the quality of pain services in general, not only in Germany, but also in other countries, since former surveys revealed that quality criteria have not been emphasized up to now. For example, the statement that epidural analgesia (EA) is performed for postoperative pain management does not assume that the quality of care is high. Similarly, continuous epidural infusion or availability of PCEA does not provide any information about quality, e.g., pain scores, patients’ satisfaction, nurses’ view, and the attitude of the surgeons. PCEA was available in about 20% of the departments in 1999 and 2000. However, we should question this impressive percentage in light of the fact that the majority of the departments do not comply with some basic quality criteria of pain management such as regular evaluation of pain scores and designated personnel for pain management (2,3). Is EA also performed on general wards or restricted to intensive or intermediate care units? What about the frequency of adverse effects and severe complications, outcome data, and cost-effectiveness? The information that EA is used in 40.9% of the patients scheduled for cardiothoracic surgery is amazing and unexpected. However, is patients’ care improved by these frequent rates of postoperative EA? Furthermore, peripheral regional techniques (e.g., sciatic, psoas compartment block) increase in popularity, especially in trauma and orthopedic patients. Those techniques are less invasive and do not bear the potentially severe complications as neuroaxial blocks do. So, we have to ask whether a figure of 17.2% of the orthopedic patients receiving EA as reported by Kampe et al. is good or bad news?
The implementation of standards of postoperative pain management, organizational structures (e.g., APS in larger institutions) and quality assurance measures have to be emphasized. Rawal (6) characterized the actual situation of APS in terse words: "good from far, far from good."
Footnotes
Dr. Kampe does not wish to respond.
References
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