Einleitung des nicht nüchternen Patienten: Welche Medikamente sind zu verwenden?

Zusammenfassung

Die Rapid Sequence Induction beschreibt ein nicht evidenzbasiertes Anästhesieverfahren zur Narkoseeinleitung bei nicht nüchternen Patienten. Ziel dieser Einleitungstechnik ist es, den anästhesierten Patienten ohne Zwischenbeatmung zügig endotracheal zu intubieren, um das Risiko für eine Aspiration zu minimieren. Der Beitrag gibt Empfehlungen für das anästhesiologische Management nicht nüchterner Patienten und verweist insbesondere auf die für die RSI benötigten Medikamente.

Abstract

The rapid sequence induction (RSI) is a not evidence-based technique designed to minimize the chance of pulmonary aspiration in high-risk patients requiring general anesthesia. Primary aim of this anesthetic technique is, therefore, a fast airway protection with an endotracheal tube to reduce the chance of passive or active regurgitation. This article discusses the anesthetic management of patients with an increased risk of aspiration, and, particularly, refers to the medications required for RSI.

Kernaussagen

• Die Rapid Sequence Induction (RSI) ist ein nicht evidenzbasiertes Verfahren zur Narkoseeinleitung bei nicht nüchternen Patienten sowie Patienten mit (Sub-)Ileus, Erbrechen und bestimmten anderen Erkrankungen sowie Schwangeren.

• Oberstes Ziel dieser Einleitungstechnik ist es, den anästhesierten Patienten ohne Maskenbeatmung zügig zu intubieren, um das Risiko für eine pulmonale Aspiration zu minimieren. Entscheidend ist das Zeitfenster zwischen dem Verlust der Schutzreflexe und der endotrachealen Intubation, da in diesem Intervall das größte Aspirationsrisiko besteht.

• Zur Einleitung kommen i. d. R. kurzwirksame Opioide wie Alfentanil und Remifentanil zur Anwendung.

• Bei einer RSI zur Sectio caesarea wird vor Abnabelung des Kindes auf Opioide üblicherweise verzichtet. Nach Abnabelung des Kindes werden Opioide zur Analgesie empfohlen.

• Opioide in Kombination mit Rocuronium schaffen Intubationsbedingungen, die denen nach Succinylcholin-Gabe vergleichbar sind.

• Propofol supprimiert laryngeale und pharyngeale Reflexe effektiv und ist deshalb gut zur RSI geeignet. In Abhängigkeit vom präoperativen kardialen Status gibt es Alternativen wie das weniger kardiodepressiv wirkende Thiopental.

• Auch während der Narkoseausleitung können gravierende Atemwegsprobleme mit der Möglichkeit einer Aspiration auftreten.

Schlüsselwörter

Blitzeinleitung - präoperative Nüchternheit - pulmonale Aspiration - Hypnotika - Muskelrelaxanzien

Key words

rapid sequence induction - preoperative fasting - pulmonary aspiration - hypnotics - neuromuscular blocking agents

