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Bestandsaufnahme der Lokalanästhetika 2020

Stocktaking of local anesthetics 2020

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Zusammenfassung

Lokalanästhetika haben sich als sichere und zuverlässig wirkende Substanzen in der klinischen Praxis bewährt und die immensen Fortschritte innerhalb der Regionalanästhesie überhaupt erst möglich gemacht. Dabei wird immer deutlicher, dass Lokalanästhetika weit mehr sind als „schlichte“ Natriumkanalinhibitoren, und dass Interaktionen mit einer ganzen Reihe weiterer Ionenkanäle und anderer molekularer Strukturen zur eigentlichen Nervenblockade beitragen. Zusätzlich lassen sich zahlreiche systemische Effekte nachweisen, die z. T. sogar klinisch genutzt werden können. Durch die gleichzeitige Applikation verschiedener Adjuvanzien wie Opioiden, Kortikosteroiden und α2-Rezeptor-Agonisten wird versucht, die Wirkdauer von Lokalanästhetika nach einmaliger Applikation immer weiter zu verlängern, um eine möglichst effektive postoperative Schmerztherapie zu erzielen. Im selben Kontext sind die Entwicklung und die klinische Einführung von ultralang wirkenden, liposomalen Formulierungen zu sehen, die zumindest theoretisch sensible Nervenfasern über mehrere Tage hinweg blockieren. Die kommenden Jahre werden zeigen, ob sich diese Ansätze zu ernstzunehmenden Alternativen zu personal- und kostenintensiven kontinuierlichen Nervenblockaden entwickeln können.

Systemisch-toxische Zwischenfälle im Rahmen der Anwendung von Lokalanästhetika sind mittlerweile extrem seltene, aber noch immer potenziell lebensbedrohliche Ereignisse, die oftmals nach unbeabsichtigter intravasaler Injektion oder ausgeprägter systemischer Resorption entstehen. Daher besteht die wichtigste Präventionsmaßnahme in der langsamen und fraktionierten Applikation dieser Substanzen mit wiederholtem Aspirieren. Kommt es dennoch zu Intoxikationserscheinungen, kann die i.v.-Gabe von 20 %igen Lipidlösungen zusätzlich zu Basismaßnahmen den Therapierfolg erhöhen.

Abstract

For decades local anesthetics have proven to be safe and effective drugs in the clinical practice, crucially promoting the enormous achievements in regional anesthesia. Meanwhile, it is a well-known fact that local anesthetics are much more than just “simple” sodium channel blockers. They also interact with numerous other ion channels and subcellular structures, enhancing nerve blockade and resulting in systemic “alternative” effects, which can sometimes even be clinically used. By the simultaneous administration of various adjuvants (e.g., opioids, corticosteroids and α2-receptor agonists) attempts are made to prolong the time of action of local anesthetics after a single administration in order to achieve the best possible improvement in postoperative analgesia. In this context, ultralong-acting local anesthetics, such as liposomal bupivacaine, which at least theoretically can provide a sensory nerve block for several days, have been developed and clinically introduced. The coming years will show whether these approaches will develop into genuine alternatives to the personnel and cost-intensive continuous nerve blockades.

Local anesthetic-induced systemic toxicity is meanwhile rare but still a potentially life-threatening event, frequently resulting from accidental intravascular injection or extensive systemic resorption. Consequently, slow and fractional application of these agents with intermittent aspiration helps to prevent toxic sequelae. If toxic symptoms occur, however, the intravenous infusion of 20% lipid solutions in addition to basic treatment measures can enhance the success of treatment.

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Authors and Affiliations

  1. Klinik für Anästhesiologie, Operative Intensivmedizin und Notfallmedizin, Klinikum der Stadt Ludwigshafen am Rhein, Bremserstr 79, 67063, Ludwigshafen, Deutschland

    W. Zink DEAA

  2. Klinik für Anästhesiologie und operative Intensivmedizin, Diakonieklinikum Schwäbisch Hall, Schwäbisch Hall, Deutschland

    T. Steinfeldt

  3. Klinik für Anästhesie und Intensivtherapie, Philipps Universität Marburg, Marburg, Deutschland

    T. Wiesmann

Authors
  1. W. Zink DEAA
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  2. T. Steinfeldt
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  3. T. Wiesmann
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Correspondence to W. Zink DEAA.

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Interessenkonflikt

W. Zink und T. Steinfeldt geben an, dass kein Interessenkonflikt besteht. T. Wiesmann erhält Vortragshonorare für Fa. Pajunk und Fa. Vygon.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Zink, W., Steinfeldt, T. & Wiesmann, T. Bestandsaufnahme der Lokalanästhetika 2020. Anaesthesist 69, 301–313 (2020). https://doi.org/10.1007/s00101-020-00740-7

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  • DOI: https://doi.org/10.1007/s00101-020-00740-7

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