Neurologische Komplikationen in der Anästhesiologie – Teil II – Schäden der peripheren Nerven

 

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Zusammenfassung

Neurologische Komplikationen nach Operationen können für den Patienten fatale Folgen haben und zu Invalidität und Erwerbslosigkeit führen. Neben zentralen Schädigungen wie dem intraoperativen Schlaganfall, der Erblindung und dem postoperativen kognitiven Defizit sowie dem Delir, die durch ein optimiertes anästhesiologisches Management entscheidend beeinflusst werden können, sind periphere neurologische Schädigungen nach Anästhesien bei Kenntnis von Pathophysiologie und Therapie oft vermeidbar. Der aktuelle Artikel beschreibt die klassischen peripheren neurologischen Komplikationen, die durch Regionalanästhesien, Anlage zentraler Katheter, peripherer arterieller und venöser Kanülierung sowie intra- und perioperativer Lagerung von Patienten auftreten können. Darüber hinaus werden juristische Aspekte im Rahmen der Arzthaftung und Aufgabenverteilung zwischen Anästhesist, Operateur und medizinischem Assistenzpersonal erörtert.

Abstract:

Neurological complications after surgery may have fatal consequences for the patient or lead to disability and inability to work. Similar to central nervous complications such as stroke, postoperative visual loss, postoperative cognitive deficit and delirium, peripheral neurological complications following anaesthesia can be decisively influenced or almost avoided by an optimized anaesthesiological management.

In the present article typical peripheral neurologic complications which can occur after regional anesthesia, central venous puncture and insertion of arterial or venous cannulas as well as etiology, diagnosis and therapy of peripheral nervous damage are described. Moreover the paper gives recommendations on intraoperative positioning of the patient and presents medicolegal aspects in the perioperative setting.

Kernaussagen

• Perioperative Nervenschädigungen sind multifaktoriell bedingt.

• Es werden direkte Schädigungen durch akzidentelle Punktion, lagerungsbedingte Zug- und Druckschädigungen sowie ischämische Nervenschädigungen unterschieden.

• Die Klassifikation von Nervenschädigungen erfolgt nach Seddon in 3 bzw. nach Sunderland in 5 Grade, wobei klinisch vor allem die Unterscheidung von Neurapraxie (Grad I) und Axonotmesis (Grad II) relevant ist.

• Auf eine sorgfältige Lagerung des Patienten mit Druckentlastung und Abpolsterung aller aufliegenden Körperregionen ist zu achten. Dabei hat der Anästhesist die Aufgabe, den Operateur über unbeabsichtigte Lagerungsänderungen, z. B. durch Zug am Patienten, zu informieren.

• Der Anstieg des intrakompartmentalen Drucks in durch Faszien begrenzten Muskellogen führt zum akuten Kompartmentsyndrom, das ohne Therapie zu einem Extremitätenverlust führen kann.

• Bei peripheren Nervenblockaden sind Nervenstimulator und Ultraschall gleichwertige Techniken, ohne dass bisher eine Präferenz einer der Methoden hinsichtlich der Vermeidung von Nervenschäden gerechtfertigt scheint.

