Prophylaxe und Therapie von Übelkeit und Erbrechen nach Narkosen (PONV)

Zusammenfassung

In den letzten Jahren gab es zahlreiche neue Erkenntnisse zur Prophylaxe und Therapie von Übelkeit und Erbrechen in der postoperativen Phase (Postoperative nausea and vomiting: PONV). Erwähnenswert ist dabei die Verfügbarkeit einer komplett neuen antiemetischen Intervention – dem Neurokininantagonisten Aprepitant – sowie die Wiederzulassung von Droperidol, einem seit vielen Jahrzehnten bewährten Dopaminantagonisten. Neu ist zudem eine mittlerweile eher kritische Bewertung eines risikoadaptiertes Vorgehens, basierend auf vereinfachten Risiko-Scores. Die Anwendung solcher Prädikationsmodelle wird vor allem aufgrund der sehr ungenauen Prädiktion des individuellen Risikos als auch aufgrund von Problemen bei der Implementierung eines risikoadaptierten Vorgehens nicht mehr uneingeschränkt empfohlen. Vielmehr geht der Trend klar zu einer liberalen Applikation von Antiemetika, die zudem viel häufiger als multimodale Prophylaxe bzw. Therapie verabreicht werden sollte. Da es keine spezifischen Spezialindikationen für das eine oder andere Antiemetikum gibt, sollte die Auswahl der antiemetischen Interventionen primär anhand der potenziellen Nebenwirkungen getroffen werden. Zu beachten ist allerdings, dass eine TIVA später nicht mehr „nachgeholt” werden kann. Kortikosteroide (Dexamethason) sollten wegen eines verzögerten Wirkeintritts eher am Anfang einer Operation verabreicht werden. 5-HT₃-Antagonisten eignen sich gut zur Behandlung auf peripheren Stationen, da meist eine geringere Hemmschwelle bei der Applikation dieser Substanzen vorhanden ist. Droperidol ist nur in Anästhesiekreisen verbreitet und stellt neben Dexamethason somit intraoperativ die Prophylaxe der ersten Wahl dar. PONV kann gut und mit vertretbarem Aufwand weitgehend eliminiert werden. Neben „schmerzfreien” Krankenhäusern sollte als weiteres Ziel nun das PONV-freie Krankenhaus auf der Agenda stehen.

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