Anästhesiol Intensivmed Notfallmed Schmerzther 2019; 54(05): 334-346
DOI: 10.1055/a-0668-4653
Topthema
CME-Fortbildung
Georg Thieme Verlag KG Stuttgart · New York

Pulmonale Hypertonie: anästhesiologisches Management

Anaesthesia in Patients with Pulmonary Hypertension
Alexander Hötzel
,
Torsten Loop
Further Information

Publication History

Publication Date:
13 May 2019 (online)

Zusammenfassung

Das perioperative Management von Patienten mit pulmonaler Hypertonie erfordert von den behandelnden Anästhesisten fundierte Kenntnisse über die zugrunde liegenden Ursachen, die Pathophysiologie, den Einfluss anästhesiologischer und chirurgischer Maßnahmen wie z. B. die mechanische Beatmung sowie intraoperative Behandlungsoptionen. In der präoperativen Vorbereitung gilt es, alle vorliegenden Befunde zu evaluieren, die Belastbarkeit des Patienten zu erheben und die bestehende Dauermedikation zu kennen. Die Basis für einen sicheren intraoperativen Verlauf stellt die Vermeidung einer pulmonalarteriellen Druckerhöhung und Rechtsherzdysfunktion dar. Hierbei gilt es Hypoxie, Hyperkapnie, Azidose, Hypothermie, Stress und eine koronare Hypoperfusion zu verhindern. Bei einem Anstieg des pulmonalarteriellen Drucks können sowohl inhalative, selektive pulmonale Vasodilatatoren, wie Stickstoffmonoxid oder Prostazykline, als auch intravenös Phosphodiesterase-3-Inhibitoren und Phosphodiesterase-5-Inhibitoren eingesetzt werden. Bei einer rechtsventrikulären Dysfunktion oder Dekompensation sollte mittels inotroper Substanzen und Inodilatoren die Herzfunktion unterstützt werden. Abhängig vom Ausmaß der Operation und dem Schweregrad der pulmonalen Hypertonie erfordert die postoperative Betreuung vor allem Expertise und Strukturen, die ein kontinuierliches Monitoring zulassen.

Für das anästhesiologische perioperative Management von Patienten mit pulmonaler Hypertonie sind fundierte Kenntnisse der Erkrankung essenziell – nur so lässt sich eine sichere Versorgung dieser Patienten gewährleisten. Das Ziel der Übersicht ist es, insbesondere Kollegen, die nicht täglich in der Herz-/Thoraxanästhesie tätig sind, das notwendige anästhesiologische Wissen zu vermitteln.

Abstract

The perioperative management of patients with pulmonary hypertension requires an in-depth knowledge of the underlying disease, its related pathophysiology, effects of anaesthesia and surgery, as well as the appropriate pharmacotherapy. With respect to preoperative assessment, it is essential to review all available diagnostic findings, evaluate the patientʼs physical state, and to plan the anaesthetic procedure. Intraoperatively, the prevention of increases in pulmonary resistance and right ventricular decompensation appears essential. For this purpose, stress, hypothermia, decreased systemic perfusion, hypercapnia, hypoxemia, acidosis, and invasive mechanical ventilation should be avoided. If the pulmonary artery pressure exacerbates, application of inhaled nitric oxide or prostacyclins (iloprost), phosphodiesterase-III-inhibitors (milrinone) and phosphodiesterase-V-inhibitors (sildenafil), reflect first-line treatment options. In order to support the right ventricle, inotropes (adrenalin, dobutamine, levosimendan) or inodilators (milrinone) increase its contractility. Dependent on severity of disease and the magnitude of surgical intervention, patients with pulmonary hypertension require a specific continuous monitoring as well as trained staff in the postoperative period.

Kernaussagen
  • Die präoperative Evaluation und Planung des Patienten mit pulmonaler Hypertonie sind für die sichere Durchführung der Anästhesie essenziell.

  • Hypoxie, Hyperkapnie, Azidose, Hypothermie, Stress und Blutdruckabfall gilt es strikt zu vermeiden.

  • Die Beatmung sollte so wenig invasiv wie möglich eingestellt und der PEEP titriert werden.

  • Zur Senkung des pulmonalarteriellen Drucks eignen sich vor allem inhalativ applizierte pulmonale Vasodilatatoren wie Stickstoffmonoxid oder Prostazykline bzw. deren Kombination.

  • Bei i. v. verabreichten pulmonalen Vasodilatatoren wie Phosphodiesterase-3- und Phosphodiesterase-5-Inhibitoren muss ein begleitender Abfall des Blutdrucks berücksichtigt und konsequent behandelt werden.

  • Bei rechtsventrikulärer Dysfunktion gilt es, mittels inotroper Substanzen und Inodilatoren die Herzfunktion zu unterstützen.

  • Auch in der postoperativen Phase besteht ein erhebliches Risiko der Dekompensation des Krankheitsbildes und es bedarf einer intensiven Überwachung.

 
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