Literatur

• 1 Welch MB, Brummett CM, Welch TD et al.. Perioperative peripheral nerve injuries: a retrospective study of 380,680 cases during a 10-year period at a single institution.  Anesthesiology. 2009;  111 490-497
  CrossrefPubMedGoogle Scholar
• 2 Winfree CJ, Kline DG. Intraoperative positioning nerve injuries.  Surg Neurol. 2005;  63
  PubMedGoogle Scholar
• 3 Prielipp RC, Warner MA. Perioperative nerve injury: a silent scream?.  Anesthesiology. 2009;  111 464-466
  CrossrefPubMedGoogle Scholar
• 4 Bund M, Heine J, Jaeger K. Complications due to patient positioning: anaesthesiological considerations.  Anasthesiol Intensivmed Notfallmed Schmerzther. 2005;  40 329-339
  Article in Thieme ConnectPubMedGoogle Scholar
• 5 Vogel P. Neurological complications through positioning – neurological viewpoint.  Anasthesiol Intensivmed Notfallmed Schmerzther. 2003;  38 475-478
  Article in Thieme ConnectPubMedGoogle Scholar
• 6 Sunderland S. A classification of peripheral nerve injuries producing loss of function.  Brain. 1951;  74 491-516
  CrossrefPubMedGoogle Scholar
• 7 Delank H-W, Gehlen W.. Neurologie. Stuttgart: Georg Thieme Verlag; 2006. 11. Auflage.
  Google Scholar
• 8 Borgeat A, Blumenthal S. Nerve injury and regional anaesthesia.  Curr Opin Anaesthesiol. 2004;  17 417-421
  CrossrefPubMedGoogle Scholar
• 9 Upton AR, McComas AJ. The double crush in nerve entrapment syndromes.  Lancet. 1973;  2 359-362
  CrossrefPubMedGoogle Scholar
• 10 Opderbecke HW, Weißauer W. Entschließungen – Empfehlungen – Vereinbarungen. Ebelsbach: Aktiv Druck & Verlag GmbH; 2006. 4. Auflage.
  Google Scholar
• 11 Heimbach D, Weissauer W. Legal aspects of injuries due to positioning of the patient in urology.  Urologe A. 2004;  43 469-478
  CrossrefPubMedGoogle Scholar
• 12 Alvine FG, Schurrer ME. Postoperative ulnar-nerve palsy. Are there predisposing factors?.  J Bone Joint Surg Am. 1987;  69 255-259
  PubMedGoogle Scholar
• 13 Warner MA, Martin JT, Schroeder DR, Offord KP, Chute CG. Lower-extremity motor neuropathy associated with surgery performed on patients in a lithotomy position.  Anesthesiology. 1994;  81 6-12
  CrossrefPubMedGoogle Scholar
• 14 Warner MA, Warner DO, Harper CM, Schroeder DR, Maxson PM. Lower extremity neuropathies associated with lithotomy positions.  Anesthesiology. 2000;  93 938-942
  CrossrefPubMedGoogle Scholar
• 15 Standl T. Viszeralchirurgie. In: Kochs E, Adams HA, Spies C, Hrsg. Anästhesiologie. Stuttgart: Thieme; 2008. 2. Aufl. 880-882
  Google Scholar
• 16 Auerhammer J. Positioning of the patient for surgery.  Anaesthesist. 2008;  57 1107-1126
  CrossrefPubMedGoogle Scholar
• 17 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group.  N Engl J Med. 1996;  334 1209-1215
  CrossrefPubMedGoogle Scholar
• 18 Teeples TJ, Rallis DJ, Rieck KL, Viozzi CF. Lower Extremity Compartment Syndrome Associated With Hypotensive General Anesthesia for Orthognathic Surgery: A Case Report and Review of the Disease.  J Oral Maxillofac Surg. 2010;  68 1166-1170
  CrossrefPubMedGoogle Scholar
• 19 Freye E, Grabitz K, Sandmann W. Spinal cord ischemia – use of spinal-evoked potentials for intraoperative monitoring in thoraco-abdominal aortic aneurysm (TAA) repair.  Acta Anaesthesiol Scand Suppl. 1996;  109 50-53
  PubMedGoogle Scholar
• 20 Fehlings MG, Brodke DS, Norvell DC, Dettori JR. The evidence for intraoperative neurophysiological monitoring in spine surgery: does it make a difference?.  Spine (Phila Pa 1976). 2010;  35 37-46
  CrossrefPubMedGoogle Scholar
• 21 Ullrich W, Biermann E, Kienzle F, Krier C. Damage due to patient positioning in anesthesia and surgical medicine (1).  Anasthesiol Intensivmed Notfallmed Schmerzther. 1997;  32 4-20
  PubMedGoogle Scholar
• 22 Albers P, Müller SC. Läsionen peripherer Nerven durch Einsatz selbsthaltender Abdominalsperrer. In: Steffens J, Langen P-H, Hrsg. Komplikationen in der Urologie. Darmstadt: Steinkopff; 2002: 397-400
  Google Scholar
• 23 Röher HD, Ohmann C, Beck L. Acute compartment syndrome due to positioning during long-lasting gynecological operations in the lithotomy position.  Gynäkologe. 2008;  41 1023-1026
  CrossrefPubMedGoogle Scholar
• 24 Schutte JK, Gerbershagen MU, Wappler F. Anaesthesia associated rhabdomyolysis. Diagnosis, therapy and prevention of skeletal muscle breakdown.  Anasthesiol Intensivmed Notfallmed Schmerzther. 2006;  41 462-453
  PubMedGoogle Scholar
• 25 Tiwari A, Haq AI, Myint F, Hamilton G. Acute compartment syndromes.  Br J Surg. 2002;  89 397-412
