Anästhesie in der extrathorakalen Gefäßchirurgie – Teil 1: Präoperative Therapieoptimierung

Zusammenfassung

Gefäßchirurgische Patienten haben aufgrund von häufig vorliegenden Komorbiditäten ein deutlich erhöhtes perioperatives Risiko. Eine präoperative Therapieoptimierung mit dem Versuch, vermeidbare Komplikationen zu reduzieren, ist oberstes Ziel einer sorgfältigen interdisziplinären Risikoevaluation. Die typischen kardiovaskulären Risikofaktoren wie ein arterieller Hypertonus, ein Diabetes mellitus, eine Herzinsuffizienz etc. müssen identifiziert und präoperativ medikamentös eingestellt werden.

Abstract

Vascular surgical patients have an increased perioperative risk for cardiovascular complications because of high incidence of cardiovascular risk factors. An optimization of the preoperative therapy is able to reduce the preventable cardiac complications. Cardiovascular risk factors such as high blood pressure, diabetes mellitus, heart failure have to be identified and treated.

Kernaussagen

• Die perioperative Behandlung gefäßchirurgischer Patienten kann anästhesiologisch eine Herausforderung sein. Aufgrund häufig bestehender Komorbiditäten sind die meisten Patienten als Risikopatienten einzustufen.

• Die präoperative Evaluation sollte interdisziplinär zur Abschätzung des perioperativen Risiko in ausreichendem zeitlichen Abstand zum operativen Eingriff erfolgen.

• Die perioperativ fortgesetzte Dauermedikation von Betarezeptorenblockern, Statinen und Thrombozytenaggregationshemmern stellt einen wesentlichen Faktor zur Reduktion des perioperativen Risikos dar.

• Ob neueste Studienergebnisse zur perioperativen Betarezeptorenblockade zu Änderungen der aktuellen Empfehlungen führen, bleibt abzuwarten.

Schlüsselwörter:

gefäßchirurgische Eingriffe - präoperative Risikoevaluation - kardiovaskuläre Risikofaktoren - perioperativeBetarezeptorenblockade - Statine

Key words:

vascular surgery procedures - preoperative risk evaluation - cardiovascular riskfactors - perioperative beta-adrenergic blockade - statins

