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DOI: 10.1055/s-2006-925141
Neue Entwicklungen in der postoperativen Schmerztherapie
New Aspects in Postoperative Pain TherapyPublikationsverlauf
Publikationsdatum:
23. März 2006 (online)
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Zusammenfassung
In dieser Übersichtsarbeit sind wesentliche und klinisch relevante neuere Arbeiten auf dem Gebiet der postoperativen Schmerztherapie dargestellt und bewertet. Aus den Studien lassen sich verschiedene Konsequenzen für die klinische Arbeit ziehen: i) Frauen schätzen postoperative Schmerzen realistischer ein als Männer, und die Inzidenz von Schmerzen ist höher. Hingegen sind Schmerzmittelverbrauch und Schmerzintensität geschlechtsunabhängig. ii) Plazebos erzeugen psychologische Phänomene (z. B. Erwartungshaltung), die neurobiologische Prozesse (z. B. Aktivierung des endogenen Opioidsystems) beeinflussen. iii) COX-2-Inhibitoren erhöhen die perioperative Letalität koronarchirurgischer Patienten durch Thrombembolien (Myokardinfarkt, Apoplex und Lungenarterienembolie). iv) NSAID führen bei einer Opioid-PCIA zu einer Reduktion von PONV und Sedierung. v) Die präoperative Gabe von Gabapentin verbessert die Anxiolyse und die postoperative Analgesie. vi) Intraoperativ gelegte Epiduralkatheter sind ein vielversprechendes schmerztherapeutisches Verfahren der Zukunft bei Wirbelsäulenoperationen. vii) Entsprechend aktueller Studienlage hat Akupunktur keine oder widersprüchliche Einflüsse auf intraoperativen Medikamenten-verbrauch und die postoperative Analgesie. Hingegen scheint es zu einer Reduktion von PONV zu führen, ohne dass eine Abnahme des Antiemetikabedarfs bisher nachgewiesen wurde. viii) Bei intravenöser Schmerztherapie führt die laparoskopische gegenüber der offenen Kolektomie bei kolorektalem Karzinom zu einer Verlängerung der Operationsdauer, zu einer Verminderung postoperativer Schmerzen und des Schmerzmittelbedarfs, zu einer frühzeitigeren Mobilisation und zu einer verkürzten Krankenhausverweildauer, falls eine konventionelle systemische, opiatbasierte Schmerztherapie durchgeführt wurde.
Abstract
This review summarizes and critically appraises important and clinically relevant publications dealing with postoperative pain therapy. Several consequences can be drawn from these studies: i) women anticipate postoperative pain more realistically and it occurs more often than in man; however, pain intensity and analgesic consumption are not different; ii) placebos elicit psychological phenomena (e. g. expectation) that trigger neurobiological processes (e. g. activation of endogenous opioid system); iii) COX-2 inhibitors increase the risk for thromboembolic complications (e. g. myocardial infarction, apoplex, pulmonary embolism) and perioperative mortality in patients undergoing aortocoronary bypass surgery; iv) NSAID as supplement to postoperative PCIA with opioids reduce the risk for PONV and sedation; v) preoperative administration of gabapentin reduces preoperative anxiety and postoperative pain; vi) epidural catheters situated at the site of major spinal surgery are promising approach to provide efficient postoperative analgesia; vii) in the literature contradictory results have been reported regarding the effect of perioperative acupuncture on intra- and postoperative consumption of anesthetics or analgesics; acupuncture appears to decrease the incidence of PONV, but no reduction in the postoperative use of antiemetic agents has not been shown yet; viii) laparoscopic versus open colectomy in patients with colon carcinoma results in prolongation of surgery, reduction of postoperative pain and analgesics, earlier mobilization and a reduced hospital stay, if conventional systemic opioid-based pain therapy was used postoperatively.
Schlüsselworte
Postoperative Schmerztherapie - Plazebo - Geschlecht - Gabapentin - Opioide - COX-2-Inhibitoren - Akupunktur
Key words
Postoperative pain therapy - Placebo - Gender - Gabapentin - Opioids - COX-2 inhibitors - acupuncture
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Prof. Dr. med. Michael Schäfer
Klinik für Anaesthesiologie und operative Intensivmedizin · Charité - Universitätsmedizin Berlin · Campus Benjamin Franklin
Hindenburgdamm 30 · 12200 Berlin
eMail: micha.schaefer@charite.de