Download PDF
Anästhesiol Intensivmed Notfallmed Schmerzther 2018; 53(04): 246-251
DOI: 10.1055/s-0043-104667
Topthema
Georg Thieme Verlag KG Stuttgart · New York

CONTRA: Postoperative Epiduralanalgesie – der Goldstandard?

Contra: Is Postoperative Epidural Analgesia the Gold Standard?
Hans Jürgen Gerbershagen
Further Information

Publication History

Publication Date:
09 May 2018 (online)

Also available at
    Permissions and Reprints

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
 

  • Literatur

  • 1 Werawatganon T, Charuluxanun S. Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intra-abdominal surgery. Cochrane Database Syst Rev 2005; (01) CD004088
    PubMedGoogle Scholar
  • 2 Pöpping DM, Elia N, Van Aken HK. et al. Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials. Ann Surg 2014; 259: 1056-1067
    CrossrefPubMedGoogle Scholar
  • 3 Gerbershagen HJ, Aduckathil S, van Wijck AJ. et al. Pain intensity on the first day after surgery: a prospective cohort study comparing 179 surgical procedures. Anesthesiology 2013; 118: 934-944
    CrossrefPubMedGoogle Scholar
  • 4 Kranke P, Jokinen J, Pace NL. et al. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery. Cochrane Database Syst Rev 2015; (07) CD009642
    PubMedGoogle Scholar
  • 5 Swenson BR, Gottschalk A, Wells LT. et al. Intravenous lidocaine is as effective as epidural bupivacaine in reducing ileus duration, hospital stay, and pain after open colon resection: a randomized clinical trial. Reg Anesth Pain Med 2010; 35: 370-376
    CrossrefPubMedGoogle Scholar
  • 6 Wongyingsinn M, Baldini G, Charlebois P. et al. Intravenous lidocaine versus thoracic epidural analgesia: a randomized controlled trial in patients undergoing laparoscopic colorectal surgery using an enhanced recovery program. Reg Anesth Pain Med 2011; 36: 241-248
    CrossrefPubMedGoogle Scholar
  • 7 Becker M. [Cost-effectiveness of peridural and intravenous analgesic schemes]. Anasthesiol Intensivmed Notfallmed Schmerzther 2010; 45: 168-169
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Corman S, Shah N, Dagenais S. Medication, equipment, and supply costs for common interventions providing extended post-surgical analgesia following total knee arthroplasty in US hospitals. J Med Econ 2018; 21: 11-18
    CrossrefPubMedGoogle Scholar
  • 9 Svircevic V, Passier MM, Nierich AP. et al. Epidural analgesia for cardiac surgery. Cochrane Database Syst Rev 2013; (06) CD006715
    PubMedGoogle Scholar
  • 10 Svircevic V, Nierich AP, Moons KG. et al. Thoracic epidural anesthesia for cardiac surgery: a randomized trial. Anesthesiology 2011; 114: 262-270
    CrossrefPubMedGoogle Scholar
  • 11 Guay J, Kopp S. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery. Cochrane Database Syst Rev 2016; (01) CD005059
    PubMedGoogle Scholar
  • 12 Bardia A, Sood A, Mahmood F. et al. Combined epidural-general anesthesia vs. general anesthesia alone for elective abdominal aortic aneurysm repair. JAMA Surg 2016; 151: 1116-1123
    CrossrefPubMedGoogle Scholar
  • 13 Rosero EB, Joshi GP. Nationwide incidence of serious complications of epidural analgesia in the United States. Acta Anaesthesiol Scand 2016; 60: 810-820
    CrossrefPubMedGoogle Scholar
  • 14 Borghi B, DʼAddabbo M, Borghi R. Can neural blocks prevent phantom limb pain?. Pain Manag 2014; 4: 261-266
    CrossrefPubMedGoogle Scholar
  • 15 Pöpping DM, Elia N, Marret E. et al. Protective effects of epidural analgesia on pulmonary complications after abdominal and thoracic surgery: a meta-analysis. Arch Surg 2008; 143: 990-999 discussion 1000
