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Neue Substanzen und Applikationsformen für die postoperative Schmerztherapie

New substances and applications for postoperative pain therapy

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Zusammenfassung

Die Entstehung postoperativer Schmerzen beruht auf unterschiedlichen pathophysiologischen Mechanismen und ist abhängig von dem durchgeführten operativen Eingriff. Daher sollte eine erfolgversprechende postoperative Schmerztherapie auf einem prozedurenspezifischen, multimodalen Analgesieregime basieren. Neben der Steigerung des Patientenkomforts und der Senkung perioperativer Komplikationen stellt eine optimale postoperative Schmerztherapie mittlerweile auch ein wichtiges Qualitätsmerkmal dar, das die Auswahl des Krankenhauses durch den Patienten beeinflussen kann. In den letzten 1–2 Jahren wurden für die postoperative Schmerztherapie bekannte Substanzgruppen neu endeckt (z. B. Gabapentin und Pregabalin, i. v. Lidocain, Ketamin oder Glukokortikoide) und neue Substanzen (Coxibe, orales Oxycodon+Naloxon) oder Applikationsverfahren entwickelt. Im vorliegenden Übersichtsartikel sollen die Vor- und Nachteile dieser Substanzen bzw. Analgesieverfahren aufgearbeitet und entsprechende spezifische Anwendungsbereiche diskutiert werden.

Abstract

The onset of postoperative pain is the result of various pathophysiological mechanisms and depends on the type of surgery performed. Therefore, any adequate postoperative pain treatment requires multimodal and procedure-specific analgesia. In addition to reducing perioperative complications and improving patient comfort, optimal postoperative pain management also represents an important quality characteristic which can influence the patient in their choice of hospital. In the past 1–2 years, known groups of substances have been rediscovered for postoperative pain therapy (e.g., Gabapentin and Pregabalin, i.v. Lidocaine, Ketamine or glucocorticoids), while new substances (coxibe, oral oxycodone+naloxone) and applications have been developed. The present overview article discusses the advantages and disadvantages of these substances and analgesic methods, as well as their specific areas of application.

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Die korrespondierende Autorin weist auf folgende Beziehungen hin: Beratungs- und/oder Referententätigkeit für Mundipharma, Pfizer, Janssen-Cilag, Köhler Chemie.

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  1. Klinik und Poliklinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Münster, Albert-Schweitzer-Straße 33, 48149, Münster, Deutschland

    E.M. Pogatzki-Zahn & P.K. Zahn

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  1. E.M. Pogatzki-Zahn
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Correspondence to E.M. Pogatzki-Zahn.

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CME-Fragebogen

Die antihyperalgetische Wirkung von Gabapentin und Pregabalin beruht u. a. auf einer Hemmung welcher Strukturen?

GABA-A-Rezeptoren.

GABA-B-Rezeptoren.

AMPA-Rezeptoren.

Opioidrezeptoren.

Spannungsabhängige Kalziumkanäle (Alpha-2/Delta-1-Untereinheit).

Welche Aussage über Gabapentin und Pregabalin trifft nicht zu?

Gabapentin und Pregabalin gehören zur Gruppe der Antikonvulsiva.

Beide Substanzen wirken antihyperalgetisch.

Sie führen im Rahmen einer multimodalen Analgesie zur Reduktion des Opioidverbrauchs und opioidinduzierter Nebenwirkungen.

Gabapentin und Pregabalin haben eine höhere analgetische Wirksamkeit als Opioide/Opiate.

Beide Substanzen können als Nebenwirkungen zu Müdigkeit und Schwindel führen.

Welche Aussage zu NMDA-Rezeptoren bzw. NMDA-Rezeptorantagonisten trifft nicht zu?

NMDA-Rezeptoren werden durch exzitatorische Aminosäuren (z. B. Glutamat) stiumliert.

NMDA-Rezeptoren liegen im Rückenmark und Gehirn vor.

Ketamin und Dextromethorphan sind nichtkompetitive NMDA-Rezeptorantagonisten.

Die neuroaxiale Gabe von NMDA-Rezeptorantagonisten hat eine starke Wirkung auf postoperative Schmerzen.