• Literaturverzeichnis

• 1 Diehm C, Schuster A, Allenberg H et al. High prevalence of peripheral arterial disease and comorbidity in 6,880 primary care patients: cross sectional study. Atherosclerosis 2004; 172: 95-105
• 2 Nowak T, Weisflog E, Böhner H et al. Perioperative Medikation bei arteriellen Operationen. Was ansetzen und was absetzen?. Gefässchirurgie 2011; 16: 324-329
• 3 Boersma E, Poldermans D, Bax JJ et al. Predictors of cardiac events after major vascular surgery: role of clinical characteristics, dobutamine echocardiography, and beta–blocker therapy. JAMA 2001; 285: 1865-1873
• 4 Abraham N, Lemech L, Sandroussi C et al. A prospective study of subclinical myocardial damage in endovascular versus open repair of infrarenal abdominal aortic aneurysms. J Vasc Surg 2005; 41: 377-380
• 5 Debus ES, Kruska P, Ivoghli A, Castan J, Kerner T. Fast Track in der Gefäßchirurgie. Chirurg 2009; 80: 711-718
• 6 Schumacher J. Anästhesie bei Operationen an der Aorta. Anästhesiol Intensivmed Notfallmed Schmerzther 2002; 37: 559-581
• 7 Markworth F, Debus ES, Blankenberg S. Elektive nicht kardiochirurgische Operationen bei Patienten mit kardialer Grunderkrankung. Gefässchirurgie 2013; 18: 21-27
• 8 Libby P. Inflammation in atherosclerosis. Arterioscler Thromb Vasc Biol 2012; 32: 2045-2051
• 9 Stadlbauer TH, Eckstein HH. Kardiovaskuläres Risiko bei offenen und endovaskulären Eingriffen. Gefässchirurgie 2013; 18: 250-252
• 10 Naughton C, Feneck RO. The impact of age on 6–month survival in patients with cardiovascular risk factors undergoing elective non–cardiac surgery. Int J Clin Pract 2007; 61: 768-776
• 11 Rerkasem K, Rothwell PM. Local versus general anaesthesia for carotid endarterectomy. Cochrane Database Syst Rev CD 000126 2008; 8
• 12 Meves SH, Diehm C, Berger K et al. Peripheral arterial disease as an independent predictor for excess stroke morbidity and mortality in primary–care patients: 5–year results of the getABI study. Cerebrovasc Dis 2010; 29: 546-554
• 13 Willigendael EM, Teijink JA, Bartelink ML et al. Influence of smoking on incidence and prevalence of peripheral arterial disease. J Vasc Surg 2004; 40: 1158-1165
• 14 Herold G und Mitarbeiter. Innere Medizin 2010;
• 15 Larsen R. Anästhesie und Intensivmedizin in Herz–, Thorax– und Gefäßchirurgie. Auflage. Heidelberg: Springer Medizin Verlag; 2005. 6.
• 16 Rath T, Kerner T. Anästhesiologische Aspekte in der Gefäßmedizin. Gefäßchirurgie 2013; 18: 28-34
• 17 Fleischmann KE, Beckmann JA, Buller CE et al. ACC/AHA focused update on perioperative beta blockade. J Am Coll Cardiol 2009; 54: 2102-2128
• 18 Fleisher LA, Beckman JA, Brown KA et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. Anesth Analg 2008; 106: 685-712
• 19 Fleisher LA, Beckman JA, Brown KA et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. Circulation 2007; 116: 1971-1996
• 20 Poldermans D, Bax JJ, Boersma E et al. Guidelines for pre–operative cardiac risk assessment and perioperative cardiac management in non–cardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non–cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anesthesiology (ESA). Eur Heart J 2009; 30: 2769-2812
• 21 Golecki N, Kehl F. Anästhesie in der Gefäßchirurgie. Anästhesie für große gefäßchirurgische Eingriffe. Anästhesiol Intensivmed Notfallmed Schmerzther 2009; 2: 118-124
• 22 Präoperative Evaluation erwachsener Patienten vor elektiven, nicht kardiochirurgischen Eingriffen. Anästhesiologie und Intensivmedizin 2010; 11: 788-796
• 23 Kelm M, Osterhues H, Hennerici MG et al. Kommentar zu den ESC Guidelines for Pre–Operative Cardiac Risk Assessment and Perioperative Cardiac Management in Non–Cardiac Surgery. Der Kardiologe 2010; 5: 375-382
• 24 Mangano DT, Goldman L. Preoperative assessment of patients with known or suspected coronary disease. N Engl J Med 1995; 333: 1750-1756
• 25 Eckstein HH, Kühnl A, Dörfler A et al. Diagnostik, Therapie und Nachsorge der extrakraniellen Carotisstenose. Dtsch Ärztebl 2013; 110: 468-476
• 26 King 3rd SB, Smith Jr. SC, Hirshfeld J et al. Focused update of the ACC/AHA/SCAI 2005 Guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice guidelines. Circulation 2008; 117: 261-295
