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Total intravenöse Anästhesie

Auf dem Weg zum Standardverfahren bei Kindern

  • Leitthema
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Zusammenfassung

Von allen verfügbaren intravenösen Hypnotika ist Propofol am besten für die Einleitung und die Aufrechterhaltung einer Kindernarkose geeignet. Die Substanz ist exzellent steuerbar; relevante hämodynamische Nebenwirkungen treten bei gesunden Kindern nicht auf. Wirkdauer und Elimination von Propofol sind weitestgehend organunabhängig; Propofol kumuliert auch nach längerer Zufuhr nicht. Das Einschlafen erfolgt rasch und ist angenehm. Ein Exzitationsstadium wird nicht durchlaufen. In einer kritischen Phase der Anästhesie ist ein sicherer Venenzugang vorhanden. Das Aufwachen erfolgt auch nach langer Zufuhr rasch und immer ohne Agitation oder Verhaltensstörungen. Nach total intravenöser Anästhesie (TIVA) sind Übelkeit und Erbrechen seltener als nach einer Narkose mit volatilen Substanzen. Propofol ermöglicht die endotracheale Intubation ohne zusätzliche Muskelrelaxation. Damit eignet sich die TIVA ganz besonders für die ambulante Kinderchirurgie sowie für Eingriffe im Bereich der Mundhöhle und des Rachens. Mit Propofol können flache Narkosen in der Magnetresonanztomographie (MRT) und im Computertomogramm (CT) ohne eine endotracheale Intubation durchgeführt werden. Die TIVA führt zu keiner Raumluftkontamination, induziert keine Hepatitisantikörper und ist nicht gentoxisch. Bei Kindern ist die TIVA ein preiswertes Verfahren. Für schmerzhafte Eingriffe muss Propofol mit einem Opioid—für die ambulante Anästhesie eignen sich Remifentanil und Alfentanil—oder einer Regionalanästhesie kombiniert werden. "Awareness" ist ein noch völlig unerforschtes Gebiet der Kinderanästhesie. Es ist völlig unbekannt, ob—und wenn ja, wie häufig—Wachheit in der Narkose bei Kindern überhaupt vorkommt. Die Verwendung des EEG für die Überwachung der Narkosetiefe ist durch altersspezifische Besonderheiten der elektrischen Hirnaktivität und eine fehlende Validierung erschwert. Auf der Wunschliste ganz oben steht eine fettfreie Zubereitung von Propofol, am besten in einer wässrigen Lösung. Das Propofol-Infusions-Syndrom bedarf dringend der Aufklärung. Eine Möglichkeit, die Serumspiegel von Propofol während einer Narkose zeitnah zu messen, fehlt bislang. Studien zur Anwendung bei Früh- und Neugeborenen fehlen vollständig. Gerade bei diesen Kindern ist eine Abstraktion von Daten, die bei älteren Kindern oder Erwachsenen erhoben wurden, aber nicht möglich. Insgesamt steht mit der TIVA ein nebenwirkungsarmes und sicheres Verfahren zur Verfügung. Es wird in vielen Fälle eine echte Alternative zur Inhalationsanästhesie sein. Seine Anwendung bei kleinen Kindern erfordert aber Erfahrung, die am besten bei großen Kindern oder Erwachsenen erworben werden sollte.

Abstract

Since venous cannulation in children has become easier and extensive experience has been gained with total intravenous anaesthesia (TIVA) in adults, the interest in TIVA for children has recently increased. An intensified sensitivity of the operating room atmosphere to contamination with volatile anaesthetic agents is another important reason to choose intravenous techniques for paediatric anaesthesia. One of the most interesting agents for TIVA in paediatric anaesthesia is propofol. The pharmacokinetic and pharmacodynamic data for modern intravenous drugs is poor. Because the interpatient variability is relatively large, pharmacokinetic data can only provide guidelines for the dosage of propofol. Propofol has a rapid and smooth onset of action and is as easy to titrate in children as in adults. Propofol can be excellently controlled. Severe haemodynamic side-effects are missing in healthy children and plasma is cleared rapidly of propofol by redistribution and metabolism. There is no evidence of significant accumulation, not even after prolonged infusion times. Because propofol has no analgetic properties it must be combined with analgetics or a regional block for all painful procedures. The combination with the ultra-short acting remifentanil is a major advantage, but requires effective analgetic concepts for painful procedures. In comparison the combination of propofol with long acting opioids abolishes some of the favourable properties of propofol. Further studies of the kinetics and dynamics of propofol and other intravenous agents are needed in paediatrics which should focus on age, maturity and severity of illness. The whole importance of the propofol-infusion syndrome has to be cleared up urgently. TIVA has an important significance in paediatric anaesthesia for diagnostic and therapeutic procedures, especially where these have to be repeated. In day-case anaesthesia TIVA has advantages for all short procedures and for ENT and ophthalmic surgery: even after prolonged infusion children have an short recovery time. There is no evidence of agitation or other behavioural disorders after TIVA with propofol in paediatric anaesthesia. Propofol has anti-emetic properties. TIVA with propofol can be combined with regional anaesthesia advantageously to provide long-lasting analgesia after surgery. TIVA with propofol has been used successfully for sedation of spontaneously breathing children for MRI and CT and other procedures with open airways like bronchoscopy or endoscopy. Propofol facilitates endotracheal intubation without the use of muscle relaxants. Of course, in malignant hyperthermia TIVA will continue to be the technique of choice. Nothing is known about awareness under TIVA in paediatric patients. TIVA must be considered by comparison with the volatile agents. The use of ultra-short acting agents may cause problems such as awareness, vagal response, involuntary movements and in some cases slow recovery after prolonged infusion of propofol. But it is not known exactly how often this happens during paediatric anaesthesia. With TIVA an effective postoperative analgesia must be provided. Newer administration techniques such as the target-controlled infusions or closed-loop control systems are under development and will help to minimise the potential risk of overdosage with TIVA in paediatrics. At the present TIVA is an interesting and practicable alternative to volatile anaesthesia for pre-school and school children. TIVA with propofol in infants younger than 1 year old requires extensive experience with TIVA in older children and with the handling of this special age group and should be undertaken with maximum precautionary measures.

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Notes

  1. Nach Auskunft der Fa. B. Braun Melsungen AG mussten sich alle Hersteller für die europäische Zulassung auf den kleinstmöglichen Nenner, in diesem Fall auf eine maximale Anwendungsdauer von 60 min einigen. Das geschah vor dem Hintergrund, dass bei den eingereichten Studien die Kindernarkosen nicht länger als 75 min gedauert haben. AstraZeneca verfügt dagegen in allen Ländern über eine nationale Zulassung und unterliegt deshalb nicht dieser Sonderregelung. Die Autoren erwarten, dass sich die Hersteller für eine Ausweitung der maximalen Anwendungsdauer einsetzen.

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  1. Klinik für Anästhesiologie und Operative Intensivmedizin, HELIOS Klinikum Berlin

    J. M. Strauß & J. Giest

  2. Klinik für Anästhesiologie und Operative Intensivmedizin, HELIOS Klinikum Berlin, Hobrechtsfelder Chaussee 100, 13122, Berlin

    J. M. Strauß

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Strauß, J.M., Giest, J. Total intravenöse Anästhesie. Anaesthesist 52, 763–777 (2003). https://doi.org/10.1007/s00101-003-0560-5

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