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Anästhesiol Intensivmed Notfallmed Schmerzther 2018; 53(05): 346-362
DOI: 10.1055/s-0043-106337
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Georg Thieme Verlag KG Stuttgart · New York

Kardioanästhesie: anästhesiologisches Management

Cardiac Anaesthesia: Anaesthesiological Management
Jochen Renner
,
Berthold Bein
,
Ole Broch
Further Information

Publication History

Publication Date:
17 May 2018 (online)

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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
 

  • Literatur

  • 1 Beckmann A, Funkat AK, Lewandowski J. et al. German Heart Surgery Report 2016: The Annual Updated Registry of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg 2017; 65: 505-518
    Article in Thieme ConnectPubMedGoogle Scholar
  • 2 Xie J, Zhang X, Xu J. et al. Effect of remote ischemic preconditioning on outcomes in adult cardiac surgery: a systematic review and meta-analysis of randomized controlled studies. Anesth Analg 2017; DOI: 10.1213/ANE.0000000000002674.
    CrossrefPubMedGoogle Scholar
  • 3 Maheshwari A, McCormick PJ, Sessler DI. et al. Prolonged concurrent hypotension and low bispectral index (‘double low’) are associated with mortality, serious complications, and prolonged hospitalization after cardiac surgery. Br J Anaesth 2017; 119: 40-49
    CrossrefPubMedGoogle Scholar
  • 4 Söhle M. et al. Neuromonitoring in der Kardioanästhesie. Eine gemeinsame Stellungnahme der: Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Cardiovascular and Thoracic Anaesthesia Group (CTA), der Schweizerischen Gesellschaft für Anästhesiologie und Reanimation (SGAR), Deutschen Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG). Anästh Intensivmed 2014; 55: 521-538 Im Internet: http://www.ak-kardioanaesthesie.de/literatur/145-empfehlung-neuromonitoring-in-der-kardioanaesthesie-a-i/file.html Stand: 11.04.2018;
    PubMedGoogle Scholar
  • 5 Royse C, Royse A, Soeding P. et al. Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery. Ann Thorac Surg 2003; 75: 93-100
    CrossrefPubMedGoogle Scholar
  • 6 Barrington MJ, Kluger R, Watson R. et al. Epidural anesthesia for coronary artery bypass surgery compared with general anesthesia alone does not reduce biochemical markers of myocardial damage. Anesth Analg 2005; 100: 921-928
    CrossrefPubMedGoogle Scholar
  • 7 Wu ZK, Iivainen T, Pehkonen E. et al. Arrhythmias in off-pump coronary artery bypass grafting and the antiarrhythmic effect of regional ischemic preconditioning. J Cardiothorac Vasc Anesth 2003; 17: 459-464
    CrossrefPubMedGoogle Scholar
  • 8 Landoni G, Biondi-Zoccai GG, Zangrillo A. et al. Desflurane and sevoflurane in cardiac surgery: a meta-analysis of randomized clinical trials. J Cardiothorac Vasc Anesth 2007; 21: 502-511
    CrossrefPubMedGoogle Scholar
  • 9 Landoni G, Fochi O, Tritapepe L. et al. Cardiac protection by volatile anesthetics. A review. Minerva Anestesiol 2009; 75: 269-273
    PubMedGoogle Scholar
  • 10 Spieckermann PG, Bruckner J, Kubler W. et al. [Preischemic stress and resuscitation time of the heart]. Verh Dtsch Ges Kreislaufforsch 1969; 35: 358-364
    PubMedGoogle Scholar
  • 11 De Hert SG, Van der Linden PJ, Cromheecke S. et al. Cardioprotective properties of sevoflurane in patients undergoing coronary surgery with cardiopulmonary bypass are related to the modalities of its administration. Anesthesiology 2004; 101: 299-310
    CrossrefPubMedGoogle Scholar
  • 12 Hillis LD, Smith PK, Anderson JL. et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58: e123-e210
