Zusammenfassung
Bislang existieren für den deutschen Sprachraum keine expertenbasierten Handlungsempfehlungen zur Vermeidung oder Therapie von „postoperative nausea and vomiting“ (postoperative Übelkeit und Erbrechen, PONV). Ziel war daher die Entwicklung von Empfehlungen, aus denen im klinikspezifischen Kontext „standard operating procedures“ (SOPs) abgeleitet werden können. Ein anästhesiologisch besetztes Expertengremium bearbeitete relevante Schlüsselthemen in Arbeitsgruppen, die anschließend im Plenum diskutiert wurden. Die Empfehlungen sollten sich auf Erkenntnisse stützen, zu denen umfassende und vertrauenswürdige Daten vorliegen. Einzelne Risikofaktoren, wie z. B. die Anamnese des Patienten, besitzen, isoliert betrachtet, keine ausreichende Sensitivität und Spezifität, um anhand dessen klinisch rationale Entscheidungen zu treffen. Im Gegensatz dazu berücksichtigen vereinfachte Risikoscores mehrere Faktoren und ermöglichen folglich eine zuverlässigere Risikoeinschätzung. Einzelne antiemetische Interventionen zur Vermeidung von PONV sind mit einer relativen Risikoreduktion von ca. 30% im Allgemeinen vergleichbar effektiv. Dieses scheint für die total intravenöse Anästhesie (TIVA) ebenso wie für Dexamethason und andere Antiemetika (Dimenhydrinat, Droperidol, Serotoninantagonisten, transdermales Scopolamin) zu gelten. Eine adäquate, hinreichend hohe Dosierung ist dabei Voraussetzung, die bei Kindern natürlich gewichtsadaptiert erfolgen sollte. Während die relative Risikoreduktion weitgehend unabhängig vom Kontext ist, sind die absolute Risikoreduktion und somit die „number needed totreat“ (NNT) einer Prophylaxe vor allem vom Patientenrisiko abhängig. Bei einem niedrigen Risiko erscheint eine Prophylaxe nicht sinnvoll. Bei mittlerem Risiko sollte eine Prophylaxe nicht vorenthalten werden. Ein hohes Risiko erfordert ein multimodales Vorgehen, das im Einzelfall angepasst werden sollte (medizinisches Risiko, Patientenpräferenz). Die Therapie von PONV sollte prompt, vorzugsweise mit zuvor noch nicht verwendeten Antiemetika erfolgen. Das Gremium schlägt Algorithmen vor, bei denen die Indikation und das Ausmaß einer Prophylaxe vor allem vom Patientenrisiko abhängig sind. Unter Berücksichtigung lokaler Gegebenheiten sollten diese eine evidenzbasierte Erstellung von SOPs erleichtern.
Abstract
There are no consensus guidelines for the management of postoperative nausea and vomiting (PONV) in German speaking countries. This meeting was intended to develop such guidelines on which individual health care facilities can derive their specific standard operating procedures (SOPs). Anesthesiologists reviewed published literature on key topics which were subsequently discussed during two meetings. It was emphasized that recommendations were based on the best available evidence. The clinical relevance of individual risk factors should be viewed with caution since even well proven risk factors, such as the history of PONV, do not allow the identification of patients at risk for PONV with a satisfactory sensitivity or specificity. A more useful approach is the use of simplified risk scores which consider the presence of several risk factors simultaneously. Most individual antiemetic interventions for the prevention of PONV have comparable efficacy with a relative risk reduction of about 30%. This appears to be true for total intravenous anesthesia (TIVA) as well as for dexamethasone and other antiemetics; assuming a sufficiently high, adequate and equipotent dosage which should be weight-adjusted in children. As the relative risk reduction is context independent and similar between the interventions, the absolute risk reduction of prophylactic interventions is mainly dependent on the patient’s individual baseline risk. Prophylaxis is thus rarely warranted in patients at low risk, generally needed in patients with a moderate risk and should include a multimodal approach in patients at high risk for PONV. Therapeutic interventions of PONV should be administered promptly using an antiemetic which has not been used before. The group suggests algorithms where prophylactic interventions are mainly dependent on the patient’s risk for PONV. These algorithms should provide evidence-based guidelines allowing the development of SOPs/policies which take local circumstances into account.
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Interessenkonflikt
Dr. C.C. Apfel erhielt in den letzten zwei Jahren Honorare für Vorträge und Beratungstätigkeit von GlaxoSmithKline (Philadelphia, PA), Merck (Whitehouse Station, NJ), MGI-Pharma (Bloomington, MN) und Fresenius Kabi (Bad Homburg). Er war auch an klinischen Studien beteiligt, die von Merck (Whitehouse Station, NJ) and MGI-Pharma (Bloomington, MN) unterstützt wurden.
Dr. P. Kranke, MBA, erhielt in den letzten zwei Jahren Honorare für Vorträge und Beratungstätigkeit von GlaxoSmithKline GmbH & Co. KG (München, Deutschland), Bayer Healthcare AG (Wuppertal, Deutschland), Fresenius Kabi Deutschland GmbH (Bad Homburg, Deutschland), Baxter Deutschland GmbH (Erlangen, Deutschland) und Pfizer GmbH (Karlsruhe, Deutschland).
Prof. D.R. Spahn erhielt in den letzten 12 Monaten Honorare für Beratungstätigkeit der Firmen B.Braun (Melsungen und Schweiz) sowie Novo Nordisk, Dänemark.
Prof. B. Zwissler erhielt in den letzten Jahren Honorare für Vorträge von Schering (Berlin), Abbott (Wiesbaden) und Fresenius-Kabi (Bad Homburg).
Prof. M. Steinfath hat in den letzten Jahren Vorträge auf Symposien und Fortbildungsveranstaltungen gehalten, die von den Firmen GlaxoSmithKline GmbH & Co. KG (München, Deutschland) und Fresenius-Kabi (Bad-Homburg, Deutschland) unterstützt wurden.
Priv.-Doz. Dr. S. Piper, Prof. T. Möllhoff, Dr. K. Danner, Dr. A. Biedler, Dr. O. Danzeisen, Dr. D. Rüsch, Prof. H. Gerber, Dr. M. Hohenhaus, Priv.-Doz. Dr. H. Kerger, Prof. F.J. Kretz, Dr. K. Stöcklein und Dr. J. Speck-Hergenröder gaben keine Interessenkonflikte innerhalb der letzten zwölf Monate an.
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Die wissenschaftliche Leitung der Konferenz hatte Herr Apfel. Organisation und Durchführung der Expertenkonferenz lag in den Händen von Herrn J. Speck-Hergenroeder. Herr Apfel, Herr Kranke und Herr Kretz haben gleichermaßen zur Erstellung des Manuskripts beigetragen und teilen sich daher die Erstautorenschaft. Das Projekt wurde durch einen Grant der Fa. Fresenius-Kabi GmbH, Bad Homburg, unterstützt.
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Apfel, C., Kranke, P., Piper, S. et al. Übelkeit und Erbrechen in der postoperativen Phase. Anaesthesist 56, 1170–1180 (2007). https://doi.org/10.1007/s00101-007-1210-0
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DOI: https://doi.org/10.1007/s00101-007-1210-0