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Anästhesiol Intensivmed Notfallmed Schmerzther 2015; 50(07/08): 484-495
DOI: 10.1055/s-0041-101556
Fachwissen
Anästhesiologie: Topthema
© Georg Thieme Verlag Stuttgart · New York

Epiduralanästhesie – Epiduralanästhesie in Kombination mit Allgemeinanästhesie

Epidural analgesia in combination with general anesthesia
Antje Gottschalk
,
Daniel M Poepping
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Publication History

Publication Date:
31 July 2015 (online)

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Zusammenfassung

Die Epiduralanalgesie findet eine breite Anwendung in der perioperativen Schmerztherapie. Aber nicht nur aufgrund ihrer hervorragenden Analgesie sondern auch wegen vieler anderer positiven Eigenschaften im Rahmen der Rekonvaleszenz der Patienten wird sie oft zusammen mit der Allgemeinanästhesie angewendet. Nicht zuletzt wird eine reversible Sympathikusblockade mit konsekutiver Abschwächung der perioperativen Stressantwort als pathophysiologsicher Hintergrund für die positiven Effekte auf das kardiovaskuläre und gastrointestinale System sowie die Immunfunktion diskutiert. Ergebnisse aus der Grundlagenforschung lassen ebenso auf einen Behandlungsvorteil bei der Anwendung der Epiduralanalgesie bei tumorchirurgischen Operationen spekulieren. Bei der korrekten Anwendung der Epiduralanalgesie ist ein Benefit auf die Mortalität der Patienten nach großen operativen Eingriffen zu erwarten. Dieser Artikel fasst die angesprochenen Aspekte der Epiduralanalgesie nun zusammen.

Abstract

Epidural anaesthesia is a widely used and accepted technique for perioperative analgesia in different kinds of surgery. Apart from analgetic effect and due to wide positve effects on patients outcome epidural analgesia is often used with general anaesthesia. It represents a reliable and reversible neural deafferentation technique that effectively contributes to a reduction of the surgical stress response with subsequent positive effects on cardiopulmonary, gastrointestinal, and immune function. Animal studies suggest that the use of epidural anaesthesia may be beneficial for cancer surgery because of less tumour recurrence. Further, a benefit is expected in patient's mortality. This article summarizes and critically discusses the current knowledge on the effects of epidural anaesthesia on pain management, cardiopulmonary as well as gastrointestinal functions and patient's outcome.

Kernaussagen

  • Die Epiduralanalgesie wirkt sich bei korrekter Anwendung in vielfältiger Weise vorteilhaft auf die Rekonvaleszen operativ versorgter Patienten aus.

  • Als Vorteile gelten: eine exzellente Analgesie, eine verbesserte postoperative Erholung und verringerte Morbidität und Letalität bei Patienten, die sich besonders invasiven Operationen unterziehen müssen.

  • Hoffnungsvolle Ansätze zeigen sich auch hinsichtlich einer reduzierten Inzidenz chronischer Schmerzen nach Operationen.

Schlüsselwörter:

Epiduralanalgesie - postoperative Analgesie - Organprotektion

Keywords:

epidural analgesia - postoperative analgesia - protective effects

Ergänzendes Material

 

