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Perioperative Schmerztherapie bei abdominellen und thorakalen Operationen

Perioperative pain management for abdominal and thoracic surgery

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Zusammenfassung

Abdominal- und thoraxchirurgische Eingriffe können mit starken akuten postoperativen Schmerzen einhergehen. Dabei zeigen neueste Untersuchungen, dass die schmerztherapeutische Versorgung gerade nach den häufig durchgeführten mittleren und kleineren Eingriffen noch deutlich verbessert werden muss. Zur effektiven Behandlung postoperativer Schmerzen nach abdominellen und thorakalen Eingriffen steht eine Reihe von Therapiemöglichkeiten (Regionalanästhesieverfahren, systemische Pharmakotherapie) zur Verfügung. In der vorliegenden Arbeit sollen zunächst die pathophysiologischen Grundlagen abdomineller und thorakaler Schmerzen nach einer Operation dargestellt und die verschiedenen Therapieoptionen im Hinblick auf ihre Indikation, Wirksamkeit und Risiko-/Nutzenbewertung diskutiert werden. Insbesondere erörtert wird der in den letzten Jahren z. T. nicht unumstrittene Einsatz einer Epiduralanalgesie sowie der mögliche Einsatz von (Alternativ-)Verfahren wie der „Transversus-abdominis-plane“(TAP)-Blockade, der Paravertebralblockade (PVB), einer lokalen Infiltration von Lokalanästhetika und der systemischen Applikation von Lidocain. Darüber hinaus werden Indikationen und Kontraindikationen einzelner Nichtopioidanalgetikagruppen speziell für abdominelle und thorakale Eingriffe angesprochen. Klare Empfehlungen werden gegeben und auf Zeitpunkt sowie Faktoren für eine individuelle Entscheidung wird hingewiesen. Auch wenn die Evidenzlage in einigen Bereichen noch nicht für einen generellen Einsatz bestimmter Verfahren ausreicht, haben die genannten Verfahren in der Klinik ihre Berechtigung. Zukünftig können sie zur Verbesserung der Ergebnisqualität hinsichtlich schmerztherapeutischer Parameter nach Operationen beitragen.

Abstract

Abdominal and thoracic surgical procedures can result in significant acute postoperative pain. Present evidence shows that postoperative pain management remains inadequate especially after “minor” surgical procedures. Various therapeutic options including regional anesthesia techniques and systemic pharmacotherapy are available for effective treatment of postoperative pain. This work summarizes the pathophysiological background of postoperative pain after abdominal and thoracic surgery and discusses the indication, effectiveness, risks, and benefits of the different therapeutic options. Special focus is given to the controversial debate about the indication for epidural analgesia, as well as various alternative therapeutic options, including transversus abdominis plane (TAP) block, paravertebral block (PVB), wound infiltration with local anesthetics, and intravenous lidocaine. In additional, indications and contraindications of nonopioid analgesics after abdominal and thoracic surgery are discussed and recommendations based on scientific evidence and individual risk and benefit analysis are made. All therapeutic options discussed are eligible for clinical use and may contribute to improve postoperative pain outcome after abdominal and thoracic surgical procedures.

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Interessenkonflikt. E.M. Pogatzki-Zahn, Beratungs- und/oder Referententätigkeiten für B. Braun, Mundipharma, MSD, Pfizer, Eli Lilly, Janssen-Cilag, Grünenthal und medupdate GmbH auszuüben. E.M. Pogatzki-Zahn bezieht Forschungsgelder von Mundipharma GmbH. J. Englbrecht gibt an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Englbrecht, J., Pogatzki-Zahn, E. Perioperative Schmerztherapie bei abdominellen und thorakalen Operationen. Schmerz 28, 265–281 (2014). https://doi.org/10.1007/s00482-014-1420-8

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  • DOI: https://doi.org/10.1007/s00482-014-1420-8

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