PDF Von der akuten zur chronischen Schmerztherapie: Update Schmerztherapie (German Edition)

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  1. Interdisziplinäre Schmerzambulanz Innenstadt
  2. CURSED HILL DOCUMENT PDF Original - Free E-Book Download
  3. Schlüsselwörter
  4. Postoperative Schmerztherapie: Systemische Analgesie

Project Gutenberg 0 editions. As part of the North Vietnamese triad system of defense, surface-to-air missiles SAMs had become an ever-increasing threat.

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Here come the SAMs. The trick is seeing the launch. You can see the steam. It goes straight up, turns more level, then the booster drops off. If it maintains a relatively stable position, it's coming right for you and you're in trouble. You're eager to make a move but can't.

Interdisziplinäre Schmerzambulanz Innenstadt

If you dodge too fast it will turn and catch you; if you wait too late it will explode near enough to get you. It can't follow that and goes under. Roll out wings level for 15 seconds, then look in your 6 o'clock about 1. It will be there. Probably you'll see mach 2 Atoll air-to-air missile smoke trail first before you see the MiG. But remember that's where the MiG is! Just ask one of the 20 aircrews shot down during Linebacker that never knew they were under attack.

CURSED HILL DOCUMENT PDF Original - Free E-Book Download

The Arab—Israeli conflicts were a series of wars between the country of Israel and its surrounding Arab neighbors. Those that involved dogfighting occurred between and The wars escalated on May 14, , the day Israel declared its sovereignty from Britain. Although usually outnumbered, the Israelis managed to defeat the air forces of Egypt, Jordan and Syria in dogfights, often achieving kill ratios ranging from The Indo-Pakistani War of saw the Indian and Pakistani Air Forces engaged in large-scale aerial combat against each other for the first time since the independence of Pakistan in The war took place during the course of September and saw both air forces conduct defensive and offensive operations over Indian and Pakistani airspace.

The aerial war saw both sides conducting thousands of sorties in a single month. By late , the intensification of the independence movement in erstwhile East Pakistan lead to the Bangladesh Liberation War between India and Pakistan. However, the IAF did not suffer significantly because the leadership had anticipated such a move and precautions were taken.

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Within the first two weeks, the IAF had carried out almost 12, sorties over East Pakistan and also provided close air support to the advancing Indian Army. Those PAF aircraft that survived took refuge at Iranian air bases or in concrete bunkers, refusing to offer a fight. India claimed large gains of territory in West Pakistan although pre-war boundaries were recognised after the war , and the independence of Pakistan's East wing as Bangladesh was confirmed.

The IAF had flown over 16, sorties [70] on both East and West fronts; including sorties by transport aircraft and helicopters. More than 80 percent of the IAF's sorties were close-support and interdiction, and according to neutral assessments about 45 IAF aircraft were lost while, Pakistan lost 75 aircraft. But the imbalance in air losses was explained by the IAF's considerably higher sortie rate, and its emphasis on ground-attack missions. On the ground Pakistan suffered most, with 9, killed and 25, wounded while India lost 3, dead and 12, wounded.

The loss of armoured vehicles was similarly imbalanced. This represented a major defeat for Pakistan. The Falklands War Spanish: Because Britain had no military bases nearby, and few aircraft carriers, the Argentinians did not expect a response from Britain, but on April 5, the British sent carriers sailing to the Falklands with Sea Harrier 'Jump-jets' on board. The Sea Harrier, being initially designed as a ground-attack fighter, was equipped not for dogfighting but for Soviet bomber interception; thus the aircraft had to undergo many modifications, and the pilots needed extra training.

The Argentinians were also handicapped by the long distance from mainland airfields and a lack of refuelling tankers. Neither side was ready for war, but both prepared all through April as diplomacy failed. The fighting started on May 1, and was to become the largest naval and air conflict since World War II. By the end of the war, Argentina lost 20 fighters in dogfights, while Britain only lost one Sea Harrier to ground fire. The Americans supplied late model Sidewinder missiles to the British; this and the analysis of French Mirage combat tactics made the difference.

At early years of the war IRIAF had the superiority see for example Operation Sultan 10 and Operation Morvarid ; however, at the end of the war, Iranian Air Force lost its superiority due to the lack of their US-made aircraft spare parts and outdated equipment, while Iraq was introducing new French and Soviet weapons in its air force. Hinds are stronger and faster, while AH-1Js are more agile.

This pain was used as the threshold value for what constitutes a tolerable degree of pain figure 1. The structural characteristics of the participating hospitals are shown in the eBox.

The response rate for surgical patients was The most common reason for non-participation was poor general health dyspnea, weakness, or severe fatigue ; in very few cases the reason was lacking consent. Of the returned questionnaires, 86 2. Lacking information for secondary items listed in the Table and eTable did not result in exclusion. Data from patients who were pain free without receiving analgesia were not included in this study of pain management Table and eTable.

The demographic data of the remaining patients non-surgical, surgical who had experienced pain or were pain free under analgesia are listed in the Table detailed data are in the eBox. In surgical patients, the diagnosis could not be ascertained. In surgical patients with such a high rating, the mean tolerability level for pain on initial activity was NRS 4 and for maximum pain, NRS 5. The corresponding threshold values for non-surgical patients were NRS 4 for both pain on movement and maximum pain figure 1.

The mean intensity of resting pain among non-surgical patients was significantly higher than in surgical patients, as was the proportion with very severe resting pain etable. Pain on movement was comparable; maximum pain was higher in surgical patients. Patients with malignancies experienced less pain postoperatively than patients without tumors etable.

