Regionalanästhesie bei Patienten mit Adipositas – Was ist anders?

Zusammenfassung

Grundsätzlich weist die Regionalanästhesie auch bei Patienten mit Adipositas gegenüber der Allgemeinanästhesie multiple Vorteile auf. Die Vermeidung von Atemwegsmanipulationen und der systemischen Applikation von Opioiden spielt dabei eine Schlüsselrolle. Obwohl sich Anästhesisten zunehmend häufiger mit der Versorgung extrem adipöser Patienten konfrontiert sehen, stellt die Regionalanästhesie dennoch bei schwer zu identifizierenden anatomischen Landmarken, tiefer liegenden nervalen Strukturen und Problemen bei der Lagerung eine Herausforderung dar. Adipositas ist bei zahlreichen Regionalanästhesien mit einer höheren Versagerquote aufgrund größerer Punktionsschwierigkeiten verbunden, aber nicht mit einer höheren Komplikationsrate assoziiert.

Ultraschall kann hier eine wichtige Hilfe sein, geht jedoch selbst mit spezifischen adipositasassoziierten Phänomenen einher. Es besteht weiterer Studienbedarf zur Entwicklung optimaler Regionalanästhesietechniken mit und ohne Sonografie, von Dosierungsempfehlungen von Lokalanästhetika zur Verminderung von Blockadeversagern sowie zurVerbesserung der Patientensicherheit und des Outcomes bei Patienten mit Adipositas.

Abstract

Basically regional anaesthesia offers a lot of advantages compared with general anaesthesia for obese patients, e.g. avoiding airway manipulation and systemic application of opioids. Although anesthesiologists are increasingly faced with obesity, regional anaesthesia poses a challenge because of missing landmarks, increased depth of nerval structures and difficulties in positioning these patients. While obesity is not associated with an increased risk for severe complications in regional anaesthesia, a higher failure rate can be observed because of difficulties in performing the blocks. Ultrasound guidance may be an important aid but it is associated with specific phenomena caused by obesity. Further studies are needed to optimize regional anaesthesia techniques and dosing of local anaesthetics avoiding block failures as well to improve the patients' safety and outcome.

Kernaussagen

• Etwa die Hälfte aller Krankenhauspatienten ist übergewichtig, 32 % von ihnen gelten als adipös.

• Es gibt Hinweise für die Existenz eines Obesity Paradox bei übergewichtigen und Adipositas-Grad II-Patienten, allerdings auch für ein signifikant höheres kardiales und renales Risiko krankhaft übergewichtiger Patienten (BMI ≥ 50 kg/m²).

• Die Versagerrate konventionell durchgeführter peripherer als auch neuroaxialer Blockaden ist in Abhängigkeit vom BMI erhöht.

• Die Versagerate für die Epiduralanästhesie ist bei Adipositas in der Schwangerschaft erhöht.

• Eine Verminderung der Lokalanästhetikadosis zur Sectio caesarea bei adipösen Schwangeren wird aktuell kontrovers diskutiert.

• Die Sonografie kann bei Adipositas eine wertvolle Hilfe bei der Planung und Durchführung sowohl peripherer als auch rückenmarksnaher Blockaden sein.

Schlüsselwörter:

Regionalanästhesie - Adipositas - periphere Nervenblockade - neuroaxialer Block - Komplikationen - Ultraschall gesteuerte Punktion - Versagerrate

Key words:

regional anaesthesia - obesity - peripheral nerve block - neuroaxial block complications - failure rate - ultrasound guided block

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