Der Anaesthesist

, Volume 56, Issue 7, pp 679–685

Klinische Pharmakologie

Postoperative Übelkeit und Erbrechen
Klinische Pharmakologie

Zusammenfassung

Die „Dreierregel“ beschreibt drei Schritte, die zur optimalen Kontrolle von postoperativer Übelkeit und Erbrechen („postoperative nausea and vomiting“, PONV) benötigt werden. Erstens sollte versucht werden, Hochrisikopatienten zu identifizieren. Risikofaktoren helfen mit, Patienten zu stratifizieren: Hochrisikopatienten profitieren am ehesten von einer Prävention; bei Niedrigrisikopatienten lohnt sich eine Prävention kaum. Zweitens sollte für Hochrisikopatienten eine Anästhesietechnik mit niedrigem emetogenen Potenzial gewählt werden. Und drittens sollten diese Patienten von einem präventiven antiemetischen Cocktail profitieren. Butyrophenone (z. B. Droperidol), 5-HT3-Rezeptoren-Antagonisten („Setrone“) und Steroide (z. B. Dexamethason) wirken am besten, wenn sie kombiniert werden. Sie gehören deshalb heute zu den logischen Komponenten eines antiemetischen Cocktails. Finanzielle Überlegungen können jedoch Zahl und Art der Antiemetika, die präventiv verabreicht werden sollen, beeinflussen. Die Identifizierung von Hochrisikopatienten bleibt der schwierigste Teil einer erfolgreichen PONV-Prävention. Zwar wurden Risikoscores vorgestellt, und diese wurden auch vielerorts in den klinischen Alltag integriert. Sensitivität und Spezifität dieser Scores sind jedoch ausgesprochen unbefriedigend, und ihre unkritische Anwendung bleibt somit unerwünscht. Solange keine zuverlässigeren Risikovoraussagen vorliegen, scheint bei manchen Patienten, eine aggressive Therapiestrategie sinnvoller und wahrscheinlich kosteneffizienter, als eine Prävention.

Schlüsselwörter

Postoperative Übelkeit und Erbrechen Hochrisikopatient Prävention Anästhesietechnik Antiemetischer Cocktail 

Clinical pharmacology

Postoperative nausea and vomiting

Abstract

The rule of three describes three steps which are needed for an optimal control of postoperative nausea and vomiting (PONV). Firstly, patients at high risk of PONV need to be identified. Knowledge about predictive factors may help to identify patients who may best profit from prophylaxis and those where prophylaxis is not worthwhile since the baseline risk is too low. Secondly, for high-risk patients a low emetogenic anaesthesia technique should be chosen, and thirdly, these patients should additionally receive a prophylactic antiemetic cocktail. At present, butyrophenones (e.g. droperidol), 5-HT3 receptor antagonists („setrons“) and steroids (e.g. dexamethasone) are the most rational choices for the antiemetic cocktail. Although there is strong evidence that there is an additive effect when these antiemetics are combined, economic constraints may influence the number of antiemetics that are eventually chosen. Identification of high-risk patients remains the most difficult part of the rule of three. Risk scores have been proposed and have been widely implemented in clinical practice. The sensitivity and specificity of such scores, however, remain particularly unsatisfactory. Unless more reliable risk scores are developed, aggressive treatment of established PONV symptoms may be more useful and more cost-effective than prophylaxis for many patients.

Keywords

Postoperative nausea and vomiting High-risk patients Prevention Anaesthesia technique Antiemetic cocktail 

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Copyright information

© Springer Medizin Verlag 2007

Authors and Affiliations

  1. 1.Service d’Anesthésiologie, Département APSIHôpitaux Universitaires de GenèveGenève 14Schweiz

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