Der geriatrische Patient aus chirurgischer Sicht — Hernienchirurgie und Lebensqualität

Zusammenfassung   Grundlagen: über die subjektive Lebensqualit?t nach Hernienoperation bei geriatrischen Patienten ist wenig bekannt. Die Indikationsstellung und die Operation selbst werden in dieser Altersgruppe sehr unterschiedlich gehandhabt. Methodik: 90 über 75j?hrige Patienten wurden in Lokalan?sthesie mittels anteriorer Patch-Plastik (Lichtenstein) operiert und 2–26 Monate postoperativ zur Lebensqualit?t und Zufriedenheit mit der Operation befragt. Ergebnisse: Bei 83 Elektiveingriffen verlief die Operation in Lokalan?sthesie problemlos. Probleme mit der Operation ergaben sich bei 7 F?llen mit Inkarzeration u.a. durch Fehleinsch?tzung der Situation. 97% der Patienten beurteilten das Operationsergebnis retrospektiv mit der bestm?glichen Note auf einer 5teiligen Skala. Bei 2 Patienten stellte sich als Ursache geringerer Zufriedenheit eine als mangelhaft empfundene postoperative Nachbetreuung heraus. Schlu?folgerungen: Für ein subjektiv positiv empfundenes Ergebnis der Leistenhernienchirurgie im hohen Alter sind folgende Faktoren ausschlaggebend: zurückhaltende Indikationsstellung, Lokalan?sthesie, optimale und schonende chirurgische Technik, pers?nliche perioperative Betreuung durch den Operateur.      

Ist die Spinalanästhesie bei Eingriffen in Bauchlage ein empfehlenswertes Verfahren?

There is still controversy on the usefulness of spinal anesthesia for operations performed in the prone or jackknife position. There is about the risk of inadvertent increase of the sensomotory blockade with the patient in the prone position and the difficulty of managing consecutive cardiorespiratory complications or inducing general anesthesia in case of failures. This article reviews the current literature in terms of safety and effectiveness of spinal anesthesia for such operations. For lower-limb or perianal operations with limited extension and blood loss, performed in the prone position, spinal anesthesia seems to be a safe, effective and economic technique in patients without severe a cardiac history. Substantial knowledge about the onset time, fixation time, duration of sensomotory block and baricity of the applied local anesthetic is crucial in this setting. Obese patients are at risk for sudden extension of the block when turned into the prone position. Additional narcotics and sedatives should be avoided and continuous monitoring of hemodynamic and respiratory parameters, of the level of the blockade and vigilance of the patient is mandatory.     

Peribulbäranästhesie versus topische Anästhesie bei der Kataraktoperation Vergleich des postoperativen Verlaufes

Hintergrund: Die intrakamerale Gabe von Konservierungsstoff-freien Lokalan?sthetika (z.B. Lidocain) zur Lokalan?sthesie bei der Kataraktoperation wird von immer mehr Operateuren als alternatives Verfahren neben der herk?mmlichen retro- oder peribulb?ren Injektion propagiert. Wir haben den postoperativen Verlauf nach peribulb?rer An?sthesie und nach intraokularer Gabe von Lidocain 1%ig untersucht und verglichen. Patienten und Methoden: Es wurden insgesamt 186 Kataraktpatienten in je zwei Gruppen in diese Studie aufgenommen. Die Lokalan?sthesie erfolgte in der ersten Gruppe mittels Peribulb?rinjektion (6 ml Xylonest?2%), in der zweiten Gruppe mittels Sponge-An?sthesie plus intrakameraler Applikation von 0,15 ml Lidocain 1%. Am ersten postoperativen Tag wurde die Hornhaut hinsichtlich Epithelstippung, Deszemetfalten, sowie der Vorderkammerreizzustand an der Spaltlampe beurteilt. Der bestkorrigierte Visus wurde festgehalten, der postoperative Schmerzverlauf dokumentiert. Ergebnisse: Der 30 min postoperativ gemessene Visus war in der Lidocaingruppe signifikant besser. Es zeigten sich signifikant st?rkere frühpostoperative Schmerzen in der Lidocaingruppe, sowie statistisch signifikant mehr Deszemetfalten am ersten postoperativen Tag. Schlussfolgerung: Die topische An?sthesie mittels intrakameraler Lidocaingabe ist eine Alternative zu der Peribulb?rinjektion. Sie bietet dem Patienten eine schnelle postoperative visuelle Rehabilitation.      

