Intraoperative Wachheit

Zusammenfassung

Seit den Anfängen der klinischen Anästhesie wird über nicht vorhersehbare Episoden von intraoperativer Wachheit und postoperativer Erinnerung berichtet. Auch heute werden von Zeit zu Zeit Fallberichte über intraoperative Wachheit veröffentlicht. Diese dürften jedoch nur die Spitze des Eisbergs darstellen, denn die Mehrzahl der Patienten mit Erinnerung an intraoperative Wachheit erzählen ihrem Anästhesisten davon nichts. Nach neueren Studien liegt die Häufigkeit postoperativer Erinnerung an intraoperative Wachheitsphasen bei 0,1 - 0,2 % aller Allgemeinanästhesien. Die Häufigkeit ist höher bei kompletter neuromuskulärer Blockade. Das Risiko ist erhöht bei Patienten, die nur geringe Mengen Anästhetika erhalten, z. B. bei hämodynamischer Instabilität, Sectio caesarea vor Abnabelung oder herzchirurgischen Eingriffen. Intraoperative Wachheit zieht nicht zwingend explizite (bewusste) Erinnerung nach sich. Auch ohne das Vorliegen expliziter Erinnerung an intraoperative Wachheit kann implizite (unbewusste) Erinnerung Folgen für den Patienten haben, schlimmstenfalls zur Entstehung der posttraumatischen Belastungsstörung führen. Positive Folgen intraoperativer Wahrnehmung scheinen durch Einsatz intraoperativer positiver Suggestionen möglich, dies ist jedoch umstritten. Der Einsatz von Benzodiazepinen zur Blockade bewusster Erinnerung sollte kritisch überdacht werden. Wichtiger scheint es, auf komplette Blockade der neuromuskulären Übertragung wann immer möglich zu verzichten. Bei Vermutung intraoperativer Wachheit sollte der Anästhesist mit dem Patienten sprechen, ihm die momentane Situation erklären und beruhigend auf ihn einwirken, bis wieder ausreichende Narkosetiefe erreicht ist. Im Rahmen der postoperativen Visite sollte nach Erinnerung an Wachheitsphasen gefragt werden. Patienten, die über intraoperative Wachheit berichten, müssen ernst genommen werden. Eine Erklärung des Geschehens sowie der rasche Beginn psychologischer Betreuung verringern die Wahrscheinlichkeit schwerer Folgen.

Abstract

The first cases of general anesthesia were already cases with awareness. Until today, case reports of patients with awareness are published. These published cases are likely to be the top of the iceberg, as most patients with postoperative recall do not inform their anesthesiologist. Incidence of awareness with recall is between 0.1 and 0.2 %. In a large multicenter-study, incidence of recall was 0.1 % without, and 0.18 % with the use of muscle relaxants. The risk is increased with decreased doses of anesthetics, e.g. in patients with hemodynamic instability (trauma cases), patients undergoing cesarean section or cardiac surgery. Intraoperative awareness does not necessarily cause explicit (conscious) memory. Even in the absence of explicit memory, implicit (unconscious) memory can still have consequences for the patient. In the worst case, it can cause post-traumatic stress disorder. There is doubt whether patients may profit from positive suggestions given during intraoperative awareness. Recommendations to administer benzodiazepines to prevent explicit memory must be reconsidered. Complete neuromuscular block should be avoided whenever possible. If a patient is thought to be aware, he should be contacted , his situation should be explained and affirming comments should be given until consciousness is lost again. Postoperative visit should include questions about awareness and recall. The anesthetist should not disbelieve reported recall. Explanation of what had happened and referral to an experienced psychologist must be offered. Thus, the incidence of severe sequelae should decrease.

Allgemeinanästhesie - Wachheit - Erinnerung - Gedächtnis - posttraumatische Belastungsstörung

Anesthesia, general - wakefulness - awareness - memory - recall - recognition - stress disorders, post-traumatic

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