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.

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

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

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