Schmerztherapeutische Aspekte bei Tumoroperationen

Zusammenfassung

Trotz einer Vielzahl von Therapieoptionen wird die Akutschmerztherapie nach onkologischen Operationen häufig als unzureichend beschrieben. Neben einer unzureichenden Akutschmerztherapie können weitere Faktoren eine Hypersensitivierung und Chronifizierung sowie den Verlauf der Tumorerkrankung beeinflussen. Dieser Beitrag erklärt pathophysiologische Hintergründe und erläutert geeignete Therapiemodalitäten.

Abstract

Due to preexisting pain or surgically induced sensitization patients undergoing oncological surgery are predisposed for a postoperative high pain intensity with the risk of developing persistent pain. In oncological surgery, pain therapy should be adapted to the underlying pain mechanism. Different treatment principles should be applied in a graded concept of acute pain therapy. The rationale implies the “conventional” use of the WHO step scheme, the administration of opioids as PCA as well as regional analgesia and agents with anti-hypersensitizing properties. Anti-hypersensitizing and anti-neuropathic treatment principles may include the use of antidepressants, anticonvulsants, intravenous lidocaine and s-ketamine. Before using such treatment, pain mechanisms should be verified by an adequate pain diagnostic. The impact of perioperative regional analgesia on the oncological outcome is subject to controversy. Opioids reveal both: tumor promoting and tumor inhibiting properties.

Kernaussagen

• Tumorchirurgisch behandelte Patienten sind wegen vorbestehender oder perioperativ bedingter Sensitivierungsmechanismen hinsichtlich einer hohen postoperativen Schmerzintensität und der Gefahr der Schmerzpersistenz mit Chronifizierung besonders prädisponiert.

• Die Schmerztherapie bei onkologischen Operationen sollte entsprechend einer Analyse der den Schmerzen zugrunde liegenden Mechanismen erfolgen und in einem abgestuften Konzept unter Einbeziehung verschiedener Wirkprinzipien durchgeführt werden. So erscheint neben der „konventionellen“ Anwendung von Stufe-1- bis -3-Substanzen, der PCIA-Technik mit Opioiden und regionalen Schmerztherapieverfahren die Anwendung antihypersensitivierender Substanzen sinnvoll.

• Zur Behandlung der Hypersensitivierungsmechanismen sowie bei neuropathischen Schmerzen können Antidepressiva, Antikonvulsiva, intravenöses Lidocain und S-Ketamin eingesetzt werden. Zuvor sollte aber eine entsprechende Schmerzdiagnostik diese Schmerzmechanismen eindeutig nachgewiesen haben.

• Der Einfluss der perioperativ eingesetzten Regionalanästhesie auf den weiteren Tumorerkrankungsverlauf wird kontrovers diskutiert.

• Opioide weisen sowohl tumorhemmende als auch tumorfördernde Eigenschaften auf.

Schlüsselwörter

Tumortherapie - Tumorchirurgie - Analgesie - Schmerztherapie - Opioide - regionale Anästhesie

Key words

tumor pain - analgesia - anti-hypersensitizing - regional anaesthesia - opioids

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