Intraoperative Beatmung bei Erwachsenen

Zusammenfassung

Die Beatmungstherapie kann offenbar nicht nur bei Patienten mit akutem Lungenversagen einen Einfluss auf den Krankheitsverlauf haben. Lungenprotektive Beatmungskonzepte werden daher auch für die Narkosebeatmung propagiert. Dieser Beitrag diskutiert verschiedene Aspekte der Beatmungstherapie in Narkose und berücksichtigt dabei auch die zunehmende Verbreitung von Adipositas bei erwachsenen Patienten.

Abstract

Avoiding postoperative pulmonary complications (PPC) is an important goal for anesthesiologists during general anesthesia, and ventilation strategies may play a role. It seems reasonable to apply knowledge from lessons we learned from ventilation of intensive care unit patients aiming at avoiding ventilator associated lung injury. Ventilation associated lung injuries occur frequently and are associated with substantial morbidity and mortality. Strategies of lung protective ventilation, like lower tidal volumes and the use of positive end-expiatory pressure (PEEP), can usually be transferred safely to perioperative ventilation, although some issues such as hemodynamic side effects must be considered. For some reasons, however, current evidence is conflicting and there is no consensus on ventilatory perioperative management to avoid PPCs so far. This paper briefly summarizes physiological backgrounds in a functional context, current evidence, and provides some recommendations at “expert” opinion level for perioperative ventilation procedures.

Especially in patients at risk and/or during surgery with higher surgical trauma and inflammation, we recommend limiting tidal volume to 6 – 8 ml/kg predicted body weight and the use of PEEP, which should be individualized e.g. by minimizing driving pressure. Recruitment maneuvers may be considered and should be carried out by using the ventilator.

Obese patients are an increasing entity and can be challenging during anesthesia and ventilation. From a physiological point of view, these patients require much higher ventilation pressures as currently used, although recent evidence is not in favor of using moderately higher PEEP, which is matter of discussion.

Kernaussagen

• Für die zeitlich meist sehr begrenzte intraoperative Beatmung ist der komplikationsreduzierende Effekt einer lungenprotektiven Beatmung wie beim ARDS nur selten eindeutig nachweisbar.

• Je nach Patienteneigenschaften, Vorerkrankungen, geplantem OP-Verfahren und damit verbundener Entzündungsreaktion auf das operative Trauma spielt eine protektive Beatmung aber ggf. eine wichtige Rolle.

• Dabei bedarf es selbstverständlich einer detaillierten OP-Vorbereitung, aber noch viel mehr einer guten Kommunikation im interdisziplinärem OP-Team.

• Insbesondere bei Risikokonstellationen lassen sich vermutlich unmittelbare und langfristige postoperative Komplikationen durch die Grundregeln der lungenprotektiven Beatmung reduzieren: V_T 6 – 8 ml/kg Idealgewicht, PEEP 8 – 12 cmH₂O (bei Adipösen individualisiert um 20 cmH₂O), niedriger Driving Pressure.

• Dabei müssen Patienteneigenschaften, Lagerung und OP-Verfahren sowie eine adäquate Kreislauftherapie bei gleichzeitiger Volumenrestriktion beachtet werden.

• In der unmittelbar postoperativen Phase können Oberkörperhochlagerung und nichtinvasive Beatmung hilfreich sein. Eine patientenadaptierte Schmerztherapie bildet die Grundlage einer effektiven Atemtherapie und beugt damit postoperativen pulmonalen Komplikationen vor.

Schlüsselwörter

intraoperative Beatmung - Tidalvolumen - PEEP - Rekrutierungsmanöver - Adipositas

Key words

Lung injury - positive end-expiratory pressure - postoperative pulmonary complications - mechanical ventilation - tidal volume - recruitment maneuver

Publication History

Article published online:
26 May 2021

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