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Anästhesie und Analgesie bei Suchtpatienten

Grundlagen zur Erstellung einer „standard operating procedure“

Anesthesia and analgesia in addicts

Basis for establishing a standard operating procedure

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Zusammenfassung

Suchtkranke haben eine ausgeprägte organische und psychische Komorbidität. Im Fall einer größeren Operation oder eines Polytraumas sind sie als Hochrisikopatienten einzustufen. Perioperativ hinzukommende Probleme sind hoher Analgetikumbedarf, „craving“ (Drogenhunger), körperliches bzw. psychisches Entzugssyndrom, Hyperalgesie und Toleranz. Deren klinische Ausprägung richtet sich nach der missbrauchten Substanz. Zum besseren Verständnis der erforderlichen perioperativen Maßnahmen ist eine Zuordnung in das Zentralnervensystem (ZNS-)dämpfende (Heroin, Alkohol, Sedativa/Hypnotika), ZNS-erregende (Kokain, Amphetamine, Designer-Drogen) sowie weitere psychotrope Substanzen (Cannabis, Halluzinogene, Inhalanzien, Nikotin) hilfreich. Die perioperative Therapie soll nicht Therapie der Suchterkrankung sein. Vielmehr müssen Besonderheiten dieser chronischen Erkrankung akzeptiert werden. Anästhesie und Analgesie müssen großzügig stressabschirmend und ausreichend analgetisch wirksam sein. Gleichrangige perioperative Behandlungsprinzipien sind 1. Stabilisation der körperlichen Abhängigkeit durch Substitution mit Methadon (bei Heroinabhängigen) oder mit Benzodiazepinen und Clonidin (bei Suchterkrankung durch Alkohol, Sedativa, Hypnotika), 2. Vermeiden von „distress“ und Craving, 3. weit gehende intra- und postoperative Stressabschirmung durch Nutzung regionaler Techniken bzw. durch systemisch höher als sonst dosierte Anästhetika/Opioide, 4. striktes Vermeiden einer analgetischen Unterversorgung, 5. postoperative Optimierung der regionalen oder systemischen Analgesie durch Nichtopioide bzw. Koanalgetika und 6. Berücksichtigung der vielschichtigen körperlichen und psychischen Besonderheiten/Komorbiditäten. Auch bei Abstinenten („clean“) muss eine analgetische Unterversorgung vermieden werden. Diese und nicht die adäquate, u. U. auch starke Opioide einschließende Schmerztherapie ist potenziell suchtaktivierend. Das protrahierte Abstinenzsyndrom nach Opioidentzug kann zu erhöhter Ansprechbarkeit (Analgesie, Nebenwirkungen) zugeführter Opioide führen.

Abstract

Addicts have an exaggerated organic and psychological comorbidity and in cases of major operations or polytrauma they are classified as high-risk patients. Additional perioperative problems are a higher analgetics requirement, craving, physical and/or psychological withdrawal symptoms, hyperalgesia and tolerance. However, the clinical expression depends on the substance abused. For a better understanding of the necessary perioperative measures, it is helpful to classify the substances into central nervous system depressors (e.g. heroin, alcohol, sedatives, hypnotics), stimulants (e.g. cocaine, amphetamines, designer drugs) and other psychotropic substances (e.g. cannabis, hallucinogens, inhalants). The perioperative therapy should not be a therapy for the addiction, as this is senseless. On the contrary, the characteristics of this chronic disease must be accepted. Anesthesia and analgesia must be generously stress protective and sufficiently analgetically effective. Equally important perioperative treatment principles are stabilization of physical dependence by substitution with methadone (for heroin addicts) or benzodiazepines/clonidine (for alcohol, sedatives and hypnotics addiction), avoidance of stress and craving, thorough intraoperative and postoperative stress relief by using regional techniques or systematically higher than normal dosages of anesthetics and opioids, strict avoidance of inadequate dosage of analgetics, postoperative optimization of regional or systemic analgesia by non-opioids and coanalgetics and consideration of the complex physical and psychological characteristics and comorbidities. Even in cases of abstinence (clean) an inadequate dosage must be avoided as this, and not an adequate pain therapy sometimes even with strong opioids, can potentially activate addiction. A protracted abstinence syndrome after withdrawal of opioids can lead to increased response to administered opioids (e.g. analgesia, side-effects).

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Jage, J., Heid, F. Anästhesie und Analgesie bei Suchtpatienten. Anaesthesist 55, 611–628 (2006). https://doi.org/10.1007/s00101-006-1012-9

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