Zusammenfassung
Von zahlreichen Fallberichten und Beobachtungsstudien wie die historisch einflussreichste von Curtis Mendelson über die Problematik der Säureaspirationspneumonitis rührte seit spätestens der 1940er Jahre die dogmatische Anwendung einer strengen Nahrungskarenz im Kreißsaal, um das Risiko schwangerer Frauen während Geburt und Entbindung zu reduzieren. Allerdings ist in den letzten Jahrzehnten sowohl die gesamte wie auch die speziell durch Aspirationszwischenfälle verursachte Müttersterblichkeit drastisch gefallen. Verantwortlich dafür sind die gleichzeitig erfolgten weit reichenden Fortschritte und Qualitätssprünge in der anästhesiologischen Versorgung, die die Bedeutung des Dogmas ,Nahrungskarenz' auch in der Geburtshilfe zunehmend kritisch hinterfragen lassen. Tatsächlich wurde bisher nie bewiesen, dass strenge Nüchternheit Morbidität und Mortalität senkt. Aufgrund der spezifischen physiologischen und anatomischen Veränderungen in der Schwangerschaft weisen Frauen theoretisch eine verlangsamte Magenpassage auf und werden daher noch häufig grundsätzlich als nicht nüchtern bewertet. Die Ergebnisse klinischer Studien, die unter verschiedenen Einflussfaktoren gastrale Residualvolumina gemessen haben, scheinen dieser Vorstellung jedoch zumindest hinsichtlich klarer Flüssigkeiten zu widersprechen oder bezweifeln deren klinische Relevanz. Jüngere Studien, die ohne offensichtliche Risikoerhöhung auf eine positive Beeinflussung des Patientinnenkomforts und Metabolismus von Mutter und Kind hindeuten, haben längst eine sinnvolle Diskussion über die Lockerung der Nahrungskarenz in der geburtshilflichen Medizin angeregt.
Summary
Numerous scientific case reports and observational studies, including that of Curtis Mendelson with its great historical relevance, have reported the problem of aspiration pneumonitis during labour. Because of this, strict fasting prior to delivery to reduce pulmonary aspiration has been doctrine since the 1940s. However, maternal mortality from anaesthesia, particularly from aspiration, has dropped dramatically over recent decades. This is due both to far-reaching improved quality of care as well as technical progress in anaesthesia, which increasingly challenge the scientific basis for fasting in obstetric anaesthesia. Strict fasting has never been proven to reduce morbidity or mortality in labouring women. Because of the physiological and anatomical changes of pregnancy, gastric emptying is theoretically prolonged, and therefore the risk of aspiration is assumed to be increased. However, the available data with patients receiving clear fluids run contrary to this assumption, or at least dispute its clinical relevance. Recent studies report positive influence of reduced fasting time on both maternal comfort and maternal/fetal metabolism without increased risk. This has already led to meaningful discussion regarding a corresponding change in official recommendations.
Schlüsselwörter
Aspiration - Nahrungskarenz - Entbindung - Magenpassage - Metabolismus
Keywords
aspiration - preoperative fasting - delivery - gastric emptying - metabolism
Kernaussagen
-
Die Fortschritte in der geburtshilflichen Anästhesie während der letzten Jahrzehnte haben die Aspiration zu einem seltenen Narkosezwischenfall und das Mendelson-Syndrom zu einem kalkulierbaren Risiko gemacht.
-
Der Zusammenhang strenge Flüssigkeitskarenz und reduzierte aspirationsassoziierte Morbidität und Mortalität konnte nie bewiesen werden. Für klare Flüssigkeiten ist bei unkomplizierter Entbindung die Magenpassage unbeeinflusst oder klinisch nicht relevant.
-
Erste Hinweise ergeben positive Einflüsse einer verkürzten Karenz für kohlenhydratreiche Trinklösungen auf mütterlichen wie fetalen Metabolismus. Die Frage nach einem signifikanten Effekt auf den Geburtsprozess und Morbidität muss weiter erforscht werden.
Literaturliste
-
1 Department of Health and others. .Reports on confidential enquiries into maternal deaths in England and Wales/United Kingdom 1952-1999 (series of 16 triennial reports.). London: HMSO 2001
-
2
Mendelson CL.
The aspiration of stomach contents into the lungs during obstetric anaesthesia.
Am J Obstet Gynecol.
1946;
52
191-205
-
3
James CF, Modell JH, Gibbs CP, Kuck EJ, Ruiz BC.