For some major operations—for example, surgery for urological malignancies on bladder or prostate, but also vascular surgery—the proportion of patients with unacceptable pain levels was lower than for operations with low degrees of tissue trauma—for example, appendicectomy, endoscopic cholecystectomy, or tonsillectomy Figure 2, bottom.

Within the different non-surgical departments the proportions of patients with unacceptable pain were comparable Figure 2, top. These patients had different types of pain that were not necessarily associated with their diagnosis on admission; most self reported pain was arthritic pain or back pain Figure 3. Figure 4 shows this for the example of herniotomy and cardiac pain in patients with coronary heart disease.


Frequency of severe pain different types of pain in surgical patients light olive bar and non-surgical patients dark olive bar. When prompted for the time when their pain was particularly severe, almost half of all patients reported nocturnal peaks. The main trigger for severe pain was getting out of bed and changing position. The subgroup of patients with unacceptable levels of pain showed comparable differences: Of non-surgical patients with or without malignancies, only half felt they had received effective treatment eTable.

Patients with malignancies called for assistance more often if they had pain; this was extremely rarely the case for patients without malignancies on non-surgical wards. With regard to the frequency of calls for assistance, notable differences existed between hospitals, with a range of 3. Non-surgical patients often had to wait longer for a reaction from doctors or nursing staff than surgical patients, even if they had requested help eTable. Pharmacotherapy with highly potent opioids was given more rarely in non-surgical wards than in surgical wards, and most often to patients with malignancies eTable.

In spite of all advances in these presumably positively pre-selected hospitals—participation was voluntary—the need for optimizing pain management could not be more obvious. They awarded far poorer marks for their pain management than for the work done by doctors and nursing staff eTable. Another objective of this study was to define threshold values in Germany for an acceptable level of pain at rest, pain on movement, and maximum pain. The literature tends to classify these into mild, moderate, and severe 13 , 15 , In order to conclude for a patient whether they are experiencing acceptable or unacceptable pain levels, details for all three types of pain are required.

The following statements regarding acceptable pain thus reflect how many patients in a hospital mentioned a level for all forms of pain that is acceptable for the majority of patients thus affected 9 , The authors chose school grades as the measure to assess pain therapy; this was largely consistent with published data on pain tolerability 15 , 19 , 20 , Levels of pain that still incurred a decent school mark for pain therapy reached a mean value of NRS 3 for resting pain, NRS 4 for pain on movement, and NRS 5 for maximum pain.

Comparable values applied to non-surgical patients; maximum pain occurred almost always on movement. This may explain the lack of a difference between pain on movement and maximum pain. In future, these pain scores can be used as empirically confirmed thresholds to assess the quality of pain therapy.

Postoperative Schmerztherapie: Systemische Analgesie

They have been adopted as the basis of the certification of hospitals by medical societies, which has been running for a few years now This may come as a surprise in view of the fact that research into the subject now dates back several decades 1 , 4 , 7 , 10 , 12 , 16 , 18 , e1 , e4 , e13 , e For some procedures Figure 2 , the proportion of unacceptable pain is even higher than in older studies 15 , e6. In our study cohort, this included patients who had surgical procedures that incurred a rather lower degree of tissue trauma—such as appendicectomies, endoscopic cholecystectomies, metal removal, or strumectomies Figure 2.

A positive development is the fact that nowadays, patients with malignancies and patients after major surgery receive better pain management than in the past 15 , 14 , e One explanation is probably that after major surgery, many hospitals nowadays use highly effective procedures—such as analgesia administered through a peridural catheter. Such complex analgesic methods are, however, not indicated in most patients who undergo small and medium procedures.

However, especially for these particularly common procedures, hardly any interdisciplinary agreements exist regarding pain management or treatment algorithms. Pain management in wards for internal medicine, neurological wards, and orthopedic-rehabilitative wards is apparently even poorer eTable. This study has shown for the first time that the majority of patients in such wards experience pain of different origin and at levels of moderate to high intensity. The reported frequency of severe back pain or joint pain in our study is not surprising in view of its high incidence Underprovision of pain care may be explained with the fact that many people experience pain that is not associated with the current diagnosis for which they are receiving treatment.

But even angina pectoris, painful polyneuropathies, or abdominal syndromes Figure 2 —lead symptoms of an underlying internal disorder—are often not treated to a sufficient degree. Patients register this as underprovision of pain management too.

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In patients without malignancies, medical professionals significantly more often react late to reported pain. The fact that patients with treatment resistant angina often do not receive adequate pain management has been common knowledge for decades, but seems to be the rule even now e24 , e After the experiences in the surgical setting, the first crucial step in non-surgical departments would be to guarantee special treatment for patients with severe or treatment resistant pain by means of an acute pain service 4 , 7 , 10 — 12 , 16 , 18 , 19 , e7 , e10 , e Further, even in non-surgical wards, more prophylactic measures should be delivered for the most common situations that trigger pain—such as mobilization, positioning at rest, and physical therapy.

By contrast, this study shows that in some hospitals, pain can be treated adequately in most surgical and non-surgical patients Figure 4. Effective pain management in hospitals thus seems possible, especially since data relating to nausea and constipation not shown here imply that effective therapy is not synonymous with more serious adverse effects. Underprovision of pain management might therefore presumably be avoided if we successfully improved the knowledge and motivation of the professional groups involved in pain management, as well as streamlining organizational structures 1 , 7 , 11 — 13 , 17 , 20 , Including nursing staff in any such measures, setting up acute pain clinics, and devising benchmark projects may well be the decisive steps 1 , 7 , 9 , 12 , 18 , 19 , e1 , e8 , e12 , e Patients do not expect the total absence of pain but adequate pain relief, rapid help when required, and administration of effective medication.