    CrossrefPubMedGoogle Scholar
  • 13 Newman MF, Murkin JM, Roach G. et al. Cerebral physiologic effects of burst suppression doses of propofol during nonpulsatile cardiopulmonary bypass. CNS Subgroup of McSPI. Anesth Analg 1995; 81: 452-457
    PubMedGoogle Scholar
  • 14 Landoni G, Guarracino F, Cariello C. et al. Volatile compared with total intravenous anaesthesia in patients undergoing high-risk cardiac surgery: a randomized multicentre study. Br J Anaesth 2014; 113: 955-963
    CrossrefPubMedGoogle Scholar
  • 15 Meybohm P, Bein B, Brosteanu O. et al. A multicenter trial of remote ischemic preconditioning for heart surgery. N Engl J Med 2015; 373: 1397-1407
    CrossrefPubMedGoogle Scholar
  • 16 Montaigne D, Marechal X, Modine T. et al. Daytime variation of perioperative myocardial injury in cardiac surgery and its prevention by Rev-Erbα antagonism: a single-centre propensity-matched cohort study and a randomised study. Lancet 2018; 391: 59-69
    CrossrefPubMedGoogle Scholar
  • 17 Im Internet: https://www.bda.de/docman/alle-dokumente-fuer-suchindex/oeffentlich/empfehlungen/580-volatile-anaesthetika-waehrend-extrakorporaler-zirkulation-bei-herzchirurgischen-eingriffen/file.html Stand: 11.04.2018
    PubMed
  • 18 Nigro Neto C, Landoni G, Cassara L. et al. Use of volatile anesthetics during cardiopulmonary bypass: a systematic review of adverse events. J Cardiothorac Vasc Anesth 2014; 28: 84-89
    CrossrefPubMedGoogle Scholar
  • 19 Nitzschke R, Wilgusch J, Kersten JF. et al. Bispectral index guided titration of sevoflurane in on-pump cardiac surgery reduces plasma sevoflurane concentration and vasopressor requirements: a prospective, controlled, sequential two-arm clinical study. Eur J Anaesthesiol 2014; 31: 482-490
    CrossrefPubMedGoogle Scholar
  • 20 Kulier A, Levin J, Moser R. et al. Impact of preoperative anemia on outcome in patients undergoing coronary artery bypass graft surgery. Circulation 2007; 116: 471-479
    CrossrefPubMedGoogle Scholar
  • 21 Murphy GJ, Pike K, Rogers CA. et al. Liberal or restrictive transfusion after cardiac surgery. N Engl J Med 2015; 372: 997-1008
    CrossrefPubMedGoogle Scholar
  • 22 Weber CF, Gorlinger K, Meininger D. et al. Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology 2012; 117: 531-547
    CrossrefPubMedGoogle Scholar
  • 23 Weber CF, Zacharowski K, Brun K. et al. [Basic algorithm for Point-of-Care based hemotherapy: perioperative treatment of coagulopathic patients]. Anaesthesist 2013; 62: 464-472
    CrossrefPubMedGoogle Scholar
  • 24 Lazarus MG, Smul TM, Roewer N. et al. Herz- und thorakale Gefäßchirurgie – Gerinnungsstörungen: klinische Grundlagen und mechanismenbasierte Therapie. Anasthesiol Intensivmed Notfallmed Schmerzther 2014; 49: 50-57
    Article in Thieme ConnectPubMedGoogle Scholar
  • 25 Bijker JB, van Klei WA, Kappen TH. et al. Incidence of intraoperative hypotension as a function of the chosen definition: literature definitions applied to a retrospective cohort using automated data collection. Anesthesiology 2007; 107: 213-220
    CrossrefPubMedGoogle Scholar
  • 26 Smul TM, Hoffmann J, Roewer N. et al. Herz- und thorakale Gefäßchirurgie – Gefäßkanülierung bei HLM-Einsatz und hämodynamisches Monitoring. Anasthesiol Intensivmed Notfallmed Schmerzther 2014; 49: 60-67
    Article in Thieme ConnectPubMedGoogle Scholar
  • 27 van Waes JA, van Klei WA, Wijeysundera DN. et al. Association between intraoperative hypotension and myocardial injury after vascular surgery. Anesthesiology 2016; 124: 35-44
    CrossrefPubMedGoogle Scholar