Pulmonary aspiration-effects of volume and pH in the rat.
Anesth Analg.
1984;
63
665-668
-
4
TEABEAUT JR.
Aspiration of gastric contents; an experimental study.
Am J Pathol.
1952;
28
51-67
-
5
Welsch H.
Müttersterblichkeit während Schwangerschaft und post abortum.
Gynäkologe.
1997;
30
682-693
-
6
Welsch H.
Müttersterblichkeit während Geburt und Wochenbett bei vaginaler Entbindung und Sectio caesariea.
Gynäkologe.
1997;
30
742-756
-
7
Hawthorne L, Wilson R, Lyons G, Dresner M.
Failed intubation revisited: 17-yr experience in a teaching maternity unit.
Br J Anaesth.
1996;
76
680-684
-
8
Roberts RB, Shirley MA.
Reducing the risk of acid aspiration during cesarean section.
Anesth Analg.
1974;
53
859-868
-
9
Awe WJ, Fletcher WS, Jacob SW.
Pathophysiology of aspiration pneumonitis.
Surgery.
1966;
60
232-239
-
10
Exharos ND, Logan WD, Abbott OA.
The importance of pH and volume in tracheobronchial aspiration.
Dis Chest.
1965;
47
167-169
-
11
Raidoo DM, Rocke DA, Brock-Utne JG, Marszalek A, Engelbrecht HE.
Critical volume for pulmonary acid aspiration: reappraisal in a primate model.
Br J Anaesth.
1990;
65
248-250
-
12
Raidoo DM, Marszalek A, Brock-Utne JG.
Acid aspiration in primates (a surprising experimental result).
Anaesth Intensive Care.
1988;
16
375-376
-
13
Roberts RB, Shirley MA.
Antacid therapy in obstetrics.
Anesthesiology.
1980;
53
83
-
14
Lahiri SK, Thomas TA, Hodgson RM.
Single-dose antacid therapy for the prevention of Mendelson's syndrome.
Br J Anaesth.
1973;
45
1143-1146
-
15
Hett DA, Scott RC, Risdall JE.
Lansoprazole in the prophylaxis of acid aspiration during elective surgery.
Br J Anaesth.
1995;
74
614-615
-
16
Salmenpera M, Korttila K, Kalima T.
Reduction of the risk of acid pulmonary aspiration in anaesthetized patients after cimetidine premedication.
Acta Anaesthesiol Scand.
1980;
24
25-30
-
17
Stoelting RK.
Gastric fluid pH in patients receiving cimetidine.
Anesth Analg.
1978;
57
675-677
-
18 Schenk M. Check-up Anästhesiologie. Standards Anästhesie, Intensivmedizin, Schmerztherapie, Notfallmedizin. In: Kox WJ, Spies C, editors. Heidelberg: Springer 2005: 301-330
-
19
Brown GW, Russell IF.
A survey of anaesthesia for caesarean section.
Int J Obstet Anesth.
1995;
4
214-218
-
20
Greene NM, Bannister WM, Cohen B. et al. .
Survey of deaths associated with anesthesia in Connecticut; a review of 120,935 anesthetics.
Conn Med.
1959;
23
512-518
-
21
Hovi-Viander M.
Death associated with anaesthesia in Finland.
Br J Anaesth.
1980;
52
483-489
-
22
Hatton F, Tiret L, Maujol L. et al. .
INSERM. Epidemiological survey of anesthesia. Initial results.
Ann Fr Anesth Reanim.
1983;
2
331-386
-
23
Cohen BB, Duncan PG, Pope WDB, Wolkeinstein C.
A survey of 112000 anaesthetics at one teaching hospital.
Can Anaesth Soc J.
1986;
33
22-31
-
24
Olsson GL, Hallen B, Hambraeus-Jonzon K.
Aspiration during anaesthesia: a computer-aided study of 185358 anaesthetics.
Acta Anaesthesiol Scand.
1986;
30
84-92
-
25
Warner MA, Warner ME, Weber JG.
Clinical significance of pulmonary aspiration during the perioperative period.
Anesthesiology.
1993;
78
56-62
-
26
Mellin-Olsen J, Fasting S, Gisvold SE.
Routine preoperative gastric emptying is seldom indicated. A study of 85,594 anaesthetics with special focus on aspiration pneumonia.
Acta Anaesthesiol Scand.
1996;
40
1184-1188
-
27
Soreide E, Bjornestad E, Steen PA.
An audit of perioperative aspiration pneumonitis in gynaecological and obstetric patients.