• 27 Kozek-Langenecker SA, Duris M, Rottmann B. Antikoagulantien und deren Reversierung. Anästh Intensivmed 2007; 48: 153-153
• 28 Sorensen LT, Hemmingsen U, Kallehave F et al. Risk factors for tissue and wound complications in gastrointestinal surgery. Ann Surg 2005; 241: 654-658
• 29 Subramaniam B, Panzica PJ, Novack V et al. Continuous Perioperative Insulin Infusion Decreases Major Cardiovascular Events in Patients Undergoing Vascular Surgery. Anesthesiology 2009; 110: 977-977
• 30 van den Berghe G, Wouters P, Weekers F et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001; 345: 1359-1367
• 31 Finfer S, Chittock DR, Su SY et al. The NICE–SUGAR Study Investigators: Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009; 360: 1283-1297
• 32 Griesdale DE, de Souza RJ, van Dam RM et al. Intensive insulin therapy and mortality among critically ill patients: a meta analysis including NICE–SUGAR study data. CMAJ 2009; 180: 821-827
• 33 Adler GK, Bonyhay I, Failing H et al. Antecedent hypoglycemia impairs autonomic cardiovascular function: implications for rigorous glycemic control. Diabetes 2009; 58: 360-366
• 34 American Diabetes Association. Standards of medical care in diabetes. Diabetes Care 2005; 28: 4-36
• 35 Willam C. Kontrastmittel induzierte Nephropathie: Inzidenz, Bedeutung und Behandlung. Gefässchirurgie 2011; 16: 454-461
• 36 Amini M, Salarifar M, Amirbaigloo A et al. N–acetylcysteine does not prevent contrast–induced nephropathy after cardiac catheterization in patients with diabetes mellitus and chronic kidney disease: a randomized clinical trial. Trials 2009; 10: 45-45
• 37 Barrett BJ, Parfrey PS. Clinical practice. Preventing nephropathy induced by contrast medium. N Engl J Med 2006; 354: 379-386
• 38 Kshirsagar AV, Poole C, Mottl A et al. N–acetylcysteine for the prevention of radiocontrast induced nephropathy: a meta–analysis of prospective controlled trials. J Am Soc Nephrol 2004; 15: 761-769
• 39 Murphy SW, Barrett BJ, Parfrey PS. Contrast nephropathy. J Am Soc Nephrol 2000; 11: 177-182
• 40 Parfrey PS, Griffiths SM, Barrett BJ et al. Contrast material–induced renal failure in patients with diabetes mellitus, renal insufficiency, or both. A prospective controlled study. N Engl J Med 1989; 320: 143-149
• 41 Rich MW, Crecelius CA. Incidence, risk factors, and clinical course of acute renal insufficiency after cardial catheterization in patients 70 years of age or older. A prospective study. Arch Intern Med 1990; 150: 1237-1242
• 42 Brezis M, Rosen S. Hypoxia of the renal medulla – its implications for disease. N Engl J Med 1995; 332: 647-655
• 43 Stacul F, Adam A, Becker CR et al. Strategies to reduce the risk of contrast–induced nephropathy. Am J Cardiol 2006; 98
• 44 Chen SL, Zhang J, Yei F et al. Clinical outcomes of contrast–induced nephropathy in patients undergoing percutaneous coronary intervention: a prospective, multicenter, randomized study to analyze the effect of hydration and acetylcysteine. Int J Cardiol 2008; 126: 407-413
• 45 Mehran R, Aymong ED, Nikolsky E et al. A simple risk score for prediction of contrast–induced nephropathy after percutaneous coronary intervention: development and initial validation. J Am Coll Cardiol 2004; 44: 1393-1399
• 46 Davidson C, Stacul F, Mccullough PA et al. Contrast medium use. Am J Cardiol 2006; 98: 42-58
• 47 Heinrich MC, Haberle L, Muller V et al. Nephrotoxicity of iso–osmolar iodixanol compared with non–ionic low–osmolar contrast media: metaanalysis of randomized controlled trials. Radiology 2009; 250: 68-86
• 48 Reed M, Meier P, Tamhane UU et al. The relative renal safety of iodixanol compared with low–osmolar contrast media: a meta–analysis of randomized controlled trials. Catheter Cardiovasc Interv 2009; 2: 645-654
• 49 Tepel M, van der Giet M, Schwarzfeld C et al. Prevention of radiographic–contrast–agent–induced reductions in renal function by acetylcysteine. N Engl J Med 2000; 343: 180-184
• 50 Kitzler TM, Jaberi A, Sendlhofer G et al. Efficacy of vitamin E and N–acetylcysteine in the prevention of contrast induced kidney injury in patients with chronic kidney disease: a double blind, randomized controlled trial. Wien Klin Wochenschr 2012; 124: 312-319
