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.

Schlüsselwörter:

Neurologische Komplikationen - peripherer Nervenschaden - Patientenlagerung

Keywords:

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.

Literatur

• 1 Welch MB, Brummett CM, Welch TD et al.. Perioperative peripheral nerve injuries: a retrospective study of 380,680 cases during a 10-year period at a single institution.  Anesthesiology. 2009;  111 490-497
• 2 Winfree CJ, Kline DG. Intraoperative positioning nerve injuries.  Surg Neurol. 2005;  63
• 3 Prielipp RC, Warner MA. Perioperative nerve injury: a silent scream?.  Anesthesiology. 2009;  111 464-466
• 4 Bund M, Heine J, Jaeger K. Complications due to patient positioning: anaesthesiological considerations.  Anasthesiol Intensivmed Notfallmed Schmerzther. 2005;  40 329-339
• 5 Vogel P. Neurological complications through positioning – neurological viewpoint.  Anasthesiol Intensivmed Notfallmed Schmerzther. 2003;  38 475-478
• 6 Sunderland S. A classification of peripheral nerve injuries producing loss of function.  Brain. 1951;  74 491-516
• 7 Delank H-W, Gehlen W.. Neurologie. Stuttgart: Georg Thieme Verlag; 2006. 11. Auflage.
• 8 Borgeat A, Blumenthal S. Nerve injury and regional anaesthesia.  Curr Opin Anaesthesiol. 2004;  17 417-421
• 9 Upton AR, McComas AJ. The double crush in nerve entrapment syndromes.  Lancet. 1973;  2 359-362
• 10 Opderbecke HW, Weißauer W. Entschließungen – Empfehlungen – Vereinbarungen. Ebelsbach: Aktiv Druck & Verlag GmbH; 2006. 4. Auflage.
• 11 Heimbach D, Weissauer W. Legal aspects of injuries due to positioning of the patient in urology.  Urologe A. 2004;  43 469-478
• 12 Alvine FG, Schurrer ME. Postoperative ulnar-nerve palsy. Are there predisposing factors?.  J Bone Joint Surg Am. 1987;  69 255-259
• 13 Warner MA, Martin JT, Schroeder DR, Offord KP, Chute CG. Lower-extremity motor neuropathy associated with surgery performed on patients in a lithotomy position.  Anesthesiology. 1994;  81 6-12
• 14 Warner MA, Warner DO, Harper CM, Schroeder DR, Maxson PM. Lower extremity neuropathies associated with lithotomy positions.  Anesthesiology. 2000;  93 938-942
• 15 Standl T. Viszeralchirurgie. In: Kochs E, Adams HA, Spies C, Hrsg. Anästhesiologie. Stuttgart: Thieme; 2008. 2. Aufl. 880-882
• 16 Auerhammer J. Positioning of the patient for surgery.  Anaesthesist. 2008;  57 1107-1126
• 17 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group.  N Engl J Med. 1996;  334 1209-1215
• 18 Teeples TJ, Rallis DJ, Rieck KL, Viozzi CF. Lower Extremity Compartment Syndrome Associated With Hypotensive General Anesthesia for Orthognathic Surgery: A Case Report and Review of the Disease.  J Oral Maxillofac Surg. 2010;  68 1166-1170
• 19 Freye E, Grabitz K, Sandmann W. Spinal cord ischemia – use of spinal-evoked potentials for intraoperative monitoring in thoraco-abdominal aortic aneurysm (TAA) repair.  Acta Anaesthesiol Scand Suppl. 1996;  109 50-53
• 20 Fehlings MG, Brodke DS, Norvell DC, Dettori JR. The evidence for intraoperative neurophysiological monitoring in spine surgery: does it make a difference?.  Spine (Phila Pa 1976). 2010;  35 37-46
• 21 Ullrich W, Biermann E, Kienzle F, Krier C. Damage due to patient positioning in anesthesia and surgical medicine (1).  Anasthesiol Intensivmed Notfallmed Schmerzther. 1997;  32 4-20
• 22 Albers P, Müller SC. Läsionen peripherer Nerven durch Einsatz selbsthaltender Abdominalsperrer. In: Steffens J, Langen P-H, Hrsg. Komplikationen in der Urologie. Darmstadt: Steinkopff; 2002: 397-400
• 23 Röher HD, Ohmann C, Beck L. Acute compartment syndrome due to positioning during long-lasting gynecological operations in the lithotomy position.  Gynäkologe. 2008;  41 1023-1026
