Postoperative Akutschmerztherapie - Die Rolle der Regionalanästhesie

Zusammenfassung

Zielsetzung der postoperativen Schmerztherapie ist nicht nur eine aus humanitären Gründen dringend gebotene gute Analgesie. Zusätzlich soll die postoperative Erholung gefördert werden. Akute Schmerzen sind durch eine stimulusspezifische Pathophysiologie gekennzeichnet, wobei postoperativ zusätzlich zur chirurgischen Inzision auch Entzündung und Nervenverletzung als Einflussgrößen diskutiert werden. Tierexperimentelle Untersuchungen zeigen, dass eine Schmerztherapie bei chirurgischen Traumen während des gesamten Zeitraums erforderlich ist, in dem Nozizeptoren aktiviert werden. Prophylaxe ist nicht möglich. Die Behandlung sollte rechtzeitig präoperativ begonnen und ausreichend lange fortgesetzt werden. Mit Regionalanalgesieverfahren lässt sich eine besonders wirksame Schmerzbehandlung durchführen. Metaanalysen zeigen, dass sowohl periphere Nervenblockaden als auch Epiduralanästhesie einer systemischen Opioidanalgesie überlegen sind.

Es wird geschätzt, dass ca. 10 - 50 % der Patienten an persistierenden postoperativen Schmerzen leiden. Phantomschmerzen nach Amputation treten bei 30 - 80 % der Patienten auf. Diese Schmerzen bilden sich in Zusammenhang mit einer Veränderung der Aktivität peripherer nozizeptiver Fasern und Rückenmarkneurone aus. Zusätzlich werden zentrale Pathomechanismen diskutiert. Die Qualität der wissenschaftlichen Untersuchungen über die Effekte der Regionalanästhesie ist sehr heterogen. Insgesamt zeigen die Beobachtungen, dass Regionalanästhesie eine wichtige, aber keine hinreichende Methode zur Reduktion der Inzidenz chronischer Schmerzen ist. Zusätzlich zum chirurgischen Trauma und zu neuroplastischen Prozessen gelten psychosoziale Einfussgrößen, genetische Faktoren und Lebensalter als wichtige Risikofaktoren. Angesichts der Komplexität dieser Risikofaktoren wird ein multimodales Behandlungskonzept gefordert.

Auch die Datenlage hinsichtlich der Reduktion postoperativer Komplikationen durch Regionalanästhesie ist kontrovers. Aufgrund der Wahrscheinlichkeit ernster postoperativer Komplikationen und der aufwändigen Kontrolle konfundierender Variablen ist die Durchführung kontrollierter Studien schwierig. Metaanalysen und Kohortenstudien führen zu unterschiedlichen Resultaten. Pathophysiologische Überlegungen lassen günstige Effekte bei Patienten mit hohem Komplikationsrisiko erwarten. Dies wird am Beispiel der Auswirkungen einer thorakalen Epiduralanalgesie auf das postoperative Herzinfarktrisiko erläutert.

Summary

Pain is the most frequent and straining symptom after surgery. Regardless of the severity of the surgical trauma patients may suffer from severe pain and may therefore not tolerate or even refuse important postoperative interventions for fear of pain. This may influence the outcome and worsen the prognosis of surgical patients. Physicians are therefore ethically and legally bound to care for adequate pain management. Regional anesthesia, especially epidural analgesia, is most effective to treat postoperative pain. It is discussed whether the incidence and severity of chronic postoperative pain can be reduced and postoperative complications can be prevented by this technique. Epidural analgesia may reduce the risk of postoperative complications (i.e. myocardial infarction) by reducing the surgical stress response and inhibiting the pathophysiological cascade that may trigger undesirable sequelea.

Schlüsselwörter:

Postoperative Schmerztherapie - Regionalanalgesie - Epiduralanästhesie - Phantomschmerzen; postoperative Komplikationen - chronischer postoperativer Schmerz

Key words:

Postoperative pain management - regional anesthesia - epidural analgesia - postoperative complications - chronic postoperative pain

