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DOI: 10.1055/s-2005-861348
Perioperatives Management bei kardialen Risikopatienten
Preoperative Management of Patients with Increased Cardiac RiskPublication History
Publication Date:
30 May 2005 (online)

Einleitung
Die koronare Herzkrankheit (KHK) stellt die häufigste Todesursache in den Industrienationen dar. Insbesondere beim alten Menschen steigt die Prävalenz der KHK exponentiell und damit auch das perioperative Risikoprofil. Darüber hinaus verändert sich die Altersstruktur der Menschen in den westlichen Staaten beständig und das durchschnittlich erreichte Lebensalter wird immer höher. Da die Häufigkeit notwendiger Operationen beim alten Menschen deutlich steigt, wird sich der Anteil der Patienten mit einer KHK, die sich einem operativen Eingriff unterziehen müssen, somit beständig vergrößern.
Das gestiegene Risiko dokumentiert sich u. a. in einer Untersuchung an 600 kardiovaskulär erkrankten Patienten, die sich großen Operationen in Allgemeinanästhesie unterziehen mussten [48]. Bei Patienten, die bereits präoperativ eingeschränkt belastbar waren, zeigte sich dabei eine Verdopplung der Rate perioperativer Komplikationen. Darüber hinaus konnte nachgewiesen werden, dass eine lange Anästhesiedauer mit einer erhöhten Inzidenz perioperativer Komplikationen einhergeht. Besonders gefährdet sind die Patienten in der ersten Woche nach der Operation. So konnte in einer prospektiven Studie belegt werden, dass 5,6 % der Patienten mit einer KHK innerhalb von sieben Tagen postoperativ Anstiege kardialer Enzyme sowie typische EKG-Veränderungen aufwiesen [2].
In diesem Kontext stellt sich die Frage, welche prognostische Relevanz perioperative Myokardischämien für das Langzeitüberleben nach elektiven Operationen haben. In einer zweijährigen Follow-up-Studie zeigte sich, dass die Inzidenz postoperativer kardialer Komplikationen bei Patienten mit stummen Ischämien in der perioperativen Phase gegenüber Patienten ohne kardiale Störungen signifikant erhöht war [37]. Patienten mit einem perioperativen Myokardinfarkt hatten während der ersten sechs Monate nach der Operation ein 28-fach erhöhtes Risiko kardiale Komplikationen zu erleiden, nach zwei Jahren war die Rate immer noch 14-fach erhöht. In dieser Studie wurden fünf Prädiktoren für das Langzeitüberleben der Patienten ermittelt: zwei der Prädiktoren reflektierten akute postoperative Ereignisse, d. h. Myokardinfarkt/instabile Angina sowie die Myokardischämie. Drei Prädiktoren bezogen sich hingegen auf vorbestehende bzw. chronische Erkrankungen wie KHK, Herzinsuffizienz und Gefäßerkrankungen. Daraus folgt, dass die Prävention des unmittelbaren Ereignisses essenziell für das Langzeitüberleben sowie ein konsequentes Therapieregime erforderlich ist.
Vor diesem Hintergrund ist es insbesondere für den Anästhesisten von großer Bedeutung, Konzepte zur perioperativen Risikominimierung zu entwickeln und klinisch zu etablieren [22]. Diese bestehen insbesondere in der präoperativen Evaluierung, der medikamentösen Ischämieprävention, der suffizienten analgetischen Therapie, der Aufrechterhaltung einer Normothermie sowie eines adäquaten Hämatokritwertes.
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Prof. Dr. med. Frank Wappler
Lehrstuhl für Anästhesiologie II, Universität Witten/Herdecke, Klinik für Anästhesiologie
Krankenhaus Köln-Merheim · Ostmerheimerstr. 200 · 51109 Köln ·
Email: wapplerf@kliniken-koeln.de