Kardioanästhesie: anästhesiologisches Management

Zusammenfassung

Das anästhesiologische Management herzchirurgischer Patienten hat sich in den letzten Jahren deutlich weiterentwickelt. Diese Übersicht widmet sich vor allem folgenden Bereichen: pharmakologische Kardioprotektion bei herzchirurgischen Eingriffen, Narkosemanagement an der Herz-Lungen-Maschine, Protokolle der „Enhanced Recovery After Cardiac Surgery“ sowie innovative minimalinvasive Operationsverfahren wie die kathetergestützte Aortenklappenimplantation.

Abstract

The anaesthesiological management of patients scheduled for cardiac surgery has been refined distinctively over the last decade due to different reasons. The continuing growth of the elderly patient population and the increasing number of combined cardiac surgery procedures in octogenarians on the one hand are one aspect. The rapid development of minimally invasive cardiac surgery and the enhancements in mechanical, artificial heart assist devices on the other hand can be seen as additional decisive factors. All of these innovations in the field of cardiac surgery implicate further enhancements regarding the anaesthesiological management. This review article addresses the following subareas of cardiac anaesthesia: significance of pharmacological myocardial protection, anaesthetic management during cardiopulmonary bypass, importance of “Enhanced Recovery After Cardiac Surgery”-protocols as well as innovations in the field of minimally invasive cardiac surgery like transcatheter aortic valve implantation.

Kernaussagen

• Das kardiochirurgische Patientenkollektiv ist in den letzten Jahren deutlich älter geworden, ohne dass sich die Gesamtsterblichkeit verändert hat. Eine Überwachung der Narkosetiefe mittels EEG-basierter Überwachungsmonitore scheint bei diesen Patienten von Vorteil zu sein.

• Die ischämische Präkonditionierung stellt eine effektive Methode zum Schutz vor myokardialem Zellschaden dar. Sie zeigt einen zweizeitigen Verlauf (Early vs. Late Preconditioning).

• Volatile Anästhetika scheinen bei bestimmten Patientenkollektiven in der Lage zu sein, kardioprotektive Effekte zu induzieren. Der protektive Effekt scheint am effektivsten zu sein, wenn das volatile Anästhetikum möglichst frühzeitig und bis zum Ende der Operation appliziert wird.

• Eine präoperative Anämie bei herzchirurgischen Patienten ist mit einer erhöhten Morbidität und Mortalität assoziiert. Hinsichtlich des Transfusionstriggers scheint bei kardiochirurgischen Patienten zum jetzigen Zeitpunkt ein restriktives Transfusionsregime einem liberalen Transfusionsmanagement nicht überlegen zu sein.

• Durch den gezielten Einsatz von Point-of-Care-Verfahren kann die Transfusionsrate bei kardiochirurgischen Patienten reduziert und der postoperative Verlauf günstig beeinflusst werden.

• Derzeit lässt sich kein optimaler Bereich für den mittleren arteriellen Blutdruck vor, während und nach der Herz-Lungen-Maschine sicher festlegen. Der mittlere arterielle Blutdruck sollte individualisiert unter Berücksichtigung der zerebralen Autoregulationskapazität eingestellt werden.

• Im Rahmen des Konzepts der „Enhanced Recovery after Cardiac Surgery“ soll durch ein Bündel von prä-, intra- und postoperativen Maßnahmen die körperliche Integrität nach kardiochirurgischen Operationen zügig wiederhergestellt werden.

• Bei einer TAVI stellt ein Patient mit begleitenden Komorbiditäten hohe Anforderungen an den betreuenden Anästhesisten. Die Analgosedierung ist bei transfemoralem Zugang sicher anzuwenden und mit einer deutlich stabileren Hämodynamik, schnelleren Mobilisierung und Erholung des Patienten assoziiert.

• Patienten zur linksventrikulären Assist-Device-Implantation weisen neben einer Vielzahl schwerer Komorbiditäten eine hohe perioperative Komplikationsrate auf. Die Überwachung der rechtsventrikulären Funktion mittels Pulmonaliskatheter wird empfohlen.

Schlüsselwörter

Herzchirurgie - Kardioanästhesie - myokardiale Protektion - Präkonditionierung - TAVI - minimalinvasiv - Mitralklappenchirurgie

Key words

cardiac surgery - cardiac anaesthesia - myocardial protection - preconditioning - TAVI - minimally invasive - mitral valve surgery

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