  • 28 Monk TG, Bronsert MR, Henderson WG. et al. Association between intraoperative hypotension and hypertension and 30-day postoperative mortality in noncardiac surgery. Anesthesiology 2015; 123: 307-319
    CrossrefPubMedGoogle Scholar
  • 29 Wickham A, Highton D, Martin D. et al. Care of elderly patients: a prospective audit of the prevalence of hypotension and the use of BIS intraoperatively in 25 hospitals in London. Perioper Med (Lond) 2016; 5: 12
    CrossrefPubMedGoogle Scholar
  • 30 Ono M, Arnaoutakis GJ, Fine DM. et al. Blood pressure excursions below the cerebral autoregulation threshold during cardiac surgery are associated with acute kidney injury. Crit Care Med 2013; 41: 464-471
    CrossrefPubMedGoogle Scholar
  • 31 Scheeren TW, Saugel B. Journal of clinical monitoring and computing 2016 end of year summary: monitoring cerebral oxygenation and autoregulation. J Clin Monit Comput 2017; 31: 241-246
    CrossrefPubMedGoogle Scholar
  • 32 Denault A, Deschamps A, Murkin JM. A proposed algorithm for the intraoperative use of cerebral near-infrared spectroscopy. Semin Cardiothorac Vasc Anesth 2007; 11: 274-281
    CrossrefPubMedGoogle Scholar
  • 33 Sun Y, Chai F, Pan C. et al. Effect of perioperative goal-directed hemodynamic therapy on postoperative recovery following major abdominal surgery-a systematic review and meta-analysis of randomized controlled trials. Crit Care 2017; 21: 141
    CrossrefPubMedGoogle Scholar
  • 34 Giglio M, Dalfino L, Puntillo F. et al. Haemodynamic goal-directed therapy in cardiac and vascular surgery. A systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2012; 15: 878-887
    CrossrefPubMedGoogle Scholar
  • 35 Gustafsson UO, Scott MJ, Schwenk W. et al. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS(®)) Society recommendations. World J Surg 2013; 37: 259-284
    CrossrefPubMedGoogle Scholar
  • 36 Fleming IO, Garratt C, Guha R. et al. Aggregation of marginal gains in cardiac surgery: feasibility of a perioperative care bundle for enhanced recovery in cardiac surgical patients. J Cardiothorac Vasc Anesth 2016; 30: 665-670
    CrossrefPubMedGoogle Scholar
  • 37 Maddali MM, Kurian E, Fahr J. Extubation time, hemodynamic stability, and postoperative pain control in patients undergoing coronary artery bypass surgery: an evaluation of fentanyl, remifentanil, and nonsteroidal antiinflammatory drugs with propofol for perioperative and postoperative management. J Clin Anesth 2006; 18: 605-610
    CrossrefPubMedGoogle Scholar
  • 38 Maessen J, Dejong CH, Hausel J. et al. A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg 2007; 94: 224-231
    CrossrefPubMedGoogle Scholar
  • 39 Rashedi N, Otto CM. Aortic stenosis: changing disease concepts. J Cardiovasc Ultrasound 2015; 23: 59-69
    CrossrefPubMedGoogle Scholar
  • 40 Ozkan A, Kapadia S, Tuzcu M. et al. Assessment of left ventricular function in aortic stenosis. Nat Rev Cardiol 2011; 8: 494-501
    CrossrefPubMedGoogle Scholar
  • 41 Renner J, Frerker C, Kuck KH. et al. Transkatheter-Aortenklappenimplantation – Was muss der Anästhesist wissen und beachten?. Anasthesiol Intensivmed Notfallmed Schmerzther 2015; 50: 672-681
    Article in Thieme ConnectPubMedGoogle Scholar
  • 42 Prekker ME, Scott NL, Hart D. et al. Point-of-care ultrasound to estimate central venous pressure: a comparison of three techniques. Crit Care Med 2013; 41: 833-841
    CrossrefPubMedGoogle Scholar
  • 43 Bergmann L, Kahlert P, Eggebrecht H. et al. Transfemoral aortic valve implantation under sedation and monitored anaesthetic care – a feasibility study. Anaesthesia 2011; 66: 977-982