Literaturverzeichnis

• 1 Zahn K. P.. Spinale Mechanismen postoperativer Schmerzen.  Anästh Intensivmed. 2006;  47 517-527
• 2 Ulsenheimer K.. Die rechtliche Verpflichtung zur postoperativen Schmerztherapie.  Anaesthesist. 1997;  46 S138-S142
• 3 Kehlet H., Jensen T.S., Woolf J.C.. Persistent postsurgical pain: risk factors and prevention.  Lancet. 2006;  367 1618-25
• 4 Flor H.. Phantom-limb pain: characteristics, causes, and treatment.  Lancet Neurol. 2002;  42 182-9
• 5 Kehlet H.. Surgical stress: The role of pain and analgesia.  Br J Anaesth. 1989;  63 189-195
• 6 Shavit Y.. et al. . Effects of surgical stress on brain prostaglandin E2 production and on the pituitary-adrenal axis: attenuation by preemptive analgesia and by central amygdala lesion.  Brain Res. 2005;  1047 10-7
• 7 Ljungqvist O.. et al. . Metabolic perioperative management: novel concepts.  Curr Opin Crit Care. 2005;  11 295-9
• 8 Herwig R.. et al. . Cystectomy causes immunosuppression in bladder cancer.  Adv Exp Med Biol. 2003;  539 741-8
• 9 Pogatzki-Zahn M. E.. Die Bedeutung peripherer und zentraler Sensibilisierungsprozesse für den postoperativen Schmerz.  Anästh Intensivmed. 2006;  47 657-683
• 10 Pogatzki E.M., Gebhart F. G., Brennan J. T.. Characterization of Adelta- and C-fibers innervating the plantar rat hindpaw one day after an incision.  J Neurophysiol. 2002;  87 721-31
• 11 Vandermeulen P. E., Brennan J. T.. Alterations in ascending dorsal horn neurons by a surgical incision in the rat foot.  Anesthesiology. 2000;  93 1294-302
• 12 Zahn K. P., Brennan J. T.. Incision-induced changes in receptive field properties of rat dorsal horn neurons.  Anesthesiology. 1999;  91 772-85
• 13 Pogatzki M. E., Vandermeulen P. E., Brennan J. T.. Effect of plantar local anesthetic injection on dorsal horn neuron activity and pain behaviors caused by incision.  Pain. 2002;  97 151-61
• 14 Brodner G.. et al. . Acute pain management: analysis, implications and consequences after prospective experience with 6349 surgical patients.  Eur J Anaesthesiol. 2000;  17 566-75
• 15 Stamer U.. et al. . Postoperative pain therapy in Germany.  Anaesthesist. 2002;  51 248-57
• 16 Richman M. J.. et al. . Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis.  Anesth Analg. 2006;  102 248-57
• 17 Brodner G.. et al. . What concentration of sufentanil should be combined with ropivacaine 0.2 % wt/vol for postoperative patient-controlled epidural analgesia?.  Anesth Analg. 2000;  90 649-657
• 18 Wu L. C.. et al. . Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis.  Anesthesiology. 2005;  103 1079-88 1109-10
• 19 Wiebalck A., Brodner G., Aken Van H.. The effects of adding sufentanil to bupivacaine for postoperative patient-controlled epidural analgesia.  Anesth Analg. 1997;  85 124-9
• 20 Kehlet H.. Effect of pain relief on the surgical stress response.  Reg Anesth. 1996;  21 35-37
• 21 Dickenson H. A.. Spinal cord pharmacology of pain.  Br J Anaesth. 1995;  75 193-200
• 22 Wiebalck A.. et al. . Konzept zur Verbesserung der postoperativen Schmerzbehandlung.  Anaesthesist. 1995;  44 831-842
• 23 Perkins M. F., Kehlet H.. Chronic pain as an outcome of surgery: A review of predictive factors.  Anesthesiology. 2000;  93 1123-33
• 24 Perttunen K., Tasmuth T., Kalso E.. Chronic pain after thoracic surgery: a follow-up study.  Acta Anaesthesiol Scand. 1999;  43 563-7
• 25 Amichetti M., Caffo O.. Pain after quadrantectomy and radiotherapy for early-stage breast cancer: incidence, characteristics and influence on quality of life. Results from a retrospective study.  Oncology. 2003;  65 23-8
• 26 Caffo O.. et al. . Pain and quality of life after surgery for breast cancer.  Breast Cancer Res Treat. 2003;  80 39-48
• 27 Woolf J. C., Salter W. M.. Neuronal plasticity: increasing the gain in pain.  Science. 2000;  288 1765-9
• 28 Shu Q. X., Mendell M. L.. Neurotrophins and hyperalgesia.  Proc Natl Acad Sci U S A. 1999;  96 7693-6
• 29 Simone A. D.. et al. . Neurogenic hyperalgesia: central neural correlates in responses of spinothalamic tract neurons.  J Neurophysiol. 1991;  66 228-46
