Zusammenfassung
Hintergrund
Die perioperative, anästhesiologische Betreuung von Ovarialkarzinompatientinnen im Rahmen von zytoreduktiven Operationen ist durch erkrankungsspezifische Komorbiditäten und therapieimmanente anästhesiologische Besonderheiten gekennzeichnet. Hierzu gehören z. B. eine mögliche präoperative Anämie, die perioperative Hypothermie oder eine mögliche Verdünnungskoagulopathie. Dabei stellen die intraoperative Flüssigkeits- und Volumensubstitution, Transfusion und Katecholamintherapie eine besondere anästhesiologische Herausforderung bei zytoreduktiven Operationen dar.
Ergebnisse
Bereits im Rahmen der präoperativen Evaluierung sollten erkrankungsspezifische Komorbiditäten wie Darmpassagehindernisse, maligner Aszites, Pleuraergüsse sowie präoperative Anämien diagnostiziert und ggf. therapiert werden. Ein präoperatives Vorwärmen der Patienten mindert das Risiko einer Redistributionshypothermie bei Narkoseeinleitung und damit das Risiko einer perioperativen Hypothermie und Nachbeatmung. Bei mangelnder Evidenz für oder gegen die ausschließliche Nutzung balancierter Vollelektrolytlösung empfiehlt sich eine bedarfsadaptierte Flüssigkeitssubstitution in Verbindung mit dem Einsatz von kolloidalen Infusionslösungen und ggf. Substitution von gefrorenem Frischplasma (GFP) und Applikation von Antifibrinolytika. Insbesondere bei präoperativ bestehendem malignem Aszites und im Rahmen einer intraoperativen Deperitonealisierung mit zu erwartenden großen Volumenverlusten kann der Einsatz eines erweiterten hämodynamischen Monitorings zur zielgerichteten Volumentherapie indiziert sein.
Schlussfolgerungen
Die perioperative anästhesiologische Versorgung sollte dem individuellen und für das Ovarialkarzinom typischen Risikoprofil angepasst werden. Um dem u. a. durch ausgeprägte operative Deperitonealisierung und Aszites ausgelösten Proteinverlust Rechnung zu tragen, empfiehlt sich eine präoperative Optimierung des Allgemeinzustands der Patientinnen. Eine bedarfsgerechte Volumentherapie und der perioperative Wärmeerhalt spielen hierbei eine zentrale Rolle.
Abstract
Background
The perioperative anesthesiological treatment of patients suffering from ovarian cancer undergoing cytoreductive surgery is characterized by disease-specific comorbidities and treatment immanent anesthesiological complications. These include preoperative anemia, inadvertent perioperative hypothermia or the development of dilutional coagulopathy. Thus, intraoperative fluid resuscitation including transfusion of packed red blood cells or fresh frozen plasma and catecholamine therapy are amongst the most challenging and crucial aspects of managing patients during cytoreductive surgery.
Results
Starting with preoperative evaluation, typical comorbidities such as intestinal obstructions, malignant ascites, pleural effusion and preoperative anemia should be diagnosed and treated accordingly. A preoperative warming minimizes the risk of redistribution hypothermia during induction of anesthesía and reduces the incidence of inadvertent perioperative hypothermia and the need for postoperative ventilation. There is insufficient evidence regarding the sole intraoperative use of balanced electrolyte solutions for cytoreductive surgery. A combined approach including colloids, antifibrinolytics and the use of fresh frozen plasma to avoid dilutional coagulopathy, has proved effective. Additional hemodynamic monitoring might help to improve the perioperative setting through goal-directed fluid therapy in patients with malignant ascites of more than 500 ml or foreseeable extensive peritonectomy.
Conclusion
The perioperative anesthesiological approach should be adjusted to the individual and ovarian cancer-specific risk profile. To account for the sometimes significant loss of protein and fluid induced by ascites and peritonectomy, preoperative patient improvement (prehabilitation), appropriate fluid therapy and perioperative normothermia are of great importance.
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P. Niggemann und L. Kaufner geben an, dass kein Interessenkonflikt besteht.
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Niggemann, P., Kaufner, L. Anästhesiologische Aspekte beim Ovarialkarzinom. Onkologe 25, 114–122 (2019). https://doi.org/10.1007/s00761-018-0508-7
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DOI: https://doi.org/10.1007/s00761-018-0508-7
Schlüsselwörter
- Anästhesiologisches Management
- Präoperative Anämie
- Perioperative Flüssigkeitstherapie
- Zytoreduktive Chirurgie
- Dilutionskoagulopathie