• Literatur

• 1 Borland LM, Sereika SM, Woelfel SK. et al. Pulmonary aspiration in pediatric patients during general anesthesia: incidence and outcome. J Clin Anesth 1998; 10: 95-102
• 2 Woodall N, Frerk C, Cook TM. Can we make airway management (even) safer?–lessons from national audit. Anaesthesia 2011; 66 (Suppl. 02) 27-33
• 3 Stept WJ, Safar P. Rapid induction-intubation for prevention of gastric-content aspiration. Anesth Analg 1970; 49: 633-636
• 4 Jensen AG, Callesen T, Hagemo JS. et al. Scandinavian clinical practice guidelines on general anaesthesia for emergency situations. Acta Anaesthesiol Scand 2010; 54: 922-950
• 5 Wetsch WA, Hinkelbein J. Current national recommendations on rapid sequence induction in Europe. How standardised is the ‘standard of care’?. Eur J Anaesthesiol 2014; 31: 443-444
• 6 Eichelsbacher C, Ilper H, Noppens R. et al. [Rapid sequence induction and intubation in patients with risk of aspiration: Recommendations for action for practical management of anesthesia]. Anaesthesist 2018; 67: 568-583
• 7 American Society of Anesthesiologists Committee. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology 2011; 114: 495-511
• 8 Ormezzano X, Francois TP, Viaud JY. et al. Aspiration pneumonitis prophylaxis in obstetric anaesthesia: comparison of effervescent cimetidine-sodium citrate mixture and sodium citrate. Br J Anaesth 1990; 64: 503-506
• 9 Orr DA, Bill KM, Gillon KR. et al. Effects of omeprazole, with and without metoclopramide, in elective obstetric anaesthesia. Anaesthesia 1993; 48: 114-119
• 10 Lavazais S, Debaene B. Choice of the hypnotic and the opioid for rapid-sequence induction. Eur J Anaesthesiol 2001; 23 (Suppl.) 66-70
• 11 Sparr HJ, Giesinger S, Ulmer H. et al. Influence of induction technique on intubating conditions after rocuronium in adults: comparison with rapid-sequence induction using thiopentone and suxamethonium. Br J Anaesth 1996; 77: 339-342
• 12 McKeating K, Bali IM, Dundee JW. The effects of thiopentone and propofol on upper airway integrity. Anaesthesia 1988; 43: 638-640
• 13 Lindgren L, Yli-Hankala A, Randell T. et al. Haemodynamic and catecholamine responses to induction of anaesthesia and tracheal intubation: comparison between propofol and thiopentone. Br J Anaesth 1993; 70: 306-310
• 14 Absalom A, Pledger D, Kong A. Adrenocortical function in critically ill patients 24 h after a single dose of etomidate. Anaesthesia 1999; 54: 861-867
• 15 Allolio B, Stuttmann R, Leonhard U. et al. Adrenocortical suppression by a single induction dose of etomidate. Klin Wochenschr 1984; 62: 1014-1017
• 16 Vinclair M, Broux C, Faure P. et al. Duration of adrenal inhibition following a single dose of etomidate in critically ill patients. Intensive Care Med 2008; 34: 714-719
• 17 Mencke T, Echternach M, Kleinschmidt S. et al. Laryngeal morbidity and quality of tracheal intubation: a randomized controlled trial. Anesthesiology 2003; 98: 1049-1056
• 18 Blobner M, Frick CG, Stauble RB. et al. Neuromuscular blockade improves surgical conditions (NISCO). Surg Endosc 2015; 29: 627-636
• 19 Kirmeier E, Eriksson LI, Lewald H. et al. Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study. Lancet Respir Med 2019; 7: 129-140 doi:10.1016/S2213-2600(18)30294-7
• 20 Kopman AF, Chin WA, Moe J. et al. The effect of nitrous oxide on the dose-response relationship of rocuronium. Anesth Analg 2005; 100: 1343-1347 table of contents
• 21 Merck Connect. Bridion (Sugammadex). Dosing. Im Internet: https://www.merckconnect.com/bridion/dosing-administration Stand: 27.09.2019
• 22 de Boer HD, Driessen JJ, Marcus MA. et al. Reversal of rocuronium-induced (1.2 mg/kg) profound neuromuscular block by sugammadex: a multicenter, dose-finding and safety study. Anesthesiology 2007; 107: 239-244
• 23 Duvaldestin P, Kuizenga K, Saldien V. et al. A randomized, dose-response study of sugammadex given for the reversal of deep rocuronium- or vecuronium-induced neuromuscular blockade under sevoflurane anesthesia. Anesth Analg 2010; 110: 74-82
• 24 Groudine SB, Soto R, Lien C. et al. A randomized, dose-finding, phase II study of the selective relaxant binding drug, Sugammadex, capable of safely reversing profound rocuronium-induced neuromuscular block. Anesth Analg 2007; 104: 555-562
• 25 Jones RK, Caldwell JE, Brull SJ. et al. Reversal of profound rocuronium-induced blockade with sugammadex: a randomized comparison with neostigmine. Anesthesiology 2008; 109: 816-824
• 26 Suy K, Morias K, Cammu G. et al. Effective reversal of moderate rocuronium- or vecuronium-induced neuromuscular block with sugammadex, a selective relaxant binding agent. Anesthesiology 2007; 106: 283-288
• 27 Plaud B, Meretoja O, Hofmockel R. et al. Reversal of rocuronium-induced neuromuscular blockade with sugammadex in pediatric and adult surgical patients. Anesthesiology 2009; 110: 284-294
• 28 Sorgenfrei IF, Norrild K, Larsen PB. et al. Reversal of rocuronium-induced neuromuscular block by the selective relaxant binding agent sugammadex: a dose-finding and safety study. Anesthesiology 2006; 104: 667-674
• 29 Vanacker BF, Vermeyen KM, Struys MM. et al. Reversal of rocuronium-induced neuromuscular block with the novel drug sugammadex is equally effective under maintenance anesthesia with propofol or sevoflurane. Anesth Analg 2007; 104: 563-568
• 30 Kaufhold N, Schaller SJ, Stäuble CG. et al. Sugammadex and neostigmine dose-finding study for reversal of residual neuromuscular block at a train-of-for ratio of 0.2 (SUNDRO20). Br J Anaesth 2016; 116: 233-240
• 31 Schaller SJ, Fink H, Ulm K. et al. Sugammadex and neostigmine dose-finding study for reversal of shallow residual neuromuscular block. Anesthesiology 2010; 113: 1054-1060
• 32 Tran DT, Newton EK, Mount VA. et al. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev 2015; (10) CD002788
• 33 Sorensen MK, Bretlau C, Gatke MR. et al. Rapid sequence induction and intubation with rocuronium-sugammadex compared with succinylcholine: a randomized trial. Br J Anaesth 2012; 108: 682-689