• 30 Melzack R.. Phantom limbs and the concept of a neuromatrix.  Trends Neurosci. 1990;  13 88-92
• 31 Poleshuck L. E.. et al. . Risk factors for chronic pain following breast cancer surgery: a prospective study.  J Pain. 2006;  7 626-34
• 32 Maguire F. M.. et al. . A questionnaire study investigating the prevalence of the neuropathic component of chronic pain after thoracic surgery.  Eur J Cardiothorac Surg. 2006;  29 800-5
• 33 Maguire F. M.. et al. . A study exploring the role of intercostal nerve damage in chronic pain after thoracic surgery.  Eur J Cardiothorac Surg. 2006;  29 873-9
• 34 Senturk M.. et al. . The effects of three different analgesia techniques on long-term postthoracotomy pain.  Anesth Analg. 2002;  94 11-5
• 35 Tiippana E., Nilsson E., Kalso E.. Post-thoracotomy pain after thoracic epidural analgesia: a prospective follow-up study.  Acta Anaesthesiol Scand. 2003;  47 433-8
• 36 Yegin A.. et al. . Early postoperative pain management after thoracic surgery; pre- and postoperative versus postoperative epidural analgesia: a randomised study.  Eur J Cardiothorac Surg. 2003;  24 420-4
• 37 Kairaluoma M. P.. et al. . Preincisional paravertebral block reduces the prevalence of chronic pain after breast surgery.  Anesth Analg. 2006;  103 703-8
• 38 Jadad R. A.. et al. . Assessing the quality of reports of randomized clinical trials: is blinding necessary?.  Control Clin Trials. 1996;  17 1-12
• 39 Moher D.. et al. . Assessing the quality of randomized controlled trials: an annotated bibliography of scales and checklists.  Control Clin Trials. 1995;  16 62-73
• 40 Halbert J., Crotty M., Cameron D. I.. Evidence for the optimal management of acute and chronic phantom pain: a systematic review.  Clin J Pain. 2002;  18 84-92
• 41 Jahangiri M.. et al. . Prevention of phantom pain after major lower limb amputation by epidural infusion of diamorphine, clonidine and bupivacaine.  Ann R Coll Surg Engl. 1994;  76 324-6
• 42 Elizaga M. A.. et al. . Continuous regional analgesia by intraneural block: effect on postoperative opioid requirements and phantom limb pain following amputation.  J Rehabil Res Dev. 1994;  31 179-87
• 43 Bach S., Noreng F. M., Tjellden U. N.. Phantom limb pain in amputees during the first 12 months following limb amputation, after preoperative lumbar epidural blockade.  Pain. 1988;  33 297-301
• 44 Pinzur S. M.. et al. . Continuous postoperative infusion of a regional anesthetic after an amputation of the lower extremity. A randomized clinical trial.  J Bone Joint Surg Am. 1996;  78 1501-5
• 45 Gehling M., Tryba M.. Prophylaxis of phantom pain: is regional analgesia ineffective?.  Schmerz. 2003;  17 11-9
• 46 Nikolajsen L.. et al. . Randomised trial of epidural bupivacaine and morphine in prevention of stump and phantom pain in lower-limb amputation.  Lancet. 1997;  350 1353-7
• 47 Hanley A. M.. et al. .Preamputation Pain and Acute Pain Predict Chronic Pain After Lower Extremity Amputation. J Pain 2006
• 48 Schley M.. et al. .Continuous brachial plexus blockade in combination with the NMDA receptor antagonist memantine prevents phantom pain in acute traumatic upper limb amputees. Eur J Pain 2006
• 49 Niesert W., Zenz M.. Prophylaxe chronischer Schmerzen.  Dtsch Ärzteblatt. 2005;  102 A1586-A1593
• 50 Waurick R., Aken H. Van. Update in thoracic epidural anaesthesia.  Best Pract Res Clin Anaesthesiol. 2005;  19 201-13
• 51 Aken H. Van. et al. . Epidural anaesthesia and analgesia in mayor surgery.  Lancet. 2002;  360 568-569
• 52 Brodner G., Möllhoff T., Aken H. Van. Thorakale Epiduralanalgesie und das Risiko postoperativer Myokardinfarkte bei Patienten mit koronarer Herzkrankheit.  Anästh Intensivmed. 2003;  44 92-97
• 53 Leon-Casasola A. de O.. When it comes to outcome, we need to define what a perioperative epidural technique is.  Anesth Analg. 2003;  96 315-8
• 54 Gogarten W., Buerkle H., Aken H. Van. The quality of epidural anesthesia is crucial in the assessment of perioperative outcome.  Anesth Analg. 2003;  97 298-9
