Kein Opioidüberhang bei Patienten mit transdermalem Buprenorphin und Fast-Track-Anästhesie nach Eingriffen am offenen Herzen

Zusammenfassung

Ziel der Studie: Führt die Anwendung einer fentanylgestützten Narkose bei Patienten mit Buprenorphin transdermal zu protrahierten Aufwachzeiten, einer verlängerten Atemdepression oder einer Toleranzentwicklung mit Fentanylresistenz? Methodik: In einer offenen Studie wurden Patienten mit einem Buprenorphinpflaster (n = 22), die sich einer Operation am offenen Herzen unter einer fentanylgestützten Enflurannarkose unterziehen mussten einer randomisierten Kontrollgruppe (n = 21) mit ähnlichen operativen Eingriffen gegenübergestellt. Gemessen wurden die Zeit bis zur Extubation, die arteriellen Blutgase, der Aldrete Erholungsscore und PONV. Ergebnisse: Bei ähnlichen Operations- und Narkosezeiten waren der intraoperative Fentanylverbrauch (0,69 mg ± 0,23 versus 0,67 mg ± 0,16), die Zeiten bis zur Extubation (25,2 min ± 6.1 versus 33,3 min ± 5,0), der Aldrete Erholungsscore (0,69 ± 0,23 versus 0,67 ± 0,16) und die postoperativen arteriellen Blutgase unter Sauerstoffatmung (paO₂ 136 torr ± 48 versus 128 torr ± 35; paCO₂ 43,3 torr ± 3,3 versus 41,9 torr ± 1,2) signifikant nicht unterschiedlich. Nausea/Emesis war dagegen in der Kontrollgruppe signifikant (p < 0,01) häufiger. Schlussfolgerung: Wegen der vorangegangenen langfristigen Buprenorphinapplikation und den daraus resultierenden Adaptationsmechanismen ist bezüglich Atmung und Vigilanz keine Wirkungsverlängerung bis in die postoperative Phase zu erwarten. Die präoperative Gewöhnung an ein Opioid wie Buprenorphin führt auch zu geringeren PONV Raten.

Abstract

Objective: Simultaneous use of opioids with a different pharmacological profile may lead to unexpected prolongation of effects. In an open label study possible overhang in post-operative respiratory effects and vigilance was determined in a group of patients (n = 22) carrying a transdermal buprenorphine patch for at least 2 months for treatment of chronic pain, undergoing a fentanyl-based fast-track enflurane anesthetic technique for open-heart operation. Data was compared with another randomised group (n = 21) undergoing similar open-heart procedures with no other opioid than fentanyl on board. Methods and Results: Following induction with fentanyl and a barbiturate, depth of anesthesia with enflurane (Fi 0.5) was guided using the bispectral index (BIS). Additional doses of fentanyl were given when blood pressure and/or heart-rate increased 20 % above pre-induction levels. Early postoperative extubation was initiated once the cardiovascular system was stable and there were no signs of respiratory impairment. Following a similar time of operation and anesthesia and a similar total dose of fentanyl (0.69 mg ± 0.23 SD versus 0.67 mg ± 0.16 SD), postoperatively, there were no significant differences between the buprenorphine- and the control group regarding the time till extubation (25.2 min ± 6.1 versus 33.3 min ± 5.0) and the arterial blood gases under oxygen inhalation (paO₂ 136 torr ± 48 SD versus 128 torr ± 35 SD; paCO₂ 43.3 torr ± 3.3 SD versus 41.9 torr ± 1.2 SD and the post-anesthetic vigilance and recovery score (6.8 ± 1.0 versus 7.5 ± 0.8) 60 minutes after end of anesthesia. Contary to the control group, there was a lower and significant (p < 0.01) incidence of PONV in patients with transdermal buprenorphine.

Conclusion: Patients using a buprenorphine patch for the relief of chronic pain cannot be regarded as opioid naïve. Due to adaptive mechanisms and the development of tolerance, there is no prolongation of the respiratory depression induced by intraoperative fentanyl. Long-term use of transdermal buprenorphine does not lead to potentiation or prolongation of opioid effects in cardiac surgery patients.

Schlüsselwörter

Transdermales Buprenorphin - Fentanyl - Opioidnarkose - Adaptationsmechanismen - Kardiochirurgie

Key words

Transdermal buprenorphine - fentanyl - opioid anesthesia - additive effects - open-heart surgery

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