Anästhesie und Outcome: Einfluss der perioperativen Prozesse

Zusammenfassung

In den letzten Jahren hat sich die Rolle des Anästhesisten vom „Narkosearzt“ zum perioperativen Mediziner und Risikospezialisten enorm gewandelt. Die Patienten sind älter, multimorbide und werden zu immer umfangreicheren Eingriffen und Interventionen aufgeboten. Sozioökonomische Aspekte haben an Bedeutung zugenommen. Der Anästhesist ist als Wegbereiter eines guten Outcomes in nahezu alle perioperativen Prozesse involviert: präoperative Evaluation, Festlegung und Optimierung der prä- und intraoperativen Bedingungen, moderne intraoperative Anästhesieführung sowie eine postoperative, medizinisch indizierte, effektive und effiziente Behandlung der teilweise hochkomplexen Patienten. Die einzelnen perioperativen Prozessschritte auf diesem Weg werden in Anlehnung an etablierte Leitlinien und die Zunahme der gegenwärtigen Anforderungen beleuchtet. Schließlich wird ein besonderer Akzent auf die Erkenntnis gelegt, dass der perioperative Prozess nicht mit dem Operationsende abgeschlossen ist – postoperatives Outcome ist nicht zuletzt von postoperativen Komplikationen auf der Normalstation negativ beeinflusst. Das Risiko für Todesfälle nach Komplikationen, „Failure to rescue“, sollte frühzeitig erkannt und umgehend behandelt werden.

Der Anästhesist spielt im perioperativen Prozess eine zentrale Rolle. Während das Hauptaugenmerk der Chirurgen auf operationsspezifische Fragen gerichtet ist, muss der Anästhesist sämtliche Patientenfaktoren berücksichtigen – mit dem Ziel, das perioperative Risiko zu reduzieren und das Outcome zu verbessern. Dies umfasst präoperative Risikostratifizierung, perioperative Behandlung sowie Planung und Durchführung der postoperativen Therapie.

Abstract

In recent years, the role of the anesthesiologist has turned tremendously from the “anaesthesia doctor” into a perioperative physician and risk specialist. Patients are older, multimorbid, and are called up for more and more extensive surgery and interventions. Socioeconomic aspects have grown in importance. The anesthesiologist, paving the way for a good outcome, is involved in nearly all perioperative processes: preoperative evaluation, definition and optimization of preoperative and intraoperative conditions, management of modern intraoperative anesthesia as well as postoperative medically indicated, effective and efficient treatment of partially highly complex patients. The individual perioperative process steps in this way are examined in accordance with established guidelines and the increase in current requirements. Finally, a special emphasis is placed on the perception that the perioperative process has not been completed with the end of surgery – postoperative outcome is not least adversely affected by postoperative complications on the normal ward. The risk of death after complications, “failure to rescue”, should be identified early and treated promptly.

Kernaussagen

• Der Anästhesist ist als perioperativer Mediziner und Risikospezialist in nahezu alle perioperativen Prozesse eingebunden.

• Die präoperative Evaluation – möglichst in der Struktur einer Anästhesieambulanz – ist zentrales Element der Risikostratifizierung.

• Risikoscores können Patienten perioperativ in Kategorien einordnen, aber kein individuelles Risiko für jeden Patienten bestimmen. Sie sind jedoch hilfreich für die Weichenstellung der perioperativen Behandlung.

• Für die Implementierung von Risikoscores, Leitlinien und Behandlungspfaden sind interdisziplinäre Kooperation und ein Change Management mit klaren Zuständigkeiten anzustreben.

• Die anästhesieassoziierte Mortalität ist mit 0,68 – 0,82 pro 100000 Fälle erfreulich niedrig; Qualitätsverbesserungen können das Outcome günstig beeinflussen.

• Checklisten und Kommunikation, Teamtraining und „Crisis Ressource Management“ sind wesentliche perioperative Prozessschritte.

• Im postoperativen Verlauf können eine frühzeitige „Postevent-Stratifizierung“ und Intensivierung der Maßnahmen Morbidität und Mortalität senken.

• Die Rate an postoperativen Todesfällen aufgrund von Komplikationen (Failure to rescue, FTR) ist hoch. FTR deutet auf eine verzögerte Reaktion beim Erkennen und Behandeln von Komplikationen hin.

• Der perioperative Risikoverlauf ist dynamisch – Risikopatienten für FTR sollten rechtzeitig und mit geeigneten Warn- und Behandlungssystemen geschützt werden.

Schlüsselwörter

präoperative Evaluation - postoperatives Outcome - Failure to rescue - Risikoscores - Patient Blood Management

Key words

preoperative evaluation - postoperative outcome - failure to rescue - risk scores - Patient Blood Management

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