Die i. v. Gabe von NMDA-Rezeptorantagonisten könnte im Rahmen eines mulitmodalen Analgesieregimes bei bestimmten Indikationen wie Opioidtoleranz oder persistierender chronischer postoperativer Schmerzen eine Rolle spielen.

Welche der aufgeführten Substanzen gehört nicht zur Gruppe der selektiven oder nichtselektiven NSAIDs?

Etoricoxib.

Celecoxib.

Diclofenac.

Lidocain.

Ibuprofen.

Welche Aussage über NSAIDs oder COX-2-Hemmer ist falsch ?

Unselektive traditionelle NSAIDs wie auch selektive NSAIDs werden für die Therapie leichter bis mittelstarker postoperativer Schmerzen eingesetzt.

Alle NSAIDs haben eine ähnliche NNT von 2–4.

Bei einer Erhöhung der Dosierung über die NNT-bezogene optimale Dosierung weisen NSAIDs einen Ceiling-Effekt auf.

COX-2-Hemmer haben ein günstigeres Risiko-Nutzen-Profil im Vergleich zu unselektiven NSAIDs bezüglich gastrointestinaler Komplikationen.

Im Vergleich zu COX-2-Hemmern ist die Einnahme von unselektiven-traditionellen NSAIDs mit einem geringeren Risiko für kardiovaskuläre Komplikationen assoziiert.

Welches NSAID hat das größte Risiko für gastrointestinaler Komplikationen?

Etoricoxib.

Ibuprofen.

Diclofenac.

Indometacin.

Ketorolac.

Welche Aussage trifft für die Fentanylapplikation mittels eines iontophoretischen transdermalen Systems (ITS) nicht zu?

Das System entspricht der Pflasterapplikation von Buprenorphin oder Fentanyl.

Pro Dosis werden 40 µg Fentanyl appliziert.

Durch den Patienten können bis zu maximal 240 µg (6 Dosen von je 10-minütiger Dauer) pro Stunde, aber nicht mehr als maximal 80 Dosen innerhalb von 24 Stunden abgerufen werden.

Die Funktion des ITS wird nach einer Therapiedauer von 24 Stunden oder 80 Dosisabgaben inaktiviert.

Das ITS ist durch die „European Medicines Evaluation Agency“ (EMEA) für die Behandlung moderater bis schwerer postoperativer Schmerzen zugelassen.

Welche Aussage zur Wundinfiltration trifft zu?

Die intraoperative Wundinfiltration mit langwirksamen Lokalanästhetika wie Ropivacain oder Bupivacain ist nicht sinnvoll im Rahmen eines multimodalen Analgesiekonzeptes.

Wundkatheter führen überwiegend zu Infektionen und Wundheilungsstörungen.

Es gibt keine Dosisbegrenzungen für die Wundinfiltration von Lokalanästhetika.

Die Anwendung von langwirksamen Lokalanästhetika über Wundkatheter führt zu einer zusätzlichen Reduktion von Schmerzen und senkt den Opioidverbrauch sowie opioidinduzierte Nebenwirkungen.

Langwirksame Lokalanästhetika sollten nicht kontinuierlich über Wundkatheter verwendet werden.

Welche Substanz gehört nicht zur Gruppe der Opioide/Opiate?

Oxycodon.

Hydromorphon.

Piritramid.

Flupirtin.

Fentanyl.

Welche Aussage zu postoperativen Schmerzen und ihrer Behandlung trifft zu?

Orale Opioide sollten nicht zur postoperativen Schmerztherapie verwendet werden.

Kleinere und mittlere operative Eingriffe erzeugen meist nur geringe Schmerzen.

Ein postoperatives Analgesiekonzept für Patienten ohne Regionalanalgesieverfahren oder nach kleineren und mittleren Eingriffen ist sinnvoll.

Ein Kombinationspräparat zusammengesetzt aus Oxycodon und Naloxon weist gegenüber dem Oxycodonpräparat keine Vorteile auf.

Oxycodon ist ein schwächeres Opioid als Piritramid.

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Pogatzki-Zahn, E., Zahn, P. Neue Substanzen und Applikationsformen für die postoperative Schmerztherapie. Schmerz 22, 353–369 (2008). https://doi.org/10.1007/s00482-008-0665-5

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