Schmerztherapie in der Thoraxchirurgie – Regionale und systemische Analgesie bei thorakalen Eingriffen

Zusammenfassung

Eine suffiziente analgetische Therapie bei thorakalen Eingriffen ist für den Patienten mehr als vorteilhaft, da schwerwiegende postoperative pulmonale Komplikationen und ein chronisches Schmerzsyndrom reduziert werden können. In der systematischen Übersicht sollen die evidenz-basierten Strategien in der analgetischen Therapie bei thorakalen Eingriffen auf der Grundlage der aktuellen Studienlage präsentiert werden.

Abstract

Effective, aggressive treatment of pain accompanied with thoracic surgery is important and beneficial for patients, since severe postoperative pulmonary complications and long-term pain will be reduced. In this systematic issue evidence-based strategies in preventing and treating pain after thoracic surgery will be reviewed.

Kernaussagen

• Die optimale Analgesie bei thoraxchirurgischen Eingriffen beschränkt sich nicht auf die Anwendung eines einzigen Verfahrens, sondern ist multimodal.

• Auf der Basis von Grad-I-Studien kann eine Stufe-A-Empfehlung gegeben werden, dass im Rahmen einer multimodalen Analgesie die systemische Applikation von Nicht-Opioiden und Opioiden in Kombination mit einem zentralen regionalen Verfahren die Schmerztherapie bei thoraxchirurgischen Eingriffen verbessert.

• Die analgetische Therapie mit parenteralen Opioiden geht mit einer erhöhten Inzidenz von Komplikationen einher.

• Aufgrund einer Vielzahl von Grad-I-Studien kann die TEA als das Verfahren der ersten Wahl bei thoraxchirurgischen Eingriffen, bei denen eine hohe Schmerzintensität erwartet wird, eingesetzt werden (Evidenzgrad A).

• Mit der TEA sollte bereits vor dem Hautschnitt begonnen werden (Evidenzgrad B) und es wird die kontinuierliche Gabe eines Lokalanästhetikums mit oder ohne Opioid empfohlen (Evidenzgrad A).

• Die TEA hat im Vergleich zur systemischen Analgesie mit parenteralen Opioiden eine geringere Komplikationsrate.

• Über den analgetischen Effekt hinaus besitzt die TEA eine Vielzahl physiologischer Wirkungen auf das Herz-Kreislauf-System, die Lunge und den Gastrointestinaltrakt, die im Kontext des thorakalen Eingriffs und der damit verbundenen neuroendokrinen Stressantwort einen günstigen Einfluss auf die Rehabilitation der Patienten haben.

• Die thorakale paravertebrale Nervenblockade (PVB) erzielt eine unilaterale, effektive Analgesie über mehrere thorakale Segmente bei thoraxchirurgischen Eingriffen.

• Mittlerweile existieren eine Vielzahl von Grad-I-Studien, welche die Empfehlung zulassen, dass die PVB ein Alternativverfahren zur TEA bei thoraxchirurgischen Eingriffen mit erwartet hoher Schmerzintensität ist (Evidenzgrad A).

• Auf der Grundlage von Grad-II-Studien mit geringen Patientenzahlen kann lediglich die Stufe-C-Empfehlung formuliert werden, intrathekale Opioide in der Analgesie thorakaler Eingriffe einzusetzen.

• Vor dem Hintergrund von Grad-II-Studien scheint die perioperative Interkostalblockade im Vergleich zur thorakalen Epiduralanalgesie bei Patienten mit thoraxchirurgischen Eingriffen signifikant unterlegen, stellt aber bei Kontraindikationen für ein zentrales neuroaxiales Verfahren oder Nichtgelingen in der Kombination mit einer systemischen Analgesie eine Alternative dar (Stufe C).

Schlüsselwörter:

Analgesie - thorakale Eingriffe - epidural - Thorakotomie

Key words:

analgesia - thoracic surgery - thoracotomy - epidural

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