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Anästhesiologisches Vorgehen bei elektiven Eingriffen an der Aorta

Anesthesiologic procedure for elective aortic surgery

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Zusammenfassung

Das Aortenaneurysma ist eine häufige Erkrankung insbesondere des älteren Mannes. Für Deutschland ist von einer Prävalenz von 250.000 Patienten mit einem kontroll- bzw. therapiebedürftigen Aortenaneurysma auszugehen. Aufgrund der kardialen und pulmonalen Begleiterkrankungen bedarf die perioperpative Betreuung dieser Patienten einer besonderen Aufmerksamkeit. Insbesondere das hämodynamische Management während der Aortenausklemmung erfordert einen kontrollierten und vorausschauenden Einsatz von Vasodilatanzien und Katecholaminen. Darüber hinaus müssen Maßnahmen zur Nephroprotektion getroffen werden. Bei Eingriffen an der thorakalen Aorta ist zur Vermeidung einer Paraplegie bei spinaler Ischämie selektiv eine spinale Liquordrainage indiziert. Seit 1991 wurde neben der konventionellen offenen Operation die endovaskuläre Ausschaltung des Aortenaneurysmas mit Stentgrafts etabliert. Diese Methode wird mittlerweile auch in der thorakalen Aorta bei unterschiedlichen Pathologien angewandt. Bei einem Teil der Patienten mit einem Aortenaneurysma ist damit eine operative Sanierung in Regional- oder Lokalanästhesie möglich geworden. In speziellen Fällen benötigen Patienten bei der thorakalen Endograft-Implantation zur sicheren Positionierung die Induktion eines medikamentösen, passageren Herzstillstandes bzw. die Reduktion des aortalen Blutflusses durch schnelle Kammerstimulation (Overpacing).

Abstract

Aortic aneurysms are frequent in the elderly who often suffer from relevant co-morbidities. In Germany it is estimated that approximately 250,000 patients suffer from an aortic aneurysm. Due to the high risk of cardiac or pulmonary complications operative management poses a challenge to the anesthesiologist. Especially hemodynamic management during aortic cross-clamping requires anesthesiologic know-how and an anticipatory use of vasodilators and catecholamines. Furthermore, the anesthesiologist has to protect renal function. In order to avoid paraplegia due to spinal ischemia cerebrospinal fluid drainage may be necessary in patients with aneurysms of the thoracic aorta. In recent years endovascular repair of aortic aneurysms has been established in addition to conventional open surgery. As a consequence in some patients aortic surgery can be performed under regional or local anesthesia. In special cases thoracic endovascular repair requires a medicinal induction of heart arrest or the reduction of aortic blood flow by overpacing.

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Danksagung

Die Autoren bedanken sich bei Herrn Dr. T. Heye (Radiologische Klinik, Universitätsklinikum Heidelberg) für die freundliche Bereitstellung der Abbildung 1 sowie bei Herrn Dr. H. von Tengg-Kobligk (Abteilung Radiologie, Deutsches Krebsforschungszentrum Heidelberg) für die Abbildungen 2 und 4.

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Authors and Affiliations

  1. Klinik für Anaesthesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland

    J. Knapp, H. Rauch & A. Walther

  2. Interdisziplinäre Notfallaufnahme, Klinikum Fulda, Fulda, Deutschland

    M. Bernhard

  3. Klinik für Gefäßchirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland

    A. Hyhlik-Dürr & D. Böckler

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  1. J. Knapp
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Knapp, J., Bernhard, M., Rauch, H. et al. Anästhesiologisches Vorgehen bei elektiven Eingriffen an der Aorta. Anaesthesist 58, 1161–1182 (2009). https://doi.org/10.1007/s00101-009-1630-0

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