• 55 Liu S. S.. Bank robbers and outcomes research.  Reg Anesth Pain Med. 2003;  28 262-4
• 56 Wu L. C.. et al. . Effect of postoperative epidural analgesia on morbidity and mortality following surgery in medicare patients.  Reg Anesth Pain Med. 2004;  29 525-33 515-9
• 57 Liu S. S., Block M. B., Wu L. C.. Effects of perioperative central neuraxial analgesia on outcome after coronary artery bypass surgery: a meta-analysis.  Anesthesiology. 2004;  101 153-61
• 58 Urwin C. S., Parker J. M., Griffiths R.. General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials.  Br J Anaesth. 2000;  84 450-5
• 59 Rodgers A.. et al. . Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials.  Bmj. 2000;  321 1493
• 60 Ballantyne C. J.. et al. . Does the evidence support the use of spinal and epidural anesthesia for surgery?.  J Clin Anesth. 2005;  17 382-91
• 61 Tziavrangos E., Schug A. S.. Regional anaesthesia and perioperative outcome.  Curr Opin Anaesthesiol. 2006;  19 521-5
• 62 Schug A. S.. The effect of neuraxial blockade on peri-operative mortality and mayor morbidity: an updated meta-analysis (abstract).  Anaesth Intens Care. 2005;  33 675-5675
• 63 Strametz R., Zwissler B.. Perioperative administration of beta-blockers : Critical appraisal of recent meta-analyses. Anaesthesist 2006
• 64 Mangano T. D.. et al. . Long-term cardiac prognosis following noncardiac surgery. The Study of Perioperative Ischemia Research Group.  Jama. 1992;  268 233-9
• 65 Riles S. T.. et al. . Plasma catecholamine concentrations during abdominal aortic aneurysm surgery: the link to perioperative myocardial ischemia.  Ann Vasc Surg. 1993;  7 213-219
• 66 Brodner G.. et al. . Multimodal perioperative management-combining thoracic epidural analgesia, forced mobilization, and oral nutrition-reduces hormonal and metabolic stress and improves convalescence after major urologic surgery.  Anesth Analg. 2001;  92 1594-600
• 67 Kohl A. B., Deutschman S. C.. The inflammatory response to surgery and trauma.  Curr Opin Crit Care. 2006;  12 325-32
• 68 Schneemilch E. C., Bank U.. Release of pro- and anti-inflammatory cytokines during different anesthesia procedures.  Anaesthesiol Reanim. 2001;  26 4-10
• 69 Vaziri D. N.. et al. . Coagulation and inhibitory and fibrinolytic proteins in essential hypertension.  J Am Soc Nephrol. 1993;  4 222-228
• 70 Hjemdahl P., Larsson T. P., Wallen H. N.. Effects of stress and beta-blockade on platelet function.  Circulation. 1991;  84 VI44-V161
• 71 Manach Y. Le. et al. . Early and delayed myocardial infarction after abdominal aortic surgery.  Anesthesiology. 2005;  102 885-91
• 72 Hansson K. G.. Inflammation, atherosclerosis, and coronary artery disease.  N Engl J Med. 2005;  352 1685-95
• 73 Mullenix S. P., Andersen A. C., Starnes W. B.. Atherosclerosis as inflammation.  Ann Vasc Surg. 2005;  19 130-8
• 74 Burke P. A.. et al. . Plaque rupture and sudden death related to exertion in men with coronary artery disease.  Jama. 1999;  281 921-6
• 75 Naghavi M.. et al. . From vulnerable plaque to vulnerable patient: a call for new definitions and risk assessment strategies: Part I.  Circulation. 2003;  108 1664-72
• 76 Sipahi I.. et al. . Paradoxical increase in lumen size during progression of coronary atherosclerosis: observations from the REVERSAL trial.  Atherosclerosis. 2006;  189 229-35
• 77 Virmani R.. et al. . Atherosclerotic plaque progression and vulnerability to rupture: angiogenesis as a source of intraplaque hemorrhage.  Arterioscler Thromb Vasc Biol. 2005;  25 2054-61
• 78 Nabel G. E., Ganz P., Gordon B. J.. Dilatation of normal and constriction of arteriosclerotic coronary arteries caused by the cold pressure test.  Circulation. 1998;  77 43-52
• 79 Slager J. C.. et al. . The role of shear stress in the destabilization of vulnerable plaques and related therapeutic implications.  Nat Clin Pract Cardiovasc Med. 2005;  2 456-64
• 80 Gronholdt L. M., Dalager-Pedersen S., Falk E.. Coronary atherosclerosis: determinants of plaque rupture.  Eur Heart J. 1998;  19 24-9