Kapselruptur bei Kataraktoperationen mit Sponge-Oberflächen- und intrakameraler Anästhesie

Background. Combined topical and intracameral anaesthesia has become increasingly popular in cataract surgery. The purpose of this study was to determine the risk of capsular lesions with an intact motility during surgery. Patients and methods. In a prospective clinical study, we analyzed 2000 phacoemulsifications with IOL implantation performed by an experienced surgeon with combined sponge and intracameral lidocain anaesthesia. Preoperatively two grades of difficulty of the surgical proceduce were defined. Results. Operations were carried out on 1,658 patients with a (grade 1) low degree and 342 patients (grade 2) with a high degree of difficulty (17.1%). Capsular lesions occurred in 17 operations (0.85%),15 in cases with a high degree of difficulty (88%). In 12 of these, an anterior vitrectomy was necessary and in 1 operation a pars plana vitrectomy after application of additional retrobulbar anaesthesia was performed. Conclusions. In this study the incidence of capsular lesions was not increased compared to other methods of anaesthesia. Anterior vitrectomy with the patient under combined sponge and intracameral anaesthesia, was possible without retrobulbar anaesthesia.     

Gefahren und Komplikationen bei rückenmarknahen Katheterverfahren

Pain therapy with epidural or intrathecal catheters is an invasive method. These techniques have specific indications in both acute and chronic pain therapy. However, complications can occur. Thus, the potential complications and the therapy necessary must be known.Drugs: Complications resulting from acute local anesthetic intoxication's are rare. High plasma levels during chronic therapy may lead to confusion. Respiratory depression can occur in opioid naive patients up to 12 (-24) h after injection. Adequate monitoring is a prerequisite for this therapy. After application of clonidine, hypotension is frequent in hypertonic and hypovolemic patients. Epidural or intrathecalcatheter placement can result in therapeutic failure, trauma by punction and inability to place the catheter. During chronic therapy, technical problems can occur, e.g., dislocation, occlusion. To exclude intrathecal and intravascular placement, application of a test dosage of a local anesthetic with adrenaline is recommended.Neurological complications can result in nerve root deficit or "simple" post-spinal headache, but cauda equina syndromes, paralyses, intracranial bleeding, sinus thrombosis and central neurological deficits have been reported. Skininfection at the insertion site of the catheter has been observed with an incidence of 1.9 to 7.7%. A spinal infection with neurological deficit is rare. Spinal infections are often associated with other diseases. Spinalhematomas are rare. Coagulation disorders and anticoagulants can lead to bleeding. Intravenous heparin should be avoided, because this is frequently associated with spinal bleeding. Therapy with cumarines is a contraindication for insertion of spinal catheters.Monitoring: During treatment with spinal catheters, adequate monitoring increases safety for the patients. Efficacy of the injections, puncture site and the neurological status should be documented daily. Neurological deficits must be diagnosed without losing time and adequate therapy must be initiated.     

Intracameral anesthesia with lidocaine in cornea guttata

Background. Combined topical and intracameral anesthesia has become increasingly popular in cataract surgery. We analyzed the use of intracameral anesthesia in patients with corneal dystrophy who had undergone cataract surgery. Patients and methods. We measured the number of endothelial cells in 40 eyes with Fuchs' corneal endothelial dystrophy preoperatively as well as three times postoperatively (after 1 day, 4 weeks, and 3 months). Performing sponge anesthesia, the additional application of 0.15 ml lidocaine 1% was randomized. Results. The lidocaine group showed the following loss of endothelial cells in the central cornea: 1 day postoperatively 9.2%, 4 weeks later 9.7%, and 3 months after surgery 10.7%. The other group had a postoperative loss of endothelial cells in the central cornea of 8.8% (1 day), 9.3% (4 weeks), and 10.5% (3 months). No significant differences between the two groups were observed. Conclusions. Cornea guttata is not a contraindication for the use of intraocular lidocaine.     

