Therapie des peri- und postoperativen hypertensiven Notfalls

Zusammenfassung

Perioperativ treten akute hypertensive „Dringlichkeiten” oder hypertensive „Notfälle” bei 5 bis 35 % aller Patienten auf. Dies geht mit einem Anstieg perioperativer Komplikationen einher: Blutungen, Myokardinfarkt, Schlaganfall und Sterblichkeit sind bis zu 4-fach erhöht. Präoperativ stehen das Erkennen von Prädiktoren für hypertensive Entgleisungen sowie eine adäquate Blutdruckeinstellung im Vordergrund. Es gibt keinen Konsens darüber, ab welchen Blutdruck-Schwellenwert behandelt werden soll. Die Behandlung ist eine „bedside”-Entscheidung des behandelnden Arztes, mit dem Ziel, Blutdruckentgleisungen rasch abzusenken ohne dabei eine Organminderperfusion zu riskieren. Das ideale Medikament zur Behandlung des hypertensiven Notfalls sollte unmittelbar und vorhersehbar wirken. Antihypertensiva der ersten Wahl sind Esmolol, Metoprolol, Urapidil oder Clonidin, wobei jede Substanz Vor- und Nachteile besitzt. Die orale Gabe von Nifedipin oder Nitrendipin bergen die Gefahr abrupter nicht vorhersagbarer Blutdruckabfälle und sollten daher nur nach Ausschluss eines akuten Koronarsyndroms und einer Herzinsuffizienz gegeben werden. Natrium-Nitroprussid ist aufgrund seiner Toxizität und zum Teil schwierigen Handhabung ein Antihypertensivum der 2. Wahl. Nitrate oder Diuretika sind Ergänzungstherapien bei Patienten mit begleitender instabiler Angina pectoris, Linksherzdekompensation oder Überwässerung bei Niereninsuffizienz. Neuere Substanzen (Fenoldopam, Nicardipine, Clevidipine), die in Deutschland noch nicht zugelassen sind, haben eine vielversprechendere Wirkungskinetik.

Summary

Acute hypertensive emergencies occur in 5 to 35 % of the patients in perioperative care. This is associated with an increase in perioperative complications: the rate of bleedings, myocardial infarctions, cerebral ischemia and overall mortality is increased 4-fold. Before an operation, it is of utmost importance to recognize predictors for hypertensive emergencies and to achieve an adequate blood pressure control. There has so far been no agreement on a blood pressure threshold at which blood pressure needs to be reduced. Antihypertensive therapy is a bedside decision of the responsible physician. It aims at a rapid decrease of hypertensive peaks without risking a reduced organ perfusion. The optimal drug for the treating hypertensive emergencies should have a rapid and safe action. Antihypertensives of first choice are esmolol, metoprolol, urapidil or clonidin. The oral therapy with nifedipine or nitrendipine has the risk of abrupt hypotensive episodes and should therefore only be administered after exclusion of an acute coronary syndrome or cardiac failure Because of its toxicity soduim nitroprusside is an antihypertensive drug of second choice. Nitrates or diuretics are supplementary drugs for patients with angina pectoris, cardiac failure or renal insufficiency. Newer substances (fenoldopam, nicardipine, clevidipine) have promising kinetic properties but are not as yet been approved for antihypertensive treatment in Germany.

Schlüsselwörter

hypertensiver Notfall - hypotensive Medikamente

Keywords

hypertensive emergency - hypotensive drugs

Literatur

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