CONTRA: Postoperative Epiduralanalgesie – der Goldstandard?

Zusammenfassung

Die Epiduralanalgesie (EDA) kann nicht für alle Eingriffe mit mittelstarkem bis starkem Schmerzniveau der Goldstandard der Therapie sein. Die EDA ist der PCA (patientenkontrollierte Analgesie) und den oralen Analgetika in Bezug auf Reduktion der postoperativen Schmerzintensität überlegen [1]. Mögliche schwerwiegende Komplikationen sowie die höheren Kosten der EDA erfordern aber eine sorgfältige, evidenzbasierte operationsspezifische Abwägung.

Abstract

As strategy for postoperative pain therapy, epidural analgesia (EDA) is superior to systemic opiate analgesia after abdominal and thoracic surgery. In addition, EDA may significantly reduce the incidence of complications in some large operations, such as, e.g. cardiac (myocardial infarction, atrial fibrillation) and pulmonary complications (pneumonia, atelectasis), and even reduce mortality. Intestinal motility can also be improved. However, these positive effects do not appear in all interventions and not to the same degree. Therefore, for benefit-risk assessment, it is important to know both the operation-specific benefits and disadvantages of EDA. In the meantime, the distinctly different complication rates of epidural bleeding and abscesses after EDA are also known for different surgical interventions. In large open abdominal interventions, open thorax operations, and especially open abdominal aortic surgeries, EDA reduces pain and complications. It should be noted that the positive effects of EDA have so far hardly been directly compared with those of intraoperative lidocaine administration.

Kernaussagen

• In der postoperativen Schmerztherapie ist die Epiduralanalgesie (EDA) der systemischen Opiatanalgesie nach abdominalen und thorakalen Operationen überlegen.

• Die EDA kann bei einigen großen Operationen zusätzlich kardiale und pulmonale Komplikationen signifikant reduzieren – wie z. B. Myokardinfarkt, Vorhofflimmern, Pneumonie, Atelektasen – und sogar die Mortalität verringern. Die Darmmotilität kann ebenfalls verbessert werden.

• Diese positiven Effekte zeigen sich jedoch nicht bei allen Eingriffen und auch nicht in gleicher Ausprägung. Daher ist es für eine gute Nutzen-Risiko-Abwägung wichtig, sowohl die operationsspezifischen Vorteile als auch Nachteile der EDA zu kennen.

• Mittlerweile sind auch für die verschiedenen operativen Fachbereiche die deutlich unterschiedlichen Komplikationsraten von epiduralen Blutungen und Abszessen nach EDA bekannt und können berücksichtigt werden.

• Demnach kann vor allem bei großen offenen abdominellen Eingriffen, bei offenen Thoraxoperationen sowie insbesondere bei offenen Bauchaortenoperationen die EDA die Schmerzen sowie die Komplikationen reduzieren.

• Zu beachten ist, dass die positiven Effekte der EDA bisher kaum direkt mit der intraoperativen i. v. Lidocain-Gabe verglichen wurden.

Schlüsselwörter

Epiduralanalgesie - Komplikationen - Nutzen-Risiko-Abwägung - Lidocain intravenös

Key words

epidural analgesia - complications - benefit-risk assessment - intravenous lidocaine

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