Was gibt es Neues in der Ophthalmoanästhesie?

 

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Zusammenfassung

In den letzten Jahren gab es eine Vielzahl von Veränderungen bezüglich der Anästhesie in der Augenheilkunde. In der Allgemeinanästhesie erhöhen Pharmaka mit exzellenter Steuerbarkeit die Sicherheit für den Patienten und erlauben besonders kurze Wechselzeiten, einhergehend mit einer Steigerung der Effizienz im OP. Zunehmend werden augenchirurgische Eingriffe unter örtlicher Betäubung durchgeführt, wobei besonders die topische Anästhesie eine steigende Verbreitung erfährt. Narkosen in der Augenheilkunde, und zwar sowohl die Allgemeinanästhesie als auch Regionalanästhesieverfahren, bieten zahlreiche Besonderheiten. Aufgrund von Alter und Begleiterkrankungen gehören Patienten häufig zu den Risikogruppen ASA III - IV. Sowohl die operativen Maßnahmen am Auge als auch intraoperativ eingesetzte Medikamente können systemische Auswirkungen für den Patienten haben, wobei besonders das kardiovaskuläre System betroffen ist. Daher ist auch bei Regionalanästhesieverfahren ein anästhesiologisches „Stand-by” sinnvoll, um supportiv antihypertensive Therapie, Rhythmustherapie, Sicherstellung einer ausreichenden Atmung bei zusätzlicher Sedierung der Patienten sicherzustellen. Weiterhin können Regionalanästhesie, Allgemeinanästhesie und für die Narkose applizierte Medikamente den intraokulären Druck (IOD) steigern oder senken. Während es viele Publikationen über den Einfluss der Anästhesie auf den IOD gibt, sind solche über den okulären Blutfluss rar. Für abschließende Empfehlungen bleibt zu berücksichtigen, dass bei vergleichbaren Effekten der Anästhesieverfahren auf den intraokulären Druck, die Effekte auf den pulsatilen okulären Blutfluss (POBF) divergieren können. Um einen Anstieg des IOD v. a. bei Intubation zu verhindern, können Succinylcholin und Rocuronium als Muskelrelaxantien verwendet werden, erscheinen Opiate essenziell, wobei Remifentanil hierbei besonders günstig sein könnte. Zusätzlich könnte der Einsatz einer Larynxmaske (LAMA) vorteilhafter sein als der eines Intubationstubus. Patienten, die lang wirkende Antikoagulantien einnehmen, erfordern ein ausgewogenes Management unter Abwägung der Risiken Blutungskomplikationen versus Komplikationen durch die zugrunde liegenden Erkrankungen. Mehrere Studien sprechen dafür, prophylaktische Langzeitantikoagulation für Augenoperationen, wie Kataraktoperationen, nicht zu unterbrechen. Die Entwicklungen der Anästhesie bei Kindern und Neugeborenen für Eingriffe am Auge und eine Reihe von Möglichkeiten, PONV (postoperative Übelkeit und Erbrechen), ein sehr häufiges Problem bei Strabismusoperationen, zu reduzieren, werden dargestellt. Die PONV-Rate hängt wesentlich von der Operationsart ab, sie ist v. a. bei retroäquatorialer Myopexie besonders hoch. Dieser Aspekt wurde bei den meisten PONV-Studien in der Augenheilkunde bisher nicht berücksichtigt. Effektivitätsvergleiche antiemetischer Prophylaxe hinken oft, da die Halbwertszeiten der eingesetzten Substanzen nicht berücksichtigt wurden. Zur Reduktion von PONV bei ophthalmologischen Operationen sollten lang wirksame Opiate vermieden, Nichtopiatanalgetika verwendet, und in Abhängigkeit von der Operationsart, eine antiemetische Prophylaxe durchgeführt werden, wobei sich Kombinationen in niedriger Dosierung als effektiver als die höher dosierte Einzelgabe erwiesen haben.

Abstract

In the past few years, there have been many changes in ophthalmic anaesthesia. Application of drugs in general anaesthesia with excellent controllability enhances patient safety and allows a more efficient OR-management. Regional anaesthesia is gaining widespread use for ophthalmic surgery, especially topical anaesthesia for cataract surgery. Patients for ophthalmic surgery concomitantly often display high age and a high level of co-morbidity and, therefore, belong to the anaesthesiological risk groups ASA III - IV. Life-threatening adverse events including cardiovascular depression are associated with general and regional anaesthesia. Intervention by anaesthesiologists is frequently required for treatment of hypertension or dysrhythmias, and sedation. Thus, monitored anaesthesia care („standby”) is justified. Drugs applied for regional and general anaesthesia may change intraocular pressure. There are a lot of publications about the impact of anaesthesia on intraocular pressure (IOD), however, few on the effects of anaesthesia on pulsatile ocular blood flow. it has to be kept in mind that the effects of anaesthesia on intra-ocular pressure and pulsatile ocular blood flow may diverge. To avoid an increase of the IOD, especially during anaesthesia induction, drugs, such as succinylcholin, rocuronium and opiates, in particular remifentanil, can be applied. In addition, the use of the laryngeal mask may be advantageous compared to general anaesthesia associated with laryngoscopic tracheal intubation. The management of patients treated with anticoagulants and antiplatelet agents, has to be taken on the balance of risks. There are risks not only in continuing therapy, but also in discontinuing it perioperatively. Postoperative nausea and vomiting (PONV) remains a distressing and common problem after strabismus repair in particular in children. The incidence of PONV depends on the type of ophthalmic surgery and drugs applied. To reduce PONV in ophthalmic surgery, application of long-lasting opiates should be avoided, and non-opiate analgesics and, depending on the kind of operation, antiemetic prophylactics are recommended.

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PD Dr. med. Henry Weigt

Universitätsklinikum Ulm · Klinik für Anästhesiologie

Steinhövelstraße 9

89075 Ulm

Phone: 0731/5027904

Email: henry.weigt@gmx.de