Perioperative Modifikation der Dauermedikation bei kardiovaskulären, pulmonalen und metabolischen Erkrankungen

Zusammenfassung

Ein großer und weiter zunehmender Anteil der Patienten, die sich dem Anästhesisten im Rahmen der Prämedikationsvisite vorstellen, nimmt täglich Medikamente zur Therapie oder Prophylaxe kardiovaskulärer, pulmonaler und/oder metabolischer Erkrankungen ein. Viele dieser Medikamente können in der perioperativen Phase pausiert werden. In manchen Fällen kann das präoperative Absetzen aber auch zur Dekompensation zuvor kompensierter Erkrankungen führen. Ziel dieses Fortbildungsartikels ist es, dem Leser eine Entscheidungshilfe für das Absetzen oder Weiterverordnen der präoperativen Dauermedikation bei kardiovaskulären, pulmonalen und metabolischen Erkrankungen an die Hand zu geben.

Abstract

Almost 50 % of all patients that are evaluated preoperatively by an anesthesiologist are receiving concurrent medication. Many of the prescribed drugs can be omitted during the perioperative period. However, perioperative cessation of certain drug therapies may cause decompensation of primarily compensated diseases. After reading this CME article, the reader should be able to decide whether any cardiovascular, pulmonary or antidiabetic drug therapy should be continued or ceased during the perioperative period, respectively.

Prämedikation - perioperative Medikation - kardiovaskuläre Medikation - COPD - Asthma bronchiale - Diabetes mellitus

Perioperative period - perioperative drug therapy - cardiovascular medication - COPD - Asthma bronchiale - Diabetes mellitus

Kernaussagen

• Alle Substanzen zur Therapie der KHK, zur Prophylaxe von Angina–Pectoris–Anfällen und für Therapie oder Prophylaxe bronchialer Obstruktionen sollen perioperativ weiter verordnet werden. Hierzu zählen β–Blocker, α₂–Agonisten, Ca⁺⁺–Antagonisten, Nitrate, Statine sowie inhalative β₂–Sympathomimitika, Anticholinergika und Kortikosteroide.

• Innerhalb von 12 Monate nach Einsetzen eines Drug–Eluting–Stents und 4 Wochen nach Einsetzen eines Bare–Metal–Stents darf eine Thienopyridin–Therapie nicht unterbrochen werden. Elektive Eingriffe werden verschoben, bis die Thienopyridin–Therapie abgesetzt werden kann.

• ASS wird bei Zustand nach instabilem Koronarsyndrom und nach kürzlich implantierten Koronarstents nur abgesetzt, wenn das Risiko der erhöhten intraoperativen Blutungsneigung gegenüber dem Risiko einer aufgehobenen Thrombozytenaggregationshemmung überwiegt. In allen anderen Fällen soll niedrigdosiertes ASS perioperativ weiter verordnet werden.

• Rückenmarksnahe Regionalanästhesieverfahren können unter Einnahme von niedrigdosiertem ASS durchgeführt werden, wenn keine gleichzeitige Heparinisierung erfolgt.

• Über die perioperative Verordnung von ACE–Hemmern, AT₁–Blockern und Diuretika muss im Einzelfall entschieden werden.

• Orale Antidiabetika werden mindestens 12 Stunden vor einem operativen Eingriff abgesetzt, um perioperative Hypoglykämien zu vermeiden. Biguanide werden 48 h vor einem operativen Eingriff abgesetzt. Gegebenenfalls wird präoperativ eine Insulin–Therapie begonnen.

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