Zusammenfassung
Hintergrund
Zur Vermeidung schädlicher Folgen schmerzhafter Reize ist auch unter Allgemeinanästhesie eine adäquate Analgesie erforderlich. Hierbei kann sowohl Über- als auch Unterdosierung negative Auswirkungen haben. Zur optimalen Dosierung bedarf es eines kontinuierlichen Monitorings der Balance zwischen stattfindender Nozizeption und Analgesie.
Methoden
Diese Übersichtsarbeit beschreibt aktuelle Verfahren zum Nozizeptions- und Analgesiemonitoring sowie deren prinzipielle Unterschiede.
Ergebnisse
Nozizeptionsmonitore erfassen durch schmerzhafte Reize ausgelöste organische Veränderungen im Körper und ermöglichen so das Erkennen von überschießender Nozizeption bei unzureichender Analgesie. Analgesiemonitore erfassen nozizeptionsspezifische organische Veränderungen, die durch spezielle Testreize ausgelöst werden und ermöglichen eine präemptive Anpassung der Analgesie, bevor ein klinischer schmerzhafter Reiz erfolgt. Sie erfordern jedoch die Applikation von Teststimuli. Erste Proof-of-concept-Studien konnten bereits das Potenzial der Verfahren demonstrieren, jedoch ist bisher noch für keine der beiden Monitoring-Varianten ein Effekt auf das klinische Langzeit-Outcome von Patienten belegt.
Schlussfolgerungen
Für den routinemäßigen Einsatz von Nozizeptions- und Analgesiemonitoren in der klinischen Praxis bedarf es großer klinischer Studien mit Nachweis eines positiven Langzeit-Outcome-Effekts. Ohne verlässliche Parameter für Nozizeption und Analgesie konnten solche Untersuchungen bisher noch nicht erfolgen. Die Entwicklung der letzten Jahre stimmt zuversichtlich, dass in nicht allzu ferner Zukunft verlässliche Parameter für Nozizeption und Analgesie vorliegen werden, anhand derer die Langzeit-Outcome-Effekte von Nozizeption und Analgesie untersucht werden können.
Abstract
Background
To avoid negative effects of painful stimuli under general anesthesia, an adequate analgesia is needed. Since both overdosing and underdosing of analgesics may lead to negative consequences, an optimal dosing is crucial, requiring a continuous monitoring of the balance between the ongoing nociception and the level of analgesia.
Methods
This review describes current methods for the monitoring of nociception and analgesia as well as their inherent differences.
Results
Monitors of nociception register organic responses that are triggered through painful stimuli and therefore allow the detection of phases of excessive nociception during inadequate analgesia. In contrast, monitors of analgesia register nociception-specific organic responses that are triggered through test stimuli and allow a preemptive adaption of the level of analgesia, before a painful clinical stimulus is applied, but require the application of test stimuli. Preliminary proof-of-concept studies were able to demonstrate the potential of the here described methods; however, an effect on the clinical outcome of patients has not yet been shown for either of the two types of monitoring.
Conclusions
For the routine application of monitors of nociception and analgesia in daily clinical practice, large clinical studies are necessary, proving a positive outcome effect. Without reliable parameters for nociception and analgesia it was hitherto impossible to perform such studies. The progress made in recent years generates optimism that in the not too distant future the currently available methods to monitor nociception and analgesia might improve to a level of reliability to allow them to be used to investigate the clinical outcome relevance of nociception and analgesia
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F. von Dincklage weist auf folgende Beziehungen hin: Der Autor erhält aktuell Drittmittelförderung für wissenschaftliche Projekte von der Dolosys GmbH und war für diese als Berater tätig. Die Dolosys GmbH ist eine Ausgründung der Charité – Universitätsmedizin Berlin zur Herstellung von Monitoren zur Messung des nozizeptiven Flexorenreflexes.
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F. von Dincklage ist Mitglied des „Arbeitskreises Wissenschaftlicher Nachwuchs (WAKWIN)“ der DGAI
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von Dincklage, F. Monitoring von Schmerz, Nozizeption und Analgesie unter Allgemeinanästhesie. Anaesthesist 64, 758–764 (2015). https://doi.org/10.1007/s00101-015-0080-0
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DOI: https://doi.org/10.1007/s00101-015-0080-0