    CrossrefPubMedGoogle Scholar
  • 16 Yeung JH, Gates S, Naidu BV. et al. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev 2016; (02) CD009121
    PubMedGoogle Scholar
  • 17 Terkawi AS, Mavridis D, Sessler DI. et al. Pain management modalities after total knee arthroplasty: a network meta-analysis of 170 randomized controlled trials. Anesthesiology 2017; 126: 923-937
    CrossrefPubMedGoogle Scholar
  • 18 Koh IJ, Choi YJ, Kim MS. et al. Femoral nerve block versus adductor canal block for analgesia after total knee arthroplasty. Knee Surg Relat Res 2017; 29: 87-95
    CrossrefPubMedGoogle Scholar
  • 19 Johnson RL, Kopp SL, Burkle CM. et al. Neuraxial vs. general anaesthesia for total hip and total knee arthroplasty: a systematic review of comparative-effectiveness research. Br J Anaesth 2016; 116: 163-176
    PubMedGoogle Scholar
  • 20 Prospect Working Group. Procedure specific postoperative pain management. Im Internet: http://www.postoppain.org/sections/ Stand: 23.02.2018
    PubMedGoogle Scholar
  • 21 Roeb MM, Wolf A, Gräber SS. et al. Epidural against systemic analgesia: an international registry analysis on postoperative pain and related perceptions after abdominal surgery. Clin J Pain 2017; 33: 189-197
    PubMedGoogle Scholar
  • 22 Khan SA, Khokhar HA, Nasr AR. et al. Effect of epidural analgesia on bowel function in laparoscopic colorectal surgery: a systematic review and meta-analysis. Surg Endosc 2013; 27: 2581-2591
    CrossrefPubMedGoogle Scholar
  • 23 Halabi WJ, Jafari MD, Nguyen VQ. et al. A nationwide analysis of the use and outcomes of epidural analgesia in open colorectal surgery. J Gastrointest Surg 2013; 17: 1130-1137
    CrossrefPubMedGoogle Scholar
  • 24 Elsharydah A, Williams TM, Rosero EB. et al. Epidural analgesia does not increase the rate of inpatient falls after major upper abdominal and thoracic surgery: a retrospective case-control study. Can J Anaesth 2016; 63: 544-551
    CrossrefPubMedGoogle Scholar
  • 25 DʼAngelo R, Smiley RM, Riley ET. et al. Serious complications related to obstetric anesthesia: the serious complication repository project of the Society for Obstetric Anesthesia and Perinatology. Anesthesiology 2014; 120: 1505-1512
    CrossrefPubMedGoogle Scholar
  • 26 Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990–1999. Anesthesiology 2004; 101: 950-959
    CrossrefPubMedGoogle Scholar
  • 27 Cook TM, Counsell D, Wildsmith JA. Royal College of Anaesthetists Third National Audit Project. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth 2009; 102: 179-190
    CrossrefPubMedGoogle Scholar
  • 28 Subramani Y, Nagappa M, Wong J. et al. Death or near-death in patients with obstructive sleep apnoea: a compendium of case reports of critical complications. Br J Anaesth 2017; 119: 885-899
    CrossrefPubMedGoogle Scholar
  • 29 Cozowicz C, Olson A, Poeran J. et al. Opioid prescription levels and postoperative outcomes in orthopedic surgery. Pain 2017; 158: 2422-2430
    CrossrefPubMedGoogle Scholar
  • 30 Hermanides J, Hollmann MW, Stevens MF. et al. Failed epidural: causes and management. Br J Anaesth 2012; 109: 144-154
    CrossrefPubMedGoogle Scholar
  • 31 Sellmann T, Bierfischer V, Schmitz A. et al. Tunneling and suture of thoracic epidural catheters decrease the incidence of catheter dislodgement. ScientificWorldJournal 2014; 2014: 610635
    PubMedGoogle Scholar