Neurologische Komplikationen in der Anästhesiologie – Teil II – Schäden der peripheren Nerven

Zusammenfassung

Neurologische Komplikationen nach Operationen können für den Patienten fatale Folgen haben und zu Invalidität und Erwerbslosigkeit führen. Neben zentralen Schädigungen wie dem intraoperativen Schlaganfall, der Erblindung und dem postoperativen kognitiven Defizit sowie dem Delir, die durch ein optimiertes anästhesiologisches Management entscheidend beeinflusst werden können, sind periphere neurologische Schädigungen nach Anästhesien bei Kenntnis von Pathophysiologie und Therapie oft vermeidbar. Der aktuelle Artikel beschreibt die klassischen peripheren neurologischen Komplikationen, die durch Regionalanästhesien, Anlage zentraler Katheter, peripherer arterieller und venöser Kanülierung sowie intra- und perioperativer Lagerung von Patienten auftreten können. Darüber hinaus werden juristische Aspekte im Rahmen der Arzthaftung und Aufgabenverteilung zwischen Anästhesist, Operateur und medizinischem Assistenzpersonal erörtert.

Abstract:

Neurological complications after surgery may have fatal consequences for the patient or lead to disability and inability to work. Similar to central nervous complications such as stroke, postoperative visual loss, postoperative cognitive deficit and delirium, peripheral neurological complications following anaesthesia can be decisively influenced or almost avoided by an optimized anaesthesiological management.

In the present article typical peripheral neurologic complications which can occur after regional anesthesia, central venous puncture and insertion of arterial or venous cannulas as well as etiology, diagnosis and therapy of peripheral nervous damage are described. Moreover the paper gives recommendations on intraoperative positioning of the patient and presents medicolegal aspects in the perioperative setting.

Neurologische Komplikationen - peripherer Nervenschaden - Patientenlagerung

neurological complications - peripheral nerve injury - patient positioning - nerve damage

Kernaussagen

• Perioperative Nervenschädigungen sind multifaktoriell bedingt.

• Es werden direkte Schädigungen durch akzidentelle Punktion, lagerungsbedingte Zug- und Druckschädigungen sowie ischämische Nervenschädigungen unterschieden.

• Die Klassifikation von Nervenschädigungen erfolgt nach Seddon in 3 bzw. nach Sunderland in 5 Grade, wobei klinisch vor allem die Unterscheidung von Neurapraxie (Grad I) und Axonotmesis (Grad II) relevant ist.

• Auf eine sorgfältige Lagerung des Patienten mit Druckentlastung und Abpolsterung aller aufliegenden Körperregionen ist zu achten. Dabei hat der Anästhesist die Aufgabe, den Operateur über unbeabsichtigte Lagerungsänderungen, z. B. durch Zug am Patienten, zu informieren.

• Der Anstieg des intrakompartmentalen Drucks in durch Faszien begrenzten Muskellogen führt zum akuten Kompartmentsyndrom, das ohne Therapie zu einem Extremitätenverlust führen kann.

• Bei peripheren Nervenblockaden sind Nervenstimulator und Ultraschall gleichwertige Techniken, ohne dass bisher eine Präferenz einer der Methoden hinsichtlich der Vermeidung von Nervenschäden gerechtfertigt scheint.

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