Acta Anaesthesiol Scand.
1996;
40
14-19
-
28
Schneck H, Hundelshausen B von, Wagner R, Scheller M, Kochs E.
Prophylaxis against obstetric acid aspiration syndrome in the German Federal Republic in 1997. A review based on results of a federal survey.
Anasthesiol Intensivmed Notfallmed Schmerzther.
1999;
34
204-213
-
29
Hawkins JL, Koonin LM, Palmer SK, Gibbs CP.
Anesthesia-related deaths during obstetric delivery in the United States, 1979-1990.
Anesthesiology.
1997;
86
277-284
-
30
Hey VM, Cowley DJ, Ganguli PC, Skinner LD, Ostick DG, Sharp DS.
Gastro-oesophageal reflux in late pregnancy.
Anaesthesia.
1977;
32
372-377
-
31
Thiel DH Van, Gavaler JS, Joshi SN, Sara RK, Stremple J.
Heartburn of pregnancy.
Gastroenterology.
1977;
72
666-668
-
32
Arndt M, Benad G.
The risks of anesthesia in obstetric interventions.
Anaesthesiol Reanim.
1994;
19
88-94
-
33
Macfie AG, Magides AD, Richmond MN, Reilly CS.
Gastric emptying in pregnancy.
Br J Anaesth.
1991;
67
54-57
-
34
Sandhar BK, Elliott RH, Windram I, Rowbotham DJ.
Peripartum changes in gastric emptying.
Anaesthesia.
1992;
47
196-198
-
35
Hardy JF, Lepage Y, Bonneville-Chouinard N.
Occurrence of gastroesophageal reflux on induction of anaesthesia does not correlate with the volume of gastric contents.
Can J Anaesth.
1990;
37
502-508
-
36
Jasson J, Lefevre G, Tallet F, Talafre ML, Legagneux F, Conseiller C.
Oral administration of sodium citrate before general anesthesia in elective cesarean section. Effect on pH and gastric volume.
Ann Fr Anesth Reanim.
1989;
8
12-18
-
37
Ngwingtin L, Hardy F, Hamer R, Glomaud D.
Changes in the pH and volume of gastric contents during pregnancy and labor.
Cah Anesthesiol.
1987;
35
607-609
-
38
McKay S, Mahan C.
How can aspiration of vomitus in obstetrics best be prevented?.
Birth.
1988;
15
222-235
-
39
Elkington KW.
At the water's edge: where obstetrics and anesthesia meet.
Obstet Gynecol.
1991;
77
304-308
-
40
Ludka LM, Roberts CC.
Eating and drinking in labor. A literature review.
J Nurse Midwifery.
1993;
38
199-207
-
41
O'Sullivan GM, Sutton AJ, Thompson SA, Carrie LE, Bullingham RE.
Noninvasive measurement of gastric emptying in obstetric patients.
Anesth Analg.
1987;
66
505-511
-
42
Carp H, Jayaram A, Stoll M.
Ultrasound examination of the stomach contents of parturients.
Anesth Analg.
1992;
74
683-687
-
43
Nimmo WS, Wilson J, Prescott LF.
Further studies of gastric emptying during labour.
Anaesthesia.
1977;
32
100-101
-
44
Davison JS, Davison MC, Hay DM.
Gastric emptying time in late pregnancy and labour.
J Obstet Gynaecol Br Commonw.
1970;
77
37-41
-
45
Salvia LA, Steffen EA.
Delayed gastric emptying time in labor.
Am J Obstet Gynecol.
1950;
59
1075-1081
-
46
Volans GN.
Absorption of effervescent aspirin during migraine.
Br Med J.
1974;
4
265-268
-
47
Nimmo WS, Wilson J, Prescott LF.
Narcotic analgesics and delayed gastric emptying during labour.
Lancet.
1975;
1
890-893
-
48
Porter JS, Bonello E, Reynolds F.
The influence of epidural administration of fentanyl infusion on gastric emptying in labour.
Anaesthesia.
1997;
52
1151-1156
-
49
Ewah B, Yau K, King M, Reynolds F, Carson RJ, Morgan B.
Effect of epidural opioids on gastric emptying in labour.
Int J Obstet Anesth.
1993;
2
125-128
-
50
Wright PM, Allen RW, Moore J, Donnelly JP.
Gastric emptying during lumbar extradural analgesia in labour: effect of fentanyl supplementation.
Br J Anaesth.
