Postoperative Akutschmerztherapie - Neue Möglichkeiten der systemischen Analgesie

Zusammenfassung

Eine suffiziente Schmerztherapie hat nicht zuletzt aufgrund der Reduktion von Patientenmorbidität und Verbesserung des Patientenoutcomes einen hohen Stellenwert im Rahmen der perioperativen Betreuung von Patienten. Obwohl patientenkontrollierte Regionalanalgesieverfahren der entsprechend gesteuerten systemischen Analgesie mit Opioiden im Rahmen der Schmerztherapie überlegen sind, kann aus vielerlei Gründen die Anwendung des etwas weniger wirksamen Verfahrens notwendig werden (z.B. Patientenwunsch, bestimmte Kontraindikationen). Adjuvante Analgetika oder Ko-Analgetika können in Zukunft große Bedeutung für die Verbesserung der Analgesiequalität, der Reduktion des Opioidverbrauchs und - damit verbunden - einer möglichen Senkung opioidinduzierter Nebenwirkungen bekommen. Darüber hinaus können bestimmte Ko-Analgetika möglicherweise auch zur Reduktion einer opioidinduzierten Hyperalgesie und zu einer Vermeidung chronischer postoperativer Schmerzen beitragen. In der folgenden Übersichtsarbeit soll der Stellenwert einer systemischen Applikation von NMDA-Rezeptorantagonisten, Antikonvulsiva, Kortikosteroiden und Lokalanästhetika für den Einsatz in der postoperativen Schmerztherapie anhand der aktuellen Literatur diskutiert werden. Zusätzlich soll in diesem Rahmen ein orales opioidbasiertes Analgesiekonzept zur Behandlung von Schmerzen nach kurzen bis mittelangen Eingriffen vorgestellt werden.

Summary

Postoperative pain is now a critical focus of perioperative patient care. The current perioperative analgesic strategy is a „balanced-multimodal analgesia”. Cornerstones of this treatment approach are patient controlled neuraxial administration of local anesthetics and opioids or patient controlled intravenous administration of opioids. However, systemic opioids are limited by side effects. Thus, adjuvants like anticonvulsants, NMDA receptor antagonists, alpha-2 adrenergic agonists and other non-Opioid analgesics are considered to reduce pain and opioid requirements in the perioperative period. In the present review we discuss recent findings about the effectiveness of different systemic administered adjuvants including ketamine, lidocaine, gabapentin, pregabalin and corticosteroids for postoperative pain treatment. Furthermore a nurse based oral analgesic concept using controlled released Oxycodon for all postoperative patients without a patient controlled analgesia device will be introduced.

Schlüsselwörter:

Adjuvante Analgetika - Ko-Analgetika - postoperativer Akutschmerz - opioidinduzierte Hyperalgesie (OIH) - chronischer Schmerz

Key words:

adjuvants - co-analgesic - postoperative pain - opioid-induced hyperalgesia (OIH) - chronic pain

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