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Anästhesiol Intensivmed Notfallmed Schmerzther 2015; 50(11/12): 704-711
DOI: 10.1055/s-0041-107320
Fachwissen
Intensivmedizin: Topthema
© Georg Thieme Verlag Stuttgart · New York

Analgesie, Sedierung und Delirmanagement – Herausforderungen bei der Analgesie und Sedierung von Neurointensivpatienten

Analgesia, sedation and delir–Treatment of patients in the neuro intensive care unit
Christine Jungk
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Publication History

Publication Date:
09 December 2015 (online)

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Zusammenfassung

Die sichere und effektive Analgesie und Sedierung von Neurointensivpatienten, v.a. bei erhöhtem intrakraniellen Druck, stellt eine Herausforderung dar. Voraussetzung ist die Festlegung eines der individuellen Situation angepassten Sedierungsziels (bei intrakranieller Hypertension RASS -5) und die regelmäßige Überprüfung von Sedierungstiefe und bedarfsgerechter Analgesie mit Hilfe standardisierter Monitoring-Instrumente (z.B. RASS, ggf. unter Zuhilfenahme apparativer Verfahren, und NCS). Ausreichend evidenz-basierte Sedierungs-Algorithmen existieren in diesem Patientenkollektiv nicht. Zur kontinuierlichen Analgesie können Remifentanil, Sufentanil und Fentanyl sicher eingesetzt werden, Bolus-Gaben von Opioiden sollten vermieden werden. (S-)-Ketamin kann als Opioid-Alternative oder ergänzend bei intubierten und mit einem GABA-Rezeptor-Agonisten sedierten Patienten eingesetzt werden. Propofol und Benzodiazepine können gleichermaßen sicher und effektiv eingesetzt werden bei kürzeren Aufwachzeiten für Propofol. Barbiturate eignen sich nur zur Behandlung des therapierefraktären Status epilepticus oder der therapierefraktären intrakraniellen Hypertension. Im Hinblick auf den Einsatz von Dexmedetomidin und volatilen Anästhetika besteht noch Forschungsbedarf.

Abstract

Analgesia and sedation of patients in the neuro intensive care unit, in particular in case of intracranial hypertension, remains a challenge even today. A goal for analgesia and sedation should be set for each individual patient (RASS -5 in case of intracranial hypertension) and should be re-evaluated repeatedly based on standardized scores (RASS plus EEG monitoring where appropriate, NCS). There are no sufficient evidence-based sedation algorithms in this patient cohort. Remifentanil, sufentanil and fentanyl have been proven safe and effective for continuous application; however, bolus application should be avoided. (S-)Ketamin can be considered safe when mechanical ventilation and sedation with GABA receptor agonists are applied. Propofol and benzodiazepines are equally safe and effective with shorter wake up times for propofol. The use of barbitarutes is restricted to intractable intracranial hypertension or status epilepicus. Evidence for alpha-2-adrenoceptoragonists and inhalative sedation is poor and requires further research.

Kernaussagen

  • Für den einzelnen Patienten soll ein der aktuellen Situation angepasstes Sedierungsziel festgelegt und dieses – gemeinsam mit dem Schmerzniveau – in regelmäßigen Abständen überprüft und ggf. angepasst werden.

  • Für Neurointensivpatienten mit intrakranieller Hypertension gilt ein Ziel-RASS von -5 unter Vermeidung von Übersedierung (apparatives Monitoring).

  • In der Neurointensivmedizin müssen die gewählten Analgetika und Sedativa den pathophysiologischen Besonderheiten von Patienten mit zerebraler Grunderkrankung angepasst werden.

  • Eine kontinuierliche i. v. Gabe von Analgetika und Sedativa sollte stets unter MAP-Kontrolle erfolgen, um deletäre Effekte auf CPP und ICP zu vermeiden.

  • Bolus-Gaben von Opioiden sollten vermieden werden.

  • Propofol und Benzodiazepine haben ein vergleichbares Sicherheitsprofil bei signifikant verkürzter Aufwachzeit für Propofol.

  • Ketamin-Razemat kann bei kontrollierter Beatmung und additiver Sedierung mit GABA-Rezeptor-Agonisten auch bei Neurointensivpatienten erwogen werden.

  • Der Einsatz von α2-Adrenozeptoragonisten und volatilen Anästhetika entbehrt ausreichender Evidenz.

  • Barbiturate sind nur zur Therapie einer therapierefraktären intrakraniellen Hypertension, bei hämodynamischer Stabilität und unter EEG-Monitoring indiziert (keine Prophylaxe!).

  • Tägliche Aufwachversuche sollen nur zur neurologischen Beurteilung bei Neurointensivpatienten mit normwertigem ICP und Sympathotonus-Blockade unternommen werden.

Schlüsselwörter

Analgesie - Sedierung - Neurointensivmedizin - intrakranielle Hypertension

Key Words

Analgesia - sedation - neuro intensive care medicine - intracranial hypertension

Ergänzendes Material

 

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