1992;
68
248-251
-
51
Zimmermann DL, Breen TW, Fick G.
Adding fentanyl 0.0002 % to epidural bupivacaine 0.125 % does not delay gastric emptying in laboring parturients.
Anesth Analg.
1996;
82
612-616
-
52
Metzger BE, Ravnikar V, Vileisis RA, Freinkel N.
"Accelerated starvation" and the skipped breakfast in late normal pregnancy.
Lancet.
1982;
1
588-592
-
53
Broach J, Newton N.
Food and beverages in labor. Part II: The effects of cessation of oral intake during labor.
Birth.
1988;
15
88-92
-
54
Dumoulin JG, Foulkes JE.
Ketonuria during labour.
Br J Obstet Gynaecol.
1984;
91
97-98
-
55
Romney SL, Gabel PV.
Meternal glucose loading in the management of fetal distress.
Am J Obstet Gyencol.
1966;
96
698-708
-
56
Kenepp NB, Kumar S, Shelley WC, Stanley CA, Gabbe SG, Gutsche BB.
Fetal and neonatal hazards of maternal hydration with 5 % dextrose before caesarean section.
Lancet.
1982;
1
1150-1152
-
57
Soreide E, Stromskag KE, Steen PA.
Statistical aspects in studies of preoperative fluid intake and gastric content.
Acta Anaesthesiol Scand.
1995;
39
738-743
-
58
Spies CD, Breuer JP, Gust R. et al. .
Preoperative fasting. An update.
Anaesthesist.
2003;
52
1039-1045
-
59
Breuer JP, Dossow V von, Heymann C von. et al. .
Preoperative oral carbohydrate administration to ASA III-IV patients undergoing elective cardiac surgery.
Anesth Analg.
2006;
103
1099-1108
-
60
Maltby JR, Pytka S, Watson NC, Cowan RA, Fick GH.
Drinking 300 mL of clear fluid two hours before surgery has no effect on gastric fluid volume and pH in fasting and non-fasting obese patients.
Can J Anaesth.
2004;
51
111-115
-
61
Scheepers HC, Jong PA de, Essed GG, Kanhai HH.
Carbohydrate solution intake during labour just before the start of the second stage: a double-blind study on metabolic effects and clinical outcome.
BJOG.
2004;
111
1382-1387
-
62
Scheepers HC, Essed GG, Brouns F.
Aspects of food and fluid intake during labour. Policies of midwives and obstetricians in The Netherlands.
Eur J Obstet Gynecol Reprod Biol.
1998;
78
37-40
-
63
Schuitemaker N, Roosmalen J van, Dekker G, Dongen P van, Geijn H van, Gravenhorst JB.
Maternal mortality after cesarean section in The Netherlands.
Acta Obstet Gynecol Scand.
1997;
76
332-334
-
64
Friedberg V, Ackermann RH.
Aspects of an interplay between endocrinological and metabolic factors during birth.
Geburtshilfe Frauenheilkd.
1983;
43
8-13
-
65
Kubli M, Scrutton MJ, Seed PT, O'Sullivan G.
An evaluation of isotonic "sport drinks" during labor.
Anesth Analg.
2002;
94
404-8
-
66
Scrutton MJ, Metcalfe GA, Lowy C, Seed PT, O'Sullivan G.
Eating in labour. A randomised controlled trial assessing the risks and benefits.
Anaesthesia.
1999;
54
329-334
-
67
Crenshaw JT, Winslow EH.
Actual versus instructed fasting times and associated discomforts in women having scheduled cesarean birth.
J Obstet Gynecol Neonatal Nurs.
2006;
35
257-264
-
68
Pearse SK, Rajakulendran Y.
Preoperative fasting and administration of regular medication adult patients presenting for elective surgery. Has the new evidence changed practice?.
Eur J Anaesthesiol.
1999;
16
565-568
-
69
Hawkins JL.
Practice guidelines for obstetrical anesthesia: a report by the American Society of Anesthesiologists Task Force on Obstetrical Anesthesia.
Anesthesiology.
1999;
90
600-611
-
70
Gogarten W, Aken H van, Bürkle H, Wulf H.
Durchführung von Regionalanästhesie in der Geburtshilfe. Überarbeitete Leitlinien der DGAI.
Anästh Intensivmed.
2004;
45
151-153
Dr. med. Jan-Philipp Breuer
Email: philipp.breuer@charite.de
Dr. med. Ingrid Correns
Prof. Dr. med. Claudia D. Spies
Email: claudia.spies@charite.de
