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Gefässchirurgie

, Volume 21, Issue 5, pp 291–300 | Cite as

Optimum versus Maximum in der gefäßchirurgischen Anästhesie

Caveats und Do-Not-Do’s
  • Balthasar EberleEmail author
Leitthema
  • 202 Downloads

Zusammenfassung

Die Anästhesiologie betreut in der Gefäßchirurgie einen besonders hohen Anteil multimorbider Patienten mit erhöhtem perioperativem Risiko. Das perioperative Management ist entsprechend anspruchsvoll. Präoperative Evaluation und Vorbereitung gefäßchirurgischer Patienten müssen anhand evidenzbasierter Leitlinien und in enger interdisziplinärer Kooperation erfolgen. Diese Erfordernisse dürfen nicht dem Effizienzdruck zum Opfer fallen. Auch eine Überdiagnostik oder Übertherapie verbietet sich aus medizinischen und wirtschaftlichen Gründen. Die Wahl zwischen allgemeinen und lokoregionalen Anästhesieverfahren bleibt Diskussionsthema zwischen den Fachgebieten, insbesondere für die Karotisendarteriektomie (CEA) und die endovaskuläre Therapie abdominaler Aortenaneurysmen (EVAR). Bei der CEA unterscheiden sich die beiden Techniken im Ergebnis nicht relevant, die Kosten der Lokalanästhesie sind allerdings geringer. Patienten zur elektiven und notfallmäßigen EVAR profitieren auch medizinisch vom Einsatz der Lokalanästhesie. Beim rupturierten abdominalen Aortenaneurysma empfehlen Leitlinien präoperativ eine Volumenrestriktion und eine permissive Hypotension auf systolische Blutdruckwerte zwischen 50 und 100 mmHg. Neuere Evidenz spricht dafür, den systolischen Druckbereich auf 70 bis 100 mmHg zu limitieren. Postoperativ ist die Balance zwischen Blutungs- und Thromboserisiko besonders kritisch. Prothrombotische (Ko-)Morbidität, antithrombotische Medikation, prokoagulatorische Ausgangszustände und chirurgischer Blutumsatz schaffen oft unübersichtliche Akutsituationen. Zwar steht heute ein rasch wirksames, potentes Arsenal zur Stillung koagulopathischer Blutungen zur Verfügung, allerdings existiert für die allgemeine Gefäßchirurgie noch zu wenig Evidenz zu deren Nutzen und Risiken. Eine unkritische Übertragung von Hämostaseprotokollen aus anderen klinischen Bereichen erscheint daher riskant. Für die Gefäßchirurgie besteht hier Forschungsbedarf.

Schlüsselwörter

Anästhesieverfahren Gefäßchirurgie Präoperative Evaluation Permissive Hypotension Hämostase 

Optimum versus maximum in anaesthesia for vascular surgery

Caveats and do not do’s

Abstract

Anaesthesia in vascular surgery routinely involves patients with significant comorbidities and elevated perioperative risk. Good outcome depends on optimal perioperative evaluation and management, which should follow multidisciplinary guidelines based on best contemporary evidence. Close cooperation of all involved parties must be maintained even under time pressure, but medical overuse is to be avoided. The choice between general (GA) and locoregional anesthesia (LA) remains a constant topic of discussion, particularly for carotid endarterectomy (CEA) and endovascular aortic repair (EVAR). For CEA there is no relevant difference in outcome between both techniques except some cost reduction with LA. Patients undergoing elective or emergency EVAR probably have better outcomes if LA is used. In the preoperative management of ruptured abdominal aortic aneurysms, restrictive fluid administration and permissive hypotension have been recommended tolerating a systolic blood pressure between 50 and 100 mmHg. Newer evidence indicates that systolic pressures should be targeted to 70–100 mmHg. The postoperative balance between risk of bleeding and thrombosis is particularly precarious. Prothrombotic comorbidities, antithrombotic medication, procoagulant conditions and surgical blood loss make optimal management difficult. Although a rapidly effective and potent armamentarium for staunching coagulopathic bleeding is currently available, in general vascular surgery there is still too little evidence on benefits and risks. The uncritical use of protocols from hemostasis in other clinical fields may entail substantial risks. More research is needed into hemostatic drug support in major vascular surgery.

Keywords

Anesthesia Vascular surgery Preoperative assessment Permissive hypotension Hemostasis 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

B. Eberle gibt an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine vom Autor durchgeführten Studien an Menschen oder Tieren.

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Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  1. 1.Universitätsklinik für Anästhesiologie und SchmerztherapieUniversitätsspital Bern, InselspitalBernSchweiz

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