Entwicklung und gegenwärtiger Stand der kombinierten Spinal-Periduralanästhesie

Zusammenfassung

Die kombinierte Spinal-Peridural-Anästhesie/Analgesie stellt eine Methode dar, bei der Medikamente intrathekal als Einzeldosis und epidural entweder kontinuierlich oder intermittierend über einen Periduralkatheter appliziert werden. Bereits vor mehr als 50 Jahren wurden erste, wenig allgemein akzeptierte Versuche unternommen, die Methode in die klinische Praxis einzuführen. Erst während der letzten Jahrzehnte sind enorme Fortschritte durch die Entwicklung neuer ausgefeilter technischer Hilfsmittel gemacht worden. Dazu zählen auf einander abgestimmte Kombinationen von Peridural- und Spinalnadeln und Kathetern, Periduralnadeln mit einer seitlich angesetzten Führungskanüle für die Spinalnadel oder auch solche mit einer eigenen, vom Periduralkatheter unabhängigen Austrittstelle sowie spezielle Fixierungsvorrichtungen für die Spinalnadel. Ein spezifisches Merkmal des Verfahrens ist die erst vor wenigen Jahren entdeckte epidurale Volumenexpansion, die niedrig dosierte Medikamentenkombinationen mit ausreichender Analgesie, aber geringerer Kreislaufbelastung und weniger Nebenwirkungen einzusetzen erlaubt. Diese Übersichtsarbeit beschreibt die wesentlichen und wichtigsten Entwicklungsschritte der Methode und führt praktische Beispiele für deren Anwendung in der ambulanten Chirurgie der unteren Extremität, der sog. „walking epidural” sowie der Sectio caesarea an. Die Methode hat heute einen hohen Stellenwert erreicht, sie stellt eine Bereicherung des Handwerkszeugs des Anästhesisten dar und gehört an vielen Kliniken zur täglichen Routine.

Abstract

Combined spinal and epidural anaesthesia/analgesia is a method whereby drugs are applied intrathecally as a single dose and epidurally either continuously or intermittently via an epidural catheter. More than 50 years ago, first attempts were made to introduce this method into clinical practice but they found little general acceptance. Only during the last decades has tremendous progress been made in developing new, highly-sophisticated equipment: matching spinal and epidural needles and catheters, epidural needles with a separate conduit for the spinal needle or with an additional hole for the exit of the spinal needle as well as fixation devices for the spinal needle. A specific feature of the method is the only recently recognised epidural volume extension, which allows the use of low-dose drug combinations with sufficient analgetic properties but less cardiovascular compromise and fewer side-effects. This review describes the main and most important developmental steps and offers practical examples for its use in day-case surgery of the lower limb, in the “walking epidural” in obstetrics and in caesarean section. The method has become a valuable new tool in the armamentarium of the anaesthetist and part of daily routine in many clinics.

Schlüsselwörter

Anästhesie/Analgesie - Periduralanästhesie - Spinalanästhesie - kombinierte Spinal-Periduralanästhesie, Methoden, Kanülen, Volumenextension - Geschichte der Anästhesie

Key words

Anaesthesia/analgesia - epidural anaesthesia - spinal anaesthesia - combined spinal-epidural anaesthesia, methods, needles, volume extension - history of anaesthesia

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1 Hier und nachfolgend wird die verbreitete Abkürzung CSE für „combined spinal epidural” verwendet, da sich das ebenfalls vorgeschlagene deutsche Akronym KSE nicht eingebürgert hat; die Bezeichnung CSE lässt jedoch offen, ob darunter die analgetische oder die anästhetische Wirkung des Verfahrens zu verstehen ist.