Postoperative Akutschmerztherapie - Schwere Komplikationen durch Regionalanalgesieverfahren - Symptome, Diagnose und Therapie

Zusammenfassung

Regionalanästhesieverfahren haben mittlerweile einen bedeutenden Stellenwert in der perioperativen Schmerztherapie. Neben den unbestrittenen Vorteilen (v.a. der thorakalen Epiduralanalgesie) hinsichtlich effektiver Analgesie und erniedrigter Patientenmorbidität v.a. bei Risikopatienten besteht aber ein gewisses Risiko für das Auftreten von Komplikationen wie einem epiduralen Hämatom, einem epiduralen Abszess oder einer systemischen Lokalanästhetika-Intoxikation. Epidurale Raumforderungen nach Anlage eines Katheters sind zwar seltene Komplikationen, können aber bis hin zu irreversiblen neurologischen Schäden wie einer kompletten Querschnittsymptomatik führen. Daher ist eine schnelle und zielgerichtete Diagnostik (MRI ist Goldstandard) und Therapie (ggf. chirurgische Entlastung) für die klinischen Prognose des Patienten entscheidend. Eine weitere, seltene, aber potenziell letale Komplikation regionaler Analgesieverfahren ist eine systemische Lokalanästhetika-Intoxikation mit den daraus resultierenden Folgen, insbesondere zentralnervöser sowie myokardialer und vaskulärer Blockade von Natriumkanäle mit hämodynamisch relevanten und zum Teil therapierefraktären kardialen Rhythmusstörungen. In der vorliegenden Übersichtsarbeit wird anhand der aktuellen Literatur die Inzidenz wichtiger, durch neuroaxiale Analgesieverfahren verursachte Komplikationen beurteilt, klinische Symptome beschrieben sowie die entsprechenden diagnostischen und therapeutischen Möglichkeiten diskutiert.

Summary

Neuroaxial anesthesia has become an integral part of perioperative pain therapy and provides several advantages over systemic opioids. Despite these benefits, rare but serious complications occur with epidural analgesia including epidural haematoma, spinal-epidural infections and local anesthetic cardiac toxicity.

Epidural haematoma and epidural abscess after catheter placement may cause irreversible neurological complications and an immediate diagnostic and therapeutic approach is crucial to assure complete recovery. Furthermore, local anesthetic-induced cardiac toxicity is another rare but potentially lethal complication during regional anesthesia. Based on lipophilic and hydrophilic properties, local anesthetics can interfere with ion channels such as sodium, potassium and calcium channels of the CNS and the heart leading to severe neuronal and cardiac (arrhythmia and contractile depression) adverse effects. In this review we take an in-depth look at severe complications associated with regional anesthesia, describe their symptoms and discuss appropriate diagnostic and therapeutical approaches.

Schlüsselwörter:

Neuroaxiale Blockade - Epiduralanalgesie - neurologische Komplikationen - postoperativer Akutschmerz - systemische Lokalanästhetika-,Intoxikation

Key words:

Neuraxial Blockade - neurological complications - postoperative pain - systemic toxicity

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