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.

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

• Literatur

• 1 Robert Koch-Institut. Daten und Fakten: Ergebnisse der Studie "Gesundheit in Deutschland aktuell 2009" (Erwachsene): Übergewicht und Adipositas. Beiträge zur Gesundheitsberichterstattung des Bundes. Berlin: Robert Koch-Institut; 2011: 100-102
• 2 Carrasco Sanchez FJ, Diaz Alcaide F, Marin Fernandez Y et al. Prevalence of obesity in hospitalized internal medicine patients. Anales de medicina interna 2002; 19: 453-456
• 3 Fettes SB, Davidson HI, Richardson RA et al. Nutritional status of elective gastrointestinal surgery patients pre- and post-operatively. Clinical nutrition 2002; 21: 249-254
• 4 Planas M, Audivert S, Perez-Portabella C et al. Nutritional status among adult patients admitted to an university-affiliated hospital in Spain at the time of genoma. Clinical nutrition 2004; 23: 1016-1024
• 5 Mullen JT, Moorman DW, Davenport DL. The obesity paradox: body mass index and outcomes in patients undergoing nonbariatric general surgery. Ann Surg 2009; 250: 166-172
• 6 Glance LG, Wissler R, Mukamel DB et al. Perioperative outcomes among patients with the modified metabolic syndrome who are undergoing noncardiac surgery. Anesthesiology 2010; 113: 859-872
• 7 Gross JB, Bachenberg KL, Benumof JL et al. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology quiz 2006; 104: 1117-1088
• 8 Lewandowski K, Turinsky S. Beatmung von Patienten mit Adipositas per magna in Anästhesie und Intensivmedizin. Anaesthesist quiz 2008; 57: 1033-1034
• 9 Kranke P, Apefel CC, Papenfuss T et al. An increased body mass index is no risk factor for postoperative nausea and vomiting. A systematic review and results of original data. Acta Anaesthesiol Scand 2001; 45: 160-166
• 10 Ingrande J, Brodsky JB, Lemmens HJ. Regional anesthesia and obesity. Curr Opin Anaesthesiol 2009; 22: 683-686
• 11 Nielsen KC, Guller U, Steele SM et al. Influence of obesity on surgical regional anesthesia in the ambulatory setting: an analysis of 9,038 blocks. Anesthesiology 2005; 102: 181-187
• 12 Brodsky JB, Mariano ER. Regional anaesthesia in the obese patient: lost landmarks and evolving ultrasound guidance. Best Pract Res Clin Anaesthesiol 2011; 25: 61-72
• 13 Michaloudis D, Fraidakis O, Petrou A et al. Continuous spinal anesthesia/analgesia for perioperative management of morbidly obese patients undergoing laparotomy for gastroplastic surgery. Obes Surg 2000; 10: 220-229
• 14 Franco CD, Gloss FJ, Voronov G et al. Supraclavicular block in the obese population: an analysis of 2020 blocks. Anesth Analg 2006; 102: 1252-1254
• 15 Hanouz JL, Grandin W, Lesage A et al. Multiple injection axillary brachial plexus block: influence of obesity on failure rate and incidence of acute complications. Anesth Analg 2010; 111: 230-233
• 16 Cotter JT, Nielsen KC, Guller U et al. Increased body mass index and ASA physical status IV are risk factors for block failure in ambulatory surgery – an analysis of 9,342 blocks. Can J Anaesth 2004; 51: 810-816
• 17 Catalano PM. Management of obesity in pregnancy. Obstet Gynecol 2007; 109: 419-433
• 18 Chu SY, Kim SY, Schmid CH et al. Maternal obesity and risk of cesarean delivery: a meta-analysis. Obesity Reviews 2007; 8: 385-394
• 19 Cantwell R, Clutton-Brock T, Cooper G et al. Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006–2008. The eighth report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011; 118 (Suppl. 01) 1-203
• 20 Lewis G Hrsg. The Confidential Enquiry into Maternal and Child Health (CEMACH). Why mothers die 2000–2002. The sixth report of Confidential Enquiry into Maternal Death in the United Kingdom. London: RCOG press; 2004
• 21 Lewis G. The Confidential Enquiry into Maternal and Child Health (CEMACH).Saving mother's lives: reviewing maternal deaths to make motherhood safer: 2003–2005.The seventh report on Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press; 2007
• 22 Rahman K, Jenkins JG. Failed tracheal intubation in obstetrics: no more frequent but still managed badly. Anaesthesia 2005; 60: 168-171
• 23 Hood DD, Dewan DM. Anesthetic and obstetric outcome in morbidly obese parturients. Anesthesiology 1993; 79: 1210-1218
• 24 Perlow JH, Morgan MA. Massive maternal obesity and perioperative cesarean morbidity. Am J Obstet Gynecol 1994; 170: 560-565
• 25 Bamgbade OA, Khalaf WM, Ajai O et al. Obstetric anaesthesia outcome in obese and non-obese parturients undergoing caesarean delivery: an observational study. Int J Obstet Anaesth 2009; 18: 221-225