• 24 Schutte JK, Gerbershagen MU, Wappler F. Anaesthesia associated rhabdomyolysis. Diagnosis, therapy and prevention of skeletal muscle breakdown.  Anasthesiol Intensivmed Notfallmed Schmerzther. 2006;  41 462-453
• 25 Tiwari A, Haq AI, Myint F, Hamilton G. Acute compartment syndromes.  Br J Surg. 2002;  89 397-412
• 26 Heemskerk J, Kitslaar P. Acute compartment syndrome of the lower leg: retrospective study on prevalence, technique, and outcome of fasciotomies.  World J Surg. 2003;  27 744-747
• 27 Fishman JM. Recurrent laryngeal nerve palsy complicating subclavian line insertion: a case report.  J Med Case Reports. 2009;  3 9034
• 28 Uslu M. Leitfaden der zentralvenösen Katheterisierung. Stuttgart: Thieme; 1997
• 29 Salman M, Potter M, Ethel M, Myint F. Recurrent laryngeal nerve injury: a complication of central venous catheterization-a case report.  Angiology. 2004;  55 345-346
• 30 Aggarwal S, Hari P, Bagga A, Mehta SN. Phrenic nerve palsy: a rare complication of indwelling subclavian vein catheter.  Pediatr Nephrol. 2000;  14 203-204
• 31 Koehler PJ, Wijngaard PR. Brown-Sequard syndrome due to spinal cord infarction after subclavian vein catheterisation.  Lancet. 1986;  2 914-915
• 32 Risch M, Aguirre J, Perniola L, Borgeat A, Ehrenberg R. Neurological complication after a vertical infraclavicular brachial plexus block.  Anaesthesist. 2010; 
• 33 Auroy Y, Benhamou D, Bargues L et al.. Major complications of regional anesthesia in France: The SOS Regional Anesthesia Hotline Service.  Anesthesiology. 2002;  97 1274-1280
• 34 Auroy Y, Narchi P, Messiah A et al.. Serious complications related to regional anesthesia: results of a prospective survey in France.  Anesthesiology. 1997;  87 479-486
• 35 Capdevila X, Pirat P, Bringuier S et al.. Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients.  Anesthesiology. 2005;  103 1035-1045
• 36 Barrington MJ, Watts SA, Gledhill SR et al.. Preliminary results of the Australasian Regional Anaesthesia Collaboration: a prospective audit of more than 7000 peripheral nerve and plexus blocks for neurologic and other complications.  Reg Anesth Pain Med. 2009;  34 534-541
• 37 Neuburger M, Breitbarth J, Reisig F, Lang D, Buttner J. Complications and adverse events in continuous peripheral regional anesthesia Results of investigations on 3,491 catheters.  Anaesthesist. 2006;  55 33-40
• 38 Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and nonacute complications associated with interscalene block and shoulder surgery: a prospective study.  Anesthesiology. 2001;  95 875-880
• 39 Brull R, McCartney CJ, Chan VW, El-Beheiry H. Neurological complications after regional anesthesia: contemporary estimates of risk.  Anesth Analg. 2007;  104 965-974
• 40 Liu SS, Zayas VM, Gordon MA et al.. A prospective, randomized, controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms.  Anesth Analg. 2009;  109 265-271
• 41 Sauter AR, Dodgson MS, Stubhaug A, Halstensen AM, Klaastad O. Electrical nerve stimulation or ultrasound guidance for lateral sagittal infraclavicular blocks: a randomized, controlled, observer-blinded, comparative study.  Anesth Analg. 2008;  106 1910-1915
• 42 Danelli G, Fanelli A, Ghisi D et al.. Ultrasound vs nerve stimulation multiple injection technique for posterior popliteal sciatic nerve block.  Anaesthesia. 2009;  64 638-642
• 43 Bigeleisen PE, Moayeri N, Groen GJ. Extraneural versus intraneural stimulation thresholds during ultrasound-guided supraclavicular block.  Anesthesiology. 2009;  110 1235-1243
• 44 Borgeat A. Regional anesthesia, intraneural injection, and nerve injury: beyond the epineurium.  Anesthesiology. 2006;  105 647-648
• 45 Pitman MI, Nainzadeh N, Ergas E, Springer S. The use of somatosensory evoked potentials for detection of neuropraxia during shoulder arthroscopy.  Arthroscopy. 1988;  4 250-255