    CrossrefPubMedGoogle Scholar
  • 44 Klein AL, Burstow DJ, Tajik AJ. et al. Age-related prevalence of valvular regurgitation in normal subjects: a comprehensive color flow examination of 118 volunteers. J Am Soc Echocardiogr 1990; 3: 54-63
    CrossrefPubMedGoogle Scholar
  • 45 Mazine A, Friedrich JO, Nedadur R. et al. Systematic review and meta-analysis of chordal replacement versus leaflet resection for posterior mitral leaflet prolapse. J Thorac Cardiovasc Surg 2018; 155: 120-128.e10
    CrossrefPubMedGoogle Scholar
  • 46 Funkat A, Beckmann A, Lewandowski J. et al. Cardiac surgery in Germany during 2013: a report on behalf of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg 2014; 62: 380-392
    Article in Thieme ConnectPubMedGoogle Scholar
  • 47 Renner J, Lorenzen U, Borzikowsky C. et al. Unilateral pulmonary oedema after minimally invasive mitral valve surgery: a single-centre experience. Eur J Cardiothorac Surg 2018; 53: 764-770
    CrossrefPubMedGoogle Scholar
  • 48 Keyl C, Staier K, Pingpoh C. et al. Unilateral pulmonary oedema after minimally invasive cardiac surgery via right anterolateral minithoracotomy. Eur J Cardiothorac Surg 2015; 47: 1097-1102
    CrossrefPubMedGoogle Scholar
  • 49 Puls M, Lubos E, Boekstegers P. et al. One-year outcomes and predictors of mortality after MitraClip therapy in contemporary clinical practice: results from the German transcatheter mitral valve interventions registry. Eur Heart J 2016; 37: 703-712
    CrossrefPubMedGoogle Scholar
  • 50 Garbade J, Bittner HB, Barten MJ. et al. Current trends in implantable left ventricular assist devices. Cardiol Res Pract 2011; 2011: 290561
    PubMedGoogle Scholar
  • 51 Kanchi M. Do we need a pulmonary artery catheter in cardiac anesthesia? – An Indian perspective. Ann Card Anaesth 2011; 14: 25-29
    PubMedGoogle Scholar
  • 52 El-Magharbel I. Ventricular assist devices and anesthesia. Semin Cardiothorac Vasc Anesth 2005; 9: 241-249
    CrossrefPubMedGoogle Scholar
  • 53 Feussner M, Mukherjee C, Garbade J. et al. Anaesthesia for patients undergoing ventricular assist-device implantation. Best Pract Res Clin Anaesthesiol 2012; 26: 167-177
    PubMedGoogle Scholar
  • 54 Kirklin JK, Naftel DC, Kormos RL. et al. Second INTERMACS annual report: more than 1,000 primary left ventricular assist device implants. J Heart Lung Transplant 2010; 29: 1-10
    CrossrefPubMedGoogle Scholar
  • 55 Deschka H, Holthaus AJ, Sindermann JR. et al. Can perioperative right ventricular support prevent postoperative right heart failure in patients with biventricular dysfunction undergoing left ventricular assist device implantation?. J Cardiothorac Vasc Anesth 2016; 30: 619-626
    CrossrefPubMedGoogle Scholar
  • 56 Oleyar M, Stone M, Neustein SM. Perioperative management of a patient with a nonpulsatile left ventricular-assist device presenting for noncardiac surgery. J Cardiothorac Vasc Anesth 2010; 24: 820-823
    CrossrefPubMedGoogle Scholar
  • 57 Schon J, Paarmann H, Heringlake M. [Cerebral oximetry: clinical importance for cardiac surgery patients]. Anaesthesist 2012; 61: 934-940
    CrossrefPubMedGoogle Scholar
  • 58 Ben-Dor I, Looser PM, Maluenda G. et al. Transcatheter aortic valve replacement under monitored anesthesia care versus general anesthesia with intubation. Cardiovasc Revasc Med 2012; 13: 207-210
    CrossrefPubMedGoogle Scholar
  • 59 Motloch LJ, Rottlaender D, Reda S. et al. Local versus general anesthesia for transfemoral aortic valve implantation. Clin Res Cardiol 2012; 101: 45-53
    CrossrefPubMedGoogle Scholar