• 81 Meißner A., Rolf N., Aken H. Van. Thoracic epidural anesthesia and the patient with heart disease: benefits, risks and controversies.  Anesth Analg. 1997;  85 517-528
• 82 Suttner S.. et al. . Continuous intra- and postoperative thoracic epidural analgesia attenuates brain natriuretic peptide release after major abdominal surgery.  Anesth Analg. 2005;  101 896-903
• 83 Poldermans D.. et al. . Bisoprolol reduces cardiac death and myocardial infarction in high-risk patients as long as 2 years after successful major vascular surgery.  Eur Heart J. 2001;  22 1353-8
• 84 Oliver F. M.. et al. . Effect of mivazerol on perioperative cardiac complications during non-cardiac surgery in patients with coronary heart disease: the European Mivazerol Trial (EMIT).  Anesthesiology. 1999;  91 951-61
• 85 Tanaka M.. et al. . The effects of cervical and lumbar epidural anesthesia on heart rate variability and spontaneous sequence baroreflex sensitivity.  Anesth Analg. 2004;  99 924-9
• 86 Loick M. H.. et al. . High thoracic epidural anesthesia, but not clonidine, attenuates the perioperative stress response via sympatholysis and reduces the release of troponin T in patients undergoing coronary artery bypass grafting.  Anesth Analg. 1999;  88 701-9
• 87 Meissner A.. et al. . Effects of thoracic epidural anesthesia with and without autonomic nervous system blockade on cardiac monophasic action potentials and effective refractoriness in awake dogs.  Anesthesiology. 2001;  95 132-8
• 88 Blomberg S.. et al. . Thoracic epidural anaesthesia in patients with unstable angina pectoris.  Eur Heart J. 1989;  10 437-444
• 89 Blomberg S.. et al. . Effect of thoracic epidural anesthesia on coronary arteries and arterioles in patients coronary artery diesease.  Anesthesiology. 1990;  73 840-847
• 90 Nygard E.. et al. . Effects of high thoracic epidural analgesia on myocardial blood flow in patients with ischemic heart disease.  Circulation. 2005;  111 2165-70
• 91 Berendes E.. et al. . Reversible cardiac sympathectomy by high thoracic epidural anesthesia improves regional left ventricular function in patients undergoing coronary artery bypass grafting: a randomized trial.  Arch Surg. 2003;  138 2183-90
• 92 Singh N.. et al. . The effects of the type of anesthesia on outcomes of lower extremity infrainguinal bypass.  J Vasc Surg. 2006;  44 964-8 968-70
• 93 Nishimori M., Ballantyne C. J., Low H. J.. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery.  Cochrane Database Syst Rev. 2006;  3
• 94 Beattie S. W., Badner H. N., Choi P.. Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis.  Anesth Analg. 2001;  93 853-8
• 95 Beattie S. W., Badner H. N., Choi T. P.. Meta-analysis demonstrates statistically significant reduction in postoperative myocardial infarction with the use of thoracic epidural analgesia.  Anesth Analg. 2003;  97 919-20
• 96 Parker J. M., Handoll H. H., Griffiths R.. Anaesthesia for hip fracture surgery in adults.  Cochrane Database Syst Rev. 2001;  4
• 97 Parker J. M., Handoll H. H., Griffiths R.. Anaesthesia for hip fracture surgery in adults.  Cochrane Database Syst Rev. 2004;  4
• 98 Ballantyne C. J.. et al. . The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials.  Anesth Analg. 1998;  86 598-612
• 99 Jorgensen H.. et al. . Epidural local anaesthetics versus opioid-based analgesic regimens on postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery.  Cochrane Database Syst Rev. 2000;  4
• 100 Kehlet H.. Manipulation of the metabolic response in clinical practice.  World J Surg. 2000;  24 690-5
• 101 Beilin B.. et al. . The effects of postoperative pain management on immune response to surgery.  Anesth Analg. 2003;  97 822-7
• 102 Brodner G.. et al. . Thoracic epidural analgesia with ropivacaine attenuates postoperative immunesuppression.  Anesthesiology. 1998;  89 A1168
• 103 Elenkov J. I.. et al. . The sympathetic nerve-an integrative interface between two supersystems: the brain and the immune system.  Pharmacol Rev. 2000;  52 595-638