Sponge-Oberflächen-Anästhesie mit intracameraler Lidocain-Applikation Kataraktchirurgie

BACKGROUND: For cataract surgery in this country retro- and peribulbar anesthesia is the standard method. It totally stops eye movement as well as sensitivity to pain. Especially peribulbar anesthesia is known as a procedure with minimal complications, but the potential risks can be severe. In the past sponge anesthesia could not be used on patients with difficult cataract surgery due to the insufficient anesthetic effect. A modified anesthetic method is demonstrated for complicated cataract surgery. PATIENTS AND METHODS: In 281 non-selected, successive phacoemulsifications, all performed by the same surgeon, we applied sponge anesthesia and 1.5 mg midazolam as premedication. Only in cases of moderate and severe sensitivity was 1% 0.15 ml lidocaine applied intraocularly. The intensity of sensitivity was graded as 1 for low, 2 moderate, and 3 severe. RESULTS: Ninety eyes had complicated cataract surgery. Of the patients, 84.3% felt no pain during surgery; 11.4% were part of group 2 (moderate). Ten of 12 patients who had stated moderate sensitivity at first were free of pain after intraocular application of lidocaine, while the other 2 patients only felt minor sensitivity. CONCLUSION: The anesthetic procedure we present offers a safe alternative method to surgeons who are able to do surgical procedures on a mobile eye.     

Vitreoretinale Operationen in Lokalanästhesie Schmerzempfinden und objektive Streßparameter *

Bei vitreoretinalen Operationen in Retrobulb?ran?sthesie (RBA) wurde bei 53 Patienten prospektiv das intra- und postoperative Schmerzempfinden untersucht. Zudem wurden objektive Stre?parameter wie Blutdruck, Herzfrequenz und die Plasmakortisolkonzentration (PCK) bestimmt. Das Schmerzempfinden wurde mittels einer 4stufigen nominellen Skala bestimmt. Der Schmerzindex als Mittelwert lag bei RBA bei 1,04, sank perioperativ auf 0,77 ab, um postoperativ nach 8 h nochmals ein Maximum mit 1,15 zu erreichen. Das subjektive Schmerzempfinden w?hrend der Operation und am Operationsende korrelierte mit der vom Operateur eingesch?tzten Wirksamkeit der RBA (p<0,001), am Operationsende korrelierte es noch mit der Operationsdauer (p<0,01). Bei 14 Patienten konnten wir die PCK pr?operativ bestimmen. Nach Pr?medikation kam es zu einem signifikanten Abfall der pr?operativen PCK im Vergleich zum Ausgangswert (18,4 auf 12,6 μg/dl, p<0,001). Bei 26 Patienten zeigten sich bezüglich des Ausgangswerts bei RBA im weiteren peri- und postoperativen Verlauf keine signifikanten Differenzen. Das subjektive Schmerzempfinden zur Operationsmitte und am Operationsende korrelierte mit der H?he der intraoperativ (p<0,01) und unmittelbar postoperativ ermittelten PCK (p<0,03). Die Parameter Blutdruck und Herzfrequenz zu Beginn der Operation, in der Operationsmitte und am Operationsende differierten nicht signifikant. 75,5% der Patienten waren mit der Operation in Lokalan?sthesie sehr zufrieden oder zufrieden, 7 Patienten wenig, 6 Patienten nicht zufrieden. 77,4% der Patienten gaben an, da? sie sich im Bedarfsfall wieder für eine RBA entscheiden würden.      

Pathophysiology and diagnosis in patients with sympathetically dependent pain

Chronic pain in a distal extremity that is accompanied by autonomic dysfunction in the same region is taken to indicate reflex sympathetic dystrophy. Typically, hyperalgesia to light touch is present in addition to the spontaneous pain. The absence of heat hyperalgesia indicates that the underlying mechanism is central rather than peripheral sensitization. This mechanism is similar to that of secondary hyperalgesia in the intact skin surrounding an injury site. Sympathetically maintained pain (SMP) is diagnosed, when these sensory symptoms are reversible under sympathetic blockade. SMP is not due to hyperactivity of sympathetic efferents but to receptor supersensitivity, probably by overexpression of alpha(1)-adrenergic receptors on nociceptive primary afferents. This way normal levels of norepinephrine can cause pathological spontaneous activity of nociceptors which maintains the central sensitization. Chronic burning pain and cutaneous hyperalgesia may also be independent of the sympathetic innervation of the skin. In this case, central sensitization is maintained by other mechanisms. A role of the sympathetic nervous system in the pathogenesis of pain cannot be deduced simply from the simultaneous presence of sensory and autonomic clinical signs and symptoms. Therefore, sympathetic blockade in a patient initially is a diagnostic procedure, aiming to demonstrate the presence of the symptom SMP. Therapeutic blockade is only indicated after this demonstration. For the substantial number of patients with sympathetically independent pain, other treatment modalities are needed which may for example attack central sensitization.