  • Literatur

  • 1 Popping DM, Zahn PK, Van Aken HK et al. Effectiveness and safety of postoperative pain management: A survey of 18 925 consecutive patients between 1998 and 2006 (2nd revision): A database analysis of prospectively raised data. Br J Anaesth 2008; 101: 832-840
    CrossrefPubMedGoogle Scholar
  • 2 Block BM, Liu SS, Rowlingson AJ, Cowan AR et al. Efficacy of postoperative epidural analgesia: A meta-analysis. Jama 2003; 290: 2455-2463
    CrossrefPubMedGoogle Scholar
  • 3 Kehlet H. Procedure specific postoperative pain management. AnesthesiolClinNorth America 2005; 23: 203-210
    PubMedGoogle Scholar
  • 4 Popping DM, Elia N, Van Aken HK et al. Impact of epidural analgesia on mortality and morbidity after surgery: Systematic review and meta-analysis of randomized controlled trials. Ann Surg 2014; 259: 1056-1067
    CrossrefPubMedGoogle Scholar
  • 5 Hughes MJ, Ventham NT, McNally S et al. Analgesia after open abdominal surgery in the setting of enhanced recovery surgery: A systematic review and meta-analysis. JAMA Surg 2014; 149: 1224-1230
    CrossrefPubMedGoogle Scholar
  • 6 Sagiroglu G, Meydan B, Copuroglu E et al. A comparison of thoracic or lumbar patient-controlled epidural analgesia methods after thoracic surgery. World J SurgOncol 2014; 12: 96-96
    PubMedGoogle Scholar
  • 7 Davies AF, Segar EP, Murdoch J et al. Epidural infusion or combined femoral and sciatic nerve blocks as perioperative analgesia for knee arthroplasty. Br J Anaesth 2004; 93: 368-374
    CrossrefPubMedGoogle Scholar
  • 8 Mondor ME, Massicotte L, Beaulieu D et al. Long-lasting analgesic effects of intraoperative thoracic epidural with bupivacaine for liver resection. RegAnesth Pain Med 2010; 35: 51-56
    PubMedGoogle Scholar
  • 9 Hermanides J, Hollmann MW, Stevens MF, Lirk P. Failed epidural: Causes and management. Br J Anaesth 2012; 109: 144-154
    CrossrefPubMedGoogle Scholar
  • 10 Schug S, Pogatzki-Zahn EM. Chronic pain after surgery or injury. IASP Pain: Clinical Updates 2011; 19: 1-5
    PubMedGoogle Scholar
  • 11 Schnabel A, Pogatzki-Zahn E. Predictors of chronic pain following surgery. What do we know?. Schmerz 2010; 24: 517-531
    CrossrefPubMedGoogle Scholar
  • 12 Andreae MH, Andreae DA. Local anaesthetics and regional anaesthesia for preventing chronic pain after surgery. Cochrane Database Syst Rev CD 007105 2012; 10
    PubMedGoogle Scholar
  • 13 Bouman EA, Theunissen M, Bons SA et al. Reduced incidence of chronic postsurgical pain after epidural analgesia for abdominal surgery. Pain Pract 2014; 14: 76-84
    CrossrefPubMedGoogle Scholar
  • 14 Salengros JC, Huybrechts I, Ducart A et al. Different anesthetic techniques associated with different incidences of chronic post-thoracotomy pain: Low-dose remifentanil plus presurgical epidural analgesia is preferable to high-dose remifentanil with postsurgical epidural analgesia. J CardiothoracVascAnesth 2010; 24: 608-616
    PubMedGoogle Scholar
  • 15 Perkins FM, Kehlet H. Chronic pain as an outcome of surgery. A review of predictive factors. Anesthesiology 2000; 93: 1123-1133
    CrossrefPubMedGoogle Scholar
  • 16 Niesert W, Zenz M. Prophylaxe chronischer schmerzen. DtschArztebl 2005; 22: 1586-1593
    PubMedGoogle Scholar
  • 17 Freise H, Meissner A, Lauer S et al. Thoracic epidural analgesia with low concentration of bupivacaine induces thoracic and lumbar sympathetic block: A randomized, double-blind clinical trial. Anesthesiology 2008; 109: 1107-1112
    CrossrefPubMedGoogle Scholar
  • 18 Stevens RA, Beardsley D, White JL et al. Does spinal anesthesia result in a more complete sympathetic block than that from epidural anesthesia?. Anesthesiology 1995; 82: 877-883
    CrossrefPubMedGoogle Scholar
  • 19 Landesberg G, Beattie WS, Mosseri M et al. Perioperative myocardial infarction. Circulation 2009; 119: 2936-2944
    CrossrefPubMedGoogle Scholar
  • 20 Beattie WS, Badner NH, Choi P. Epidural analgesia reduces postoperative myocardial infarction: A meta-analysis. AnesthAnalg 2001; 93: 853-858
    PubMedGoogle Scholar