• 46 Bigeleisen PE. Nerve puncture and apparent intraneural injection during ultrasound-guided axillary block does not invariably result in neurologic injury.  Anesthesiology. 2006;  105 779-783
• 47 Jochum D, Bondar A, Delaunay L, Egan M, Bouaziz H. One size does not fit all: proposed algorithm for ultrasonography in combination with nerve stimulation for peripheral nerve blockade.  Br J Anaesth. 2009;  103 773-774
• 48 Beach ML, Sites BD, Gallagher JD. Use of a nerve stimulator does not improve the efficacy of ultrasound-guided supraclavicular nerve blocks.  J Clin Anesth. 2006;  18 580-584
• 49 Benumof JL. Permanent loss of cervical spinal cord function associated with interscalene block performed under general anesthesia.  Anesthesiology. 2000;  93 1541-1544
• 50 Neal JM, Bernards CM, Hadzic A et al.. ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine.  Reg Anesth Pain Med. 2008;  33 404-415
• 51 Bogdanov A, Loveland R. Is there a place for interscalene block performed after induction of general anaesthesia?.  Eur J Anaesthesiol. 2005;  22 107-110
• 52 Borgeat A, Aguirre J, Curt A. Case scenario: neurologic complication after continuous interscalene block.  Anesthesiology. 2010;  112 742-745
• 53 Wallach SG. Cannulation injury of the radial artery: diagnosis and treatment algorithm.  Am J Crit Care. 2004;  13 315-319
• 54 Slogoff S, Keats AS, Arlund C. On the safety of radial artery cannulation.  Anesthesiology. 1983;  59 42-47
• 55 Bhananker SM, Liau DW, Kooner PK et al.. Liability related to peripheral venous and arterial catheterization: a closed claims analysis.  Anesth Analg. 2009;  109 124-129
• 56 Singleton RJ, Webb RK, Ludbrook GL, Fox MA. The Australian Incident Monitoring Study. Problems associated with vascular access: an analysis of 2000 incident reports.  Anaesth Intensive Care. 1993;  21 664-669
• 57 Debnath D, Wallace S, Mylona E, Myint F. Aneurysm of antecubital vein: an unusual complication of peripheral intravenous cannulation.  BMC Surg. 2007;  7 9
• 58 Liau DW. Injuries and liability related to periphereal catheters: A closed Claims Analysis.  ASA Newsletter. 2006;  70
• 59 Horlocker TT, Bishop AT. Compartment syndrome of the forearm and hand after brachial artery cannulation.  Anesth Analg. 1995;  81 1092-1094
• 60 Martin C, Saux P, Papazian L, Gouin F. Long-term arterial cannulation in ICU patients using the radial artery or dorsalis pedis artery.  Chest. 2001;  119 901-906
• 61 Karacalar S, Ture H, Baris S, Karakaya D, Sarihasan B. Ulnar artery versus radial artery approach for arterial cannulation: a prospective, comparative study.  J Clin Anesth. 2007;  19 209-213
• 62 Dashkoff N, Dashkoff PB, Zizzi Sr. JA, Wadhwani J, Zizzi Jr. JA. Ulnar artery cannulation for coronary angiography and percutaneous coronary intervention: case reports and anatomic considerations.  Catheter Cardiovasc Interv. 2002;  55 93-96
• 63 Bazaral MG, Welch M, Golding LA, Badhwar K. Comparison of brachial and radial arterial pressure monitoring in patients undergoing coronary artery bypass surgery.  Anesthesiology. 1990;  73 38-45
• 64 Barnes RW, Foster EJ, Janssen GA, Boutros AR. Safety of brachial arterial catheters as monitors in the intensive care unit--prospective evaluation with the Doppler ultrasonic velocity detector.  Anesthesiology. 1976;  44 260-264
• 65 Maki DG, Ringer M. Risk factors for infusion-related phlebitis with small peripheral venous catheters. A randomized controlled trial.  Ann Intern Med. 1991;  114 845-854
• 66 Oexmann B. Juristische Aspekte bei intraoperativ bedingten Lagerungsschäden / Abgrenzung der Verantwortlichkeit zwischen Anästhesist und Operateur.  Hamm. 2008; 
• 67 Adam C, Quabach R, Standl T. Neurological complications following anesthesia – Perioperative stroke, postoperative visual loss, anticholingeric syndrom.  Anästhesiol Intensivmed Notfallmed Schmerzther. 2010;  45 440-447