• 51 Toso A, Maioli M, Leoncini M et al. Usefullness of atorvastatin (80 mg) in prevention of contrast–induced nephropathy in patients with chronic renal disease. Am J Cardiol 2009; 105: 288-292
• 52 Sadat U. Contrast–induced nephropathy: do statins offer protection?. Curr Opin Cardiol 2011; 26: 334-337
• 53 Frank H, Werner D, Lorusso V et al. Simultaneous hemodialysis during coronary angiography fails to prevent radiocontrast–induced nephropathy in chronic renal failure. Clin Nephrol 2003; 60: 176-182
• 54 Westenfeld R, Rump LC. Kontrastmittel–induzierte Nephropathie. Dtsch Med Wschr 2013; 138: 71-78
• 55 Goergen SK, Rumbold G, Compton G et al. Systematic review of current guidelines, and their evidence base, on risk of lactic acidosis after administrationof contrast medium for patients receiving metformin. Radiology 2010; 254: 261-269
• 56 Naghavi M, Libby P, Falke E et al. From vulnerable plaque to vulnerable patient: a call for new definitions and risk assessment strategies: Part I. Circulation 2003; 108: 1662-1672
• 57 Poldermans D, Hoeks SE, Feringa HH. Preoperative risk assessment and risk reduction before surgery. Am j Coll Cardiol 2008; 51: 1913-1924
• 58 Monahan TS, Shrikhande GV, Pomposelli FB et al. Preoperative cardiac evaluation does not improve or predict perioperative or late survival in asymptomatic diabetic patients undergoing elective infrainguinal arterial reconstruction. J Vasc Surg 2005; 41: 38-45
• 59 Hoeks SE, Scholte OP, Reimer WJ et al. Increase of 1–year mortality after perioperative beta–blocker withdrawal in endovascular and vascular surgery patients. Eur J Vasc Endovasc Surg 2007; 33: 13-19
• 60 Mangano DT, Layug EL, Wallace A et al. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med 1996; 333: 1713-1720
• 61 Lindauer PK, Pekow P, Wang K et al. Perioperative beta–blockade therapy and mortality after major noncardiac surgery. N Engl J Med 2005; 353: 349-361
• 62 Poldermans D, Boersma E, Bax JJ et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high–risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiographic Study Group. N Engl J Med 1999; 341: 1789-1794
• 63 Brady AR, Gibbs JS, Greenhalgh RM et al. Perioperative beta–blockade (POBBLE) for patients undergoing infrarenal vascular surgery: results of a randomized double–blind controlled trial. J Vasc Surg 2005; 41: 602-609
• 64 Juul AB, Wetterslev J, Gluud C et al. Effect of perioperative beta–blockade in patients with diabetes undergoing major non–cardiac surgery: randomized placebo controlled blinded multicentre trial. BMJ 2006; 332: 1482-1482
• 65 Yang H, Raymer K, Butler R et al. The effects of perioperative beta–blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial. Am Heart J 2006; 152: 983-990
• 66 Devereaux PJ, Yang H, Yusuf S et al. Effects of extended–release metoprolol succinate in patients undergoing non–cardiac surgery (POISE trial): a randomised controlled trial. Lancet 2008; 371: 1839-1847
• 67 Sipahi I, Tuzcu EM, Wolski KE et al. Beta–Blockers and progression of coronary atherosclerosis: pooled analysis of 4 intravascular ultrasonography trials. Ann Intern Med 2007; 147: 10-18
• 68 Hawkes N. Use of β–blockers during surgery may have caused 10 000 deaths in the UK. BMJ 2013; 347
• 69 Bouri S, Shun-Shin MJ, Cole GD et al. Meta–analysis of secure randomised controlled trials of β–blockade to prevent perioperative death in non–cardiac surgery. Heart Published online first doi: DOI: 10.1136/heartjnl-2013-304262. 2013;
• 70 Schouten O, Boersma E, Hoeks SE et al. Fluvastatin and preoperative events in patients undergoing vascular surgery. N Engl J Med 2009; 361: 980-989
• 71 Williams TM, Harken AH. Statins for surgical patients. Ann Surg 2008; 247: 30-37
• 72 Poldermans D, Bax JJ, Kertai MD et al. Statins are associated with reduced incidence of perioperative mortality in patients undergoing major nooncardiac vascular surgery. Circulation 2003; 107: 1848-1851