  • 21 Schmidt C, Hinder F, Van Aken H et al. The effect of high thoracic epidural anesthesia on systolic and diastolic left ventricular function in patients with coronary artery disease. AnesthAnalg 2005; 100: 1561-1569
    PubMedGoogle Scholar
  • 22 Meissner A, Rolf N, Van Aken H. Thoracic epidural anesthesia and the patient with heart disease: Benefits, risks, and controversies. AnesthAnalg 1997; 85: 517-528
    PubMedGoogle Scholar
  • 23 Berendes E, Schmidt C, Van Aken H et al. Reversible cardiac sympathectomy by high thoracic epidural anesthesia improves regional left ventricular function in patients undergoing coronary artery bypass grafting: A randomized trial. ArchSurg 2003; 138: 1283-1290
    PubMedGoogle Scholar
  • 24 Svircevic V, Passier MM, Nierich AP et al. Epidural analgesia for cardiac surgery. Cochrane Database Syst Rev CD 006715 2013; 6
    PubMedGoogle Scholar
  • 25 Leslie K, Myles P, Devereaux P et al. Neuraxial block, death and serious cardiovascular morbidity in the POISE trial. Br J Anaesth 2013; 111: 382-390
    CrossrefPubMedGoogle Scholar
  • 26 Alcock RF, Kouzios D, Naoum C et al. Perioperative myocardial necrosis in patients at high cardiovascular risk undergoing elective non-cardiac surgery. Heart 2012; 98: 792-798
    CrossrefPubMedGoogle Scholar
  • 27 Sabate S, Mases A, Guilera N et al. ANESCARDIOCAT Group. Incidence and predictors of major perioperative adverse cardiac and cerebrovascular events in non-cardiac surgery. Br J Anaesth 2011; 107: 879-890
    CrossrefPubMedGoogle Scholar
  • 28 Slogoff S, Keats AS. Does perioperative myocardial ischemia lead to postoperative myocardial infarction?. Anesthesiology 1985; 62: 107-114
    CrossrefPubMedGoogle Scholar
  • 29 Warner DO. Preventing postoperative pulmonary complications: The role of the anesthesiologist. Anesthesiology 2000; 92: 1467-1472
    CrossrefPubMedGoogle Scholar
  • 30 Xue FS, Li BW, Zhang GS et al. The influence of surgical sites on early postoperative hypoxemia in adults undergoing elective surgery. AnesthAnalg 1999; 88: 213-219
    PubMedGoogle Scholar
  • 31 Ballantyne JC, Carr DB, deFerranti S et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: Cumulative meta-analyses of randomized, controlled trials. AnesthAnalg 1998; 86: 598-612
    PubMedGoogle Scholar
  • 32 Beaussier M, Genty T, Lescot T, Aissou M. Influence of pain on postoperative ventilatory disturbances. management and expected benefits. Ann Fr AnesthReanim 2014; 33: 484-486
    PubMedGoogle Scholar
  • 33 Popping DM, Elia N, Marret E et al. Protective effects of epidural analgesia on pulmonary complications after abdominal and thoracic surgery: A meta-analysis. ArchSurg 2008; 143: 990-999
    PubMedGoogle Scholar
  • 34 van Lier F, van der Geest PJ, Hoeks SE et al. Epidural analgesia is associated with improved health outcomes of surgical patients with chronic obstructive pulmonary disease. Anesthesiology 2011; 115: 315-321
    CrossrefPubMedGoogle Scholar
  • 35 Scarci M, Joshi A, Attia R. In patients undergoing thoracic surgery is paravertebral block as effective as epidural analgesia for pain management?. InteractCardiovascThoracSurg 2010; 10: 92-96
    PubMedGoogle Scholar
  • 36 Freise H, Van Aken HK. Risks and benefits of thoracic epidural anaesthesia. Br J Anaesth 2011; 107: 859-868
    CrossrefPubMedGoogle Scholar
  • 37 Steinbrook RA. Epidural anesthesia and gastrointestinal motility. AnesthAnalg 1998; 86: 837-844
    PubMedGoogle Scholar
  • 38 Kehlet H. Postoperative ileus--an update on preventive techniques. Nat ClinPractGastroenterolHepatol 2008; 5: 552-558
    PubMedGoogle Scholar
  • 39 Bredtmann RD, Herden HN, Teichmann W et al. Epidural analgesia in colonic surgery: Results of a randomized prospective study. Br J Surg 1990; 77: 638-642
    CrossrefPubMedGoogle Scholar
  • 40 Gendall KA, Kennedy RR, Watson AJ, Frizelle FA. The effect of epidural analgesia on postoperative outcome after colorectal surgery. Colorectal Dis 2007; 9: 584-598
    CrossrefPubMedGoogle Scholar
  • 41 Jestin P, Pahlman L, Gunnarsson U. Risk factors for anastomotic leakage after rectal cancer surgery: A case-control study. Colorectal Dis 2008; 10: 715-721