• 26 Ellinas EH, Eastwood DC, Patel SN et al. The effect of obesity on neuraxial technique difficulty in pregnant patients: a prospective, observational study. Anesth Analg 2009; 109: 1225-1231
• 27 von Ungern-Sternberg BS, Regli A, Bucher E et al. Impact of spinal anaesthesia and obesity on maternal respiratory function during elective Caesarean section. Anaesthesia 2004; 59: 743-749
• 28 Regli A, von Ungern-Sternberg BS, Reber A et al. Impact of spinal anaesthesia on peri-operative lung volumes in obese and morbidly obese female patients. Anaesthesia 2006; 61: 215-221
• 29 Pitkanen MT. Body mass and spread of spinal anesthesia with bupivacaine. Anesth Analg 1987; 66: 127-131
• 30 Taivainen T, Tuominen M, Rosenberg PH. Influence of obesity on the spread of spinal analgesia after injection of plain 0,5% bupivacaine at the L3–4 or L4–5 interspace. Br J Anaesth 1990; 64: 542-546
• 31 Carvalho B, Collins J, Drover DR et al. ED(50) and ED(95) of intrathecal bupivacaine in morbidly obese patients undergoing cesarean delivery. Anesthesiology 2011; 114: 529-535
• 32 Pace NL. Intrathecal dosing for cesarean delivery in obese and nonobese patients. Anesthesiology author reply 2011; 115
• 33 Palmer CM. Let's just call it "evidence-based practice". Anesthesiology 2011; 114: 481-482
• 34 Norris MC. Height, weight, and the spread of subarachnoid hyperbaric bupivacaine in the term parturient. Anesth Analg 1988; 67: 555-558
• 35 Norris MC. Patient variables and the subarachnoid spread of hyperbaric bupivacaine in the term parturient. Anesthesiology 1990; 72: 478-482
• 36 Hartwell BL, Aglio LS, Hauch MA et al. Vertebral column length and spread of hyperbaric subarachnoid bupivacaine in the term parturient. Reg Anesth 1991; 16: 17-19
• 37 Panni MK, Columb MO. Obese parturients have lower epidural local anaesthetic requirements for analgesia in labour. Br J Anaesth 2006; 96: 106-110
• 38 Hodgkinson R, Husain FJ. Obesity and the cephalad spread of analgesia following epidural administration of bupivacaine for Cesarean section. Anesth Analg 1980; 59: 89-92
• 39 Hogan QH, Prost R, Kulier A et al. Magnetic resonance imaging of cerebrospinal fluid volume and the influence of body habitus and abdominal pressure. Anesthesiology 1996; 84: 1341-1349
• 40 Carpenter RL, Hogan QH, Liu SS et al. Lumbosacral cerebrospinal fluid volume is the primary determinant of sensory block extent and duration during spinal anesthesia. Anesthesiology 1998; 89: 24-29
• 41 Schwemmer U, Papenfuss T, Greim C et al. Ultrasound-guided interscalene brachial plexus anaesthesia: differences in success between patients of normal and excessive weight. Ultraschall in Med 2006; 27: 245-250
• 42 Chantzi C, Saranteas T, Zogogiannis J et al. Ultrasound examination of the sciatic nerve at the anterior thigh in obese patients. Acta Anaesthesiol Scand 2007; 51: 132-132
• 43 Mariano ER, Brodsky JB. Comparison of procedural times for ultrasound-guided perineural catheter insertion in obese and nonobese patients. J Ultrasound Med 2011; 30: 1357-1361
• 44 Clinkscales CP, Greenfield ML, Vanarase M et al. An observational study of the relationship between lumbar epidural space depth and body mass index in Michigan parturients. Int J Obstet Anaesth 2007; 16: 323-327
• 45 Arzola C, Davies S, Rofaeel A et al. Ultrasound using the transverse approach to the lumbar spine provides reliable landmarks for labor epidurals. Anesth Analg 2007; 104: 1188-1192
• 46 Balki M, Lee Y, Halpern S et al. Ultrasound imaging of the lumbar spine in the transverse plane: the correlation between estimated and actual depth to the epidural space in obese parturients. Anesth Analg 2009; 108: 1876-1881
• 47 Chin KJ, Perlas A, Chan V et al. Ultrasound imaging facilitates spinal anesthesia in adults with difficult surface anatomic landmarks. Anesthesiology 2011; 115: 94-101
• 48 Saranteas T. Limitations in ultrasound imaging techniques in anesthesia: obesity and muscle atrophy?. Anesth Analg 2009; 109: 993-994
• 49 Halpern SH, Banerjee A, Stocche R et al. The use of ultrasound for lumbar spinous process identification: A pilot study. Can JAnaesth 2010; 57: 817-822
• 50 Margarido CB, Arzola C, Balki M et al. Anesthesiologists' learning curves for ultrasound assessment of the lumbar spine. Can JAnaesth 2010; 57: 120-126
• 51 Guh DP, Zhang W, Bansback N et al. The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis. BMC public health 2009; 9: 88-88
• 52 Brodsky JB, Lemmens HJ, Brock-Utne JG et al. Morbid obesity and tracheal intubation. Anesth Analg 2002; 94: 732-736
• 53 Bein B, Hocker J, Fudickar A et al. Anästhesie bei Adipositas – Begleiterkrankungen und perioperatives Management bei adipösen Erwachsenen. Anästhesiol Intensivmed Notfallmed Schmerzther quiz 2009; 44