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Intraoperative Remifentanilgabe und postoperative Schmerztherapie

Gibt es ein optimales Vorgehen?

Remifentanil-based intraoperative anaesthesia and postoperative pain therapy

Is there an optimal treatment strategy?

  • Schmerztherapie
  • Published:
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Zusammenfassung

Remifentanil ist ein synthetisches Opioid mit einer direkten agonistischen Wirkung am μ-Opioidrezeptor. Remifentanil unterscheidet sich zu anderen synthetischen Opioiden durch sein pharmakokinetisches Profil. Ubiquitär in Gewebe und Plasma vorkommende Esterasen bewirken eine schnelle Elimination der Substanz. Die dabei entstehenden Metaboliten sind am μ-Rezeptor nahezu unwirksam. Dieser schnelle Abbau von Remifentanil kann jedoch im Rahmen der postoperativen Betreuung von Patienten zu Problemen führen. Insbesondere bei Eingriffen mit zu erwartenden starken postoperativen Schmerzen kann der abrupte Analgesieverlust beim Übergang von der intra- zur postoperativen Phase mit starken Schmerzen und einem erhöhten postoperativen Morphinverbrauch verbunden sein. Darüber hinaus führt der schnelle Entzug von Remifentanil zur Aktivierung kompensatorischer Mechanismen, die eine postoperative Hyperalgesie verstärken können. Diese Übersichtsarbeit versucht den Stand der experimentellen und der klinischen Untersuchungen zur postoperativen Analgesie nach remifentanilbasierten Anästhesieverfahren zusammenzufassen. Gleichzeitig soll eine mögliche Strategie für eine effektive postoperative Schmerztherapie nach intraoperativer Remifentanilgabe aufgezeigt werden.

Abstract

Remifentanil is a synthetic opioid derivate with an agonist activity at μ-opioid receptors. The pharmacokinetic profile differs from other synthetic opioids. Remifentanil is rapidly metabolised by unspecific blood and tissue esterases and the metabolites have almost no intrinsic activity. According to its unique pharmacokinetic profile, remifentanil-based anaesthesia might be associated with a high level of postoperative pain, therefore, an appropriate postoperative pain management is an import aspect. In addition, remifentanil withdrawal induces a compensatory up-regulation of secondary messenger pathways, inducing hyperalgesia. This review provides a comprehensive summary of basic and clinical research concerning the intraoperative use of remifentanil and postoperative pain therapy. The relative contribution of rapid degradation and withdrawal-induced hyperalgesia to postoperative pain will be discussed. In addition, this review attempts to identify potential clinical implications and treatment strategies.

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  1. Klinik für Anaesthesiologie und operative Intensivmedizin, Charité – Universitätsmedizin Berlin,Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Deutschland

    C. Zöllner & M. Schäfer

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  2. M. Schäfer
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Correspondence to C. Zöllner.

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Zöllner, C., Schäfer, M. Intraoperative Remifentanilgabe und postoperative Schmerztherapie. Anaesthesist 56, 1038–1046 (2007). https://doi.org/10.1007/s00101-007-1246-1

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