    CrossrefPubMedGoogle Scholar
  • 42 Shi WZ, Miao YL, Yakoob MY et al. Recovery of gastrointestinal function with thoracic epidural vs. systemic analgesia following gastrointestinal surgery. ActaAnaesthesiolScand 2014; 58: 923-932
    PubMedGoogle Scholar
  • 43 Michelet P, D'Journo XB, Roch A et al. Perioperative risk factors for anastomotic leakage after esophagectomy: Influence of thoracic epidural analgesia. Chest 2005; 128: 3461-3466
    CrossrefPubMedGoogle Scholar
  • 44 Brady K, Hogue CW. Intraoperative hypotension and patient outcome: Does "one size fit all?". Anesthesiology 2013; 119: 495-497
    CrossrefPubMedGoogle Scholar
  • 45 Hiltebrand LB, Koepfli E, Kimberger O, Sigurdsson GH, Brandt S. Hypotension during fluid-restricted abdominal surgery: Effects of norepinephrine treatment on regional and microcirculatory blood flow in the intestinal tract. Anesthesiology 2011; 114: 557-564
    CrossrefPubMedGoogle Scholar
  • 46 Gottschalk A, Sharma S, Ford J et al. Review article: The role of the perioperative period in recurrence after cancer surgery. AnesthAnalg 2010; 110: 1636-1643
    PubMedGoogle Scholar
  • 47 Hiller J, Brodner G, Gottschalk A. Understanding clinical strategies that may impact tumour growth and metastatic spread at the time of cancer surgery. Best Pract Res ClinAnaesthesiol 2013; 27: 427-439
    PubMedGoogle Scholar
  • 48 Yeager MP, Glass DD, Neff RK, Brinck-Johnsen T. Epidural anesthesia and analgesia in high-risk surgical patients. Anesthesiology 1987; 66: 729-736
    CrossrefPubMedGoogle Scholar
  • 49 Rodgers A, Walker N, Schug S et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: Results from overview of randomised trials. BMJ 2000; 321: 1493-1493
    CrossrefPubMedGoogle Scholar
  • 50 McCulloch TJ, Loadsman JA. Reduction of postoperative mortality and morbidity.little information was given on inclusion criteria. BMJ author reply 2001; 322: 1182-1183
    CrossrefPubMedGoogle Scholar
  • 51 Higham H, Mishra P, Foex P. Reduction of postoperative mortality and morbidity. research into modern anaesthesia techniques and perioperative medicine is needed. BMJ 2001; 322: 1182-1183
    CrossrefPubMedGoogle Scholar
  • 52 Rigg JR, Jamrozik K, Myles PS et al. MASTER Anaethesia Trial Study Group. Epidural anaesthesia and analgesia and outcome of major surgery: A randomised trial. Lancet 2002; 359: 1276-1282
    CrossrefPubMedGoogle Scholar
  • 53 Van Aken H, Gogarten W, Brussel T, Brodner G. Epidural anaesthesia and analgesia in mayor surgery. Lancet author reply 2002; 360
    PubMedGoogle Scholar
  • 54 Wijeysundera DN, Beattie WS, Austin PC et al. Epidural anaesthesia and survival after intermediate-to-high risk non-cardiac surgery: A population-based cohort study. Lancet 2008; 372: 562-569
    CrossrefPubMedGoogle Scholar
  • 55 Wu CL, Rowlingson AJ, Herbert R et al. Correlation of postoperative epidural analgesia on morbidity and mortality after colectomy in medicare patients. J ClinAnesth 2006; 18: 594-599
    PubMedGoogle Scholar
  • 56 Herminghaus A, Wachowiak M, Wilhelm W et al. Intravenous administration of lidocaine for perioperative analgesia. review and recommendations for practical usage. Anaesthesist 2011; 60: 152-160
    CrossrefPubMedGoogle Scholar
  • 57 Sun Y, Li T, Wang N et al. Perioperative systemic lidocaine for postoperative analgesia and recovery after abdominal surgery: A meta-analysis of randomized controlled trials. Dis Colon Rectum 2012; 55: 1183-1194
    CrossrefPubMedGoogle Scholar
  • 58 Wongyingsinn M, Baldini G, Charlebois P et al. Intravenous lidocaine versus thoracic epidural analgesia: A randomized controlled trial in patients undergoing laparoscopic colorectal surgery using an enhanced recovery program. RegAnesth Pain Med 2011; 36: 241-248
    PubMedGoogle Scholar
  • 59 Swenson BR, Gottschalk A, Wells LT et al. Intravenous lidocaine is as effective as epidural bupivacaine in reducing ileus duration, hospital stay, and pain after open colon resection: A randomized clinical trial. Reg AnesthPain Med 2010; 35: 370-376
    PubMedGoogle Scholar