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Kardiorespiratorische Effekte perioperativer Positionierungsmaßnahmen

Cardiorespiratory effects of perioperative positioning techniques

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Zusammenfassung

Die Rückenlage ist nach wie vor die am häufigsten praktizierte Form der intraoperativen Positionierung von Patienten. Positionierungsformen, abweichend von der Rückenlage, führen zu ausgeprägten physiologischen Veränderungen, die den Narkose- und Operationsablauf beeinflussen. Die Homöostase des Patienten wird beeinflusst durch Volumenverschiebungen in die (dann) abhängigen Körperpartien (aufrechtsitzende Positionen, aber auch Trendelenburg-Positionierung [TBP]) sowie durch ein Tiefertreten des Zwerchfells mit reduzierten Lungenvolumina und verminderter Compliance bei allen Formen der Oberkörpertieflage. Oberkörperhochlagen („beach chair position“) sind charakterisiert durch eine relative Hypovolämie, mit Abfall des mittleren arteriellen Blutdrucks, des Herzzeit- und des Schlagvolumens, während die pulmonalen Funktionen unbeeinflusst bleiben. Gravierende Komplikationen (postoperative Apoplexie) sind beschrieben. Pathophysiologische Grundlagen und Auswirkungen der hämodynamischen Veränderungen werden im vorliegenden Leitthemenbeitrag dargestellt, potenzielle Vermeidungsstrategien diskutiert. Oberkörpertieflagen bewirken dagegen einen, in der Mehrzahl der Fälle gut tolerierten, Anstieg des kardialen Preload. Die TBP hat aber – insbesondere in Kombination mit einem Kapnoperitoneum – negative Auswirkungen auf die Lungenfunktion, möglicherweise auf den intrakraniellen Druck und ggf. auch auf die Durchblutung intraabdomineller Organe. Die Pathophysiologie der intraoperativen TBP wird skizziert; Lösungsansätze zur Vermeidung von Komplikationen werden angesprochen. Bauch- und Seitenlagen beeinflussen die Homöostase dagegen wenig, auf die Besonderheiten der 15°-Linksseiten-Lage von Gebärenden wird in einem gesonderten Abschnitt eingegangen.

Abstract

The supine position is still the most frequently used type of positioning during surgical procedures. Positions other than the supine position lead to physiological alterations that have a relevant influence on the course of anesthesia and surgery. As a matter of principle, hemodynamic stability is at risk because venous blood is pooled in the lower positioned body parts. In addition, head down positions (Trendelenburg position) may lead to an impairment of respiratory function by reducing lung volumes as well as lung compliance. Upright positions (beach chair position) are characterized by a relative hypovolemia accompanied by a reduction of mean arterial pressure, cardiac output and stroke volume, whereas pulmonary functions remain unchanged. Some severe adverse events have been described in the literature (e.g. intraoperative apoplexy, postoperative blindness). The pathophysiological principles and effects of hemodynamic alterations as well as potential strategies to avoid complications are presented and discussed in this lead article. Head down positions, especially the Trendelenburg position, cause a relative (intrathoracic) hypervolemia and an increase in cardiac preload that is usually well-tolerated in patients without heart problems; however, the Trendelenburg position, especially if combined with a capnoperitoneum, significantly impairs pulmonary function, can have a negative effect on intracerebral pressure and may reduce blood flow of intra-abdominal organs. The pathophysiological intraoperative changes caused by Trendelenburg positioning are described and approaches suitable for risk reduction are discussed. The prone position and lateral decubitus position have little influence on the intraoperative homeostasis. Nevertheless, there is an ongoing discussion concerning the efficacy of a 15° left lateral position during caesarean section, which is also discussed in a separate section of this review.

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Abbreviations

ARDS:

„Acute respiratory distress syndrome“ (akutes Atemnotsyndrom)

BCP:

„Beach chair position“

CBF:

„Cerebral blood flow“ (zerebraler Blutfluss)

CI:

„Cardiac index“ (Herzindex)

CPP:

„Cerebral perfusion pressure“ (zerebraler Perfusionsdruck)

CVR:

„Cerebral vascular resistance“ (intrazerebraler Gefäßwiderstand)

FEV1 :

Forcierte exspiratorische Einsekundenkapazität

FIO2 :

Inspiratorische Sauerstofffraktion

FRC:

„Functional residual capacity“ (funktionelle Residualkapazität)

FVC:

„Forced vital capacity“ (forcierte Vitalkapazität)

HZV:

Herzzeitvolumen

ICP:

„Intracranial pressure“ (intrakranieller Druck)

MAD:

Mittlerer arterieller Druck

NIRS:

Nahinfrarotspektroskopie

paO2 :

Arterieller Sauerstoffpartialdruck

paCO2 :

Arterieller Kohlenstoffdioxidpartialdruck

petCO2 :

Endexspiratorischer Kohlenstoffdioxidpartialdruck

PEEP:

„Positive endexpiratory pressure“ (positiver endexspiratorischer Druck)

RL:

Rückenlage

rSO2 :

Regionale zerebrale Sauerstoffsättigung

SV:

Schlagvolumen

SVI:

Schlagvolumenindex

SVR:

„Systemic vascular resistance“ (systemvaskulärer Gefäßwiderstand)

SVV:

Schlagvolumenvariation

TBP:

Trendelenburg-Position

ZVD:

Zentraler Venendruck

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Authors and Affiliations

  1. Klinik für Anaesthesiologie, Klinikum der Universität München, Nussbaumstr. 20, 80336, München, Deutschland

    C. Zeuzem-Lampert,  P. Groene,  V. Brummer &  K. Hofmann-Kiefer

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  1. C. Zeuzem-Lampert
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  2. P. Groene
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Correspondence to K. Hofmann-Kiefer.

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C. Zeuzem-Lampert, P. Groene, V. Brummer und K. Hofmann-Kiefer geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Zeuzem-Lampert, C., Groene, P., Brummer, V. et al. Kardiorespiratorische Effekte perioperativer Positionierungsmaßnahmen. Anaesthesist 68, 805–813 (2019). https://doi.org/10.1007/s00101-019-00674-9

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