• 73 Kertai MD, Boersma E, Westerhout CM et al. A combination of statins and beta–blockers is independently associated with a reduction in the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery. Eur J Vasc Endovasc Surg 2004; 28: 343-352
• 74 Durazzo AE, Machado FS, Ikeoka DT et al. Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized trial. J Vasc Surg 2004; 39: 967-975
• 75 Lindauer PK, Pekow P, Wang K et al. Lipidlowering therapy and in–hospital mortality after major noncardiac surgery. JAMA 2004; 291: 2092-2099
• 76 O'Neill-Callahan K, Katsimaglis G, Tepper MR et al. Statins decrease perioperative cardiac complications in patients undergoing noncardiac vascular surgery: the statins for Risk Reduction in Surgery (StaRRS) study. J Am Coll Cardiol 2005; 45: 366-342
• 77 Le Manach Y, Godet G, Coriat P et al. The impact of postoperative discontinuation or continuation of chronic statin therapy on cardiac outcome after major vasculars surgery. Anest Analg 2007; 104: 1322-1324
• 78 Burger W, Chemnitius JM, Kneissl GD et al. Low dose aspirin for secondary cardiovascular prevention: cardivascular risks after ist perioperative withdrawal versus bleeding risks with ist continuation: review and meta–analysis. J Intern Med 2005; 257: 399-414
• 79 Merrit JC, Bhatt DL. The efficacy and safety of perioperative antiplatelet therapy. J Thromb Thrombolysis 2004; 17: 21-27
• 80 Jambor C, Spannagl M, Zwissler B. Perioperative management of patients with coronary stents in non–cardiac surgery. Anästhesist 2009; 58: 971-985
• 81 Schlitt A, Jambor C, Spannagl M et al. The perioperative management of treatment with anticoagulants and platelet aggregation inhibitors. Dtsch Arztebl Int 2013; 110: 525-532
• 82 O'Donoghue ML, Braunwald E, Antman EM et al. Pharmacodynamic effect andclinical efficacy of clopidogrel and prasugrel with or without a proton pump inhibitor: an analysis of two randomized trials. Lancet 2009; 374: 989-997
• 83 Siller-Matula JM, Jilma B, Schrör K et al. Effect of proton pump inhibitors on clinical outcome in patients treated with clopidogrel: a systemic review and meta–analysis. 2010; 8: 2624-2641
• 84 Siller-Matula JM, Spiel AO, Lang IM et al. Effects of pantoprazole and esopremazole on platelet inhibition by clopidogrel. Am Heart J 2009; 157
• 85 Tentzeris I, Jarai R, Farhan S et al. Impact of concomitant treatment with proton pump inhibitors and clopidogrel on clinical outcome in patients after coronary stent implantation. Thromb Haemost 2010; 104: 1211-1218
• 86 de Heer G, Sensen B, Kluge S. Stressulkus–Prophylaxe. DIVI 2013; 4: 94-99
• 87 Macaione F, Montaina C, Evola S et al. Impact of dual antiplatelet therapy with proton pump inhibitors on the outcome of patients with acute coronary syndrome undergoing drug–eluting stent implantation. ISRN Cardiol 2012; 692761-692761
• 88 Bhatt DL, Cryer BL, Contant CF et al. Clopidogrel with or without Omeprazole in Coronary Artery Disease. N Engl J Med 2010; 363: 1909-1917
• 89 Sibbing D, Morath T, Stegherr J et al. Impact of proton pump inhibitors on the antiplatelet effects of clopidogrel. Thromb Haemost 2009; 101: 714-719
• 90 Meyer FP. Clopidogrel und Protonenpumpenhemmer. Arzneiverordnung in der Praxis 2010; 37: 57-59
• 91 Venerito M, Kandulski A, Malfertheiner P. Dilemma between gastroprotection and cardiovascular prevention. Dtsch Med Wochenschr 2010; 135: 2193-2198
• 92 Depta JP, Bhatt DL. Antiplatelet therapy and proton pump inhibition: cause for concern?. Curr Opin Cardiol 2012; 27: 642-650
• 93 Mahabaleshwarkar RK, Yang Y, Datar MV et al. Risk of adverse cardiovascular outcomes and all–cause mortality associated with concomitant use of clopidogrel und proton pump inhibitors in elderly patients. Curr Med Res Opin (Epub ahead of print) 2013;
• 94 Chen J, Chen SY, Lian JJ et al. Pharmacodynamic impacts of proton pump inhibitors on the efficacy of clopidogrel in vivo – a systematic review. Clin Cardiol (Epub ahead of print) 2013;
• 95 Harrison RW, Mahaffey KW. Clopidogrel and PPI interaction: clinically relevant or not?. Curr Cardiol Rep 2012; 14: 49-58
• 96 Gogarten W, Van Aken H, Buttner J et al. Ruckenmarksnahe Regionalanästhesien und Thromboembolieprophylaxe / antithrombotische Medikation. Anasth Intensivmed 2007; 48: 109-124