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Postoperative Übelkeit und Erbrechen

Postoperative nausea and vomiting

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Zusammenfassung

Zahlreiche pathophysiologische Mechanismen für Übelkeit und Erbrechen sind tierexperimentell belegt, ihre Bedeutung für postoperative Übelkeit und Erbrechen (PONV) ist aber noch unklar. Volatile Anästhetika, Lachgas und Opioide sind wohl die wichtigsten Ursachen. Hinzu kommen weibliches Geschlecht, Nichtraucherstatus und positive Anamnese als relevante Risikofaktoren, mit denen sich anhand eines validierten Risikoscores das PONV-Risiko einschätzen lässt, das eine rationale Grundlage für eine risikoadaptierte, individuelle Prophylaxe bietet.

Eine Prophylaxe ist bei niedrigem Risiko nicht gerechtfertigt, bei einem sehr hohen Risiko kann jedoch sogar ein multimodaler Ansatz geboten sein. So reicht eine total intravenöse Anästhesie (TIVA) bei sehr hohem Risiko allein nicht aus. Eine TIVA senkt die PONV-Inzidenz um ca. 30%. Dieses entspricht der Effektivität von Antiemetika wie Serotoninantagonisten, Dexamethason oder auch Droperidol. Hingegen ist Metoclopramid auch in höheren Dosierungen ineffektiv. Nach der europäischen Multicenterstudie „IMPACT“ kann eine Prophylaxe bei niedrigem Risiko nicht effektiv sein. Bei mittlerem Risiko kann eine TIVA oder ein Antiemetikum empfohlen werden. Patienten mit einem (sehr) hohen Risiko sollten eine 2–3fache Prophylaxe erhalten.

Zur Therapie von PONV sollten Antiemetika eingesetzt werden, die noch nicht zuvor als Prophylaxe verabreicht wurden. Hierbei scheinen geringere Dosierungen als zur Prophylaxe ausreichend.

Abstract

Numerous pathophysiological mechanisms are known to cause nausea or vomiting but their role for postoperative nausea and vomiting (PONV) is not quite clear. Volatile anesthetics, nitrous oxide and opioids appear to be the most important causes for PONV. Female gender, non-smoking and a history of motion sickness and PONV are the most important patient specific risk factors. With these risk factors an objective risk assessment is achievable as a good rational basis for a risk dependent antiemetic approach: When the risk is low, moderate, or high, the use of none, a single or a combination of prophylactic antiemetic interventions seems to be justified.

Performing a total intravenous anesthesia (TIVA) with propofol is a reasonable prophylactic approach, but does not solve the problem satisfactorily alone if the risk is very high, reducing the risk of PONV only by 30%. This is comparable to the reduction rate of antiemetics, such as serotonin antagonists, dexamethasone and droperidol. It must be stressed that metoclopramide is ineffective. Data from IMPACT indicate that prophylaxis is not very effective if the patients risk is low. At a moderate risk the use of TIVA or an antiemetic is reasonable and only a (very) high risk justifies the combination of several prophylactic antiemetic interventions.

For the treatment of PONV an antiemetic should be chosen which has not been used prophylactically. The necessary doses are usually a quarter of those needed for prophylaxis.

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Der korrespondierende Autor weist auf eine Verbindung mit folgender Firma/Firmen hin: GSK, Roche, Astra Zeneca

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Authors and Affiliations

  1. Department of Anesthesiology and Perioperative Medicine, Outcomes Research™ Institute, University of Louisville, USA

    C. C. Apfel

  2. Klinik für Anästhesiologie, Universität Würzburg

    N. Roewer

  3. Department of Anesthesiology and Perioperative Medicine, Outcomes Research™ Institute, University of Louisville, Suite 210, MedCenter One, 501 East Broadway, Louisville, KY 40202, USA

    C. C. Apfel

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Apfel, C.C., Roewer, N. Postoperative Übelkeit und Erbrechen. Anaesthesist 53, 377–392 (2004). https://doi.org/10.1007/s00101-004-0662-8

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