  CrossrefPubMedGoogle Scholar
• 26 Heemskerk J, Kitslaar P. Acute compartment syndrome of the lower leg: retrospective study on prevalence, technique, and outcome of fasciotomies.  World J Surg. 2003;  27 744-747
  CrossrefPubMedGoogle Scholar
• 27 Fishman JM. Recurrent laryngeal nerve palsy complicating subclavian line insertion: a case report.  J Med Case Reports. 2009;  3 9034
  CrossrefPubMedGoogle Scholar
• 28 Uslu M. Leitfaden der zentralvenösen Katheterisierung. Stuttgart: Thieme; 1997
  Google Scholar
• 29 Salman M, Potter M, Ethel M, Myint F. Recurrent laryngeal nerve injury: a complication of central venous catheterization-a case report.  Angiology. 2004;  55 345-346
  CrossrefPubMedGoogle Scholar
• 30 Aggarwal S, Hari P, Bagga A, Mehta SN. Phrenic nerve palsy: a rare complication of indwelling subclavian vein catheter.  Pediatr Nephrol. 2000;  14 203-204
  CrossrefPubMedGoogle Scholar
• 31 Koehler PJ, Wijngaard PR. Brown-Sequard syndrome due to spinal cord infarction after subclavian vein catheterisation.  Lancet. 1986;  2 914-915
  PubMedGoogle Scholar
• 32 Risch M, Aguirre J, Perniola L, Borgeat A, Ehrenberg R. Neurological complication after a vertical infraclavicular brachial plexus block.  Anaesthesist. 2010; 
  PubMedGoogle Scholar
• 33 Auroy Y, Benhamou D, Bargues L et al.. Major complications of regional anesthesia in France: The SOS Regional Anesthesia Hotline Service.  Anesthesiology. 2002;  97 1274-1280
  CrossrefPubMedGoogle Scholar
• 34 Auroy Y, Narchi P, Messiah A et al.. Serious complications related to regional anesthesia: results of a prospective survey in France.  Anesthesiology. 1997;  87 479-486
  CrossrefPubMedGoogle Scholar
• 35 Capdevila X, Pirat P, Bringuier S et al.. Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients.  Anesthesiology. 2005;  103 1035-1045
  CrossrefPubMedGoogle Scholar
• 36 Barrington MJ, Watts SA, Gledhill SR et al.. Preliminary results of the Australasian Regional Anaesthesia Collaboration: a prospective audit of more than 7000 peripheral nerve and plexus blocks for neurologic and other complications.  Reg Anesth Pain Med. 2009;  34 534-541
  CrossrefPubMedGoogle Scholar
• 37 Neuburger M, Breitbarth J, Reisig F, Lang D, Buttner J. Complications and adverse events in continuous peripheral regional anesthesia Results of investigations on 3,491 catheters.  Anaesthesist. 2006;  55 33-40
  CrossrefPubMedGoogle Scholar
• 38 Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and nonacute complications associated with interscalene block and shoulder surgery: a prospective study.  Anesthesiology. 2001;  95 875-880
  CrossrefPubMedGoogle Scholar
• 39 Brull R, McCartney CJ, Chan VW, El-Beheiry H. Neurological complications after regional anesthesia: contemporary estimates of risk.  Anesth Analg. 2007;  104 965-974
  CrossrefPubMedGoogle Scholar
• 40 Liu SS, Zayas VM, Gordon MA et al.. A prospective, randomized, controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms.  Anesth Analg. 2009;  109 265-271
  CrossrefPubMedGoogle Scholar
• 41 Sauter AR, Dodgson MS, Stubhaug A, Halstensen AM, Klaastad O. Electrical nerve stimulation or ultrasound guidance for lateral sagittal infraclavicular blocks: a randomized, controlled, observer-blinded, comparative study.  Anesth Analg. 2008;  106 1910-1915
  CrossrefPubMedGoogle Scholar
• 42 Danelli G, Fanelli A, Ghisi D et al.. Ultrasound vs nerve stimulation multiple injection technique for posterior popliteal sciatic nerve block.  Anaesthesia. 2009;  64 638-642
  CrossrefPubMedGoogle Scholar
• 43 Bigeleisen PE, Moayeri N, Groen GJ. Extraneural versus intraneural stimulation thresholds during ultrasound-guided supraclavicular block.  Anesthesiology. 2009;  110 1235-1243
  CrossrefPubMedGoogle Scholar
• 44 Borgeat A. Regional anesthesia, intraneural injection, and nerve injury: beyond the epineurium.  Anesthesiology. 2006;  105 647-648
  CrossrefPubMedGoogle Scholar
• 45 Pitman MI, Nainzadeh N, Ergas E, Springer S. The use of somatosensory evoked potentials for detection of neuropraxia during shoulder arthroscopy.  Arthroscopy. 1988;  4 250-255
  CrossrefPubMedGoogle Scholar
• 46 Bigeleisen PE. Nerve puncture and apparent intraneural injection during ultrasound-guided axillary block does not invariably result in neurologic injury.  Anesthesiology. 2006;  105 779-783
  CrossrefPubMedGoogle Scholar
• 47 Jochum D, Bondar A, Delaunay L, Egan M, Bouaziz H. One size does not fit all: proposed algorithm for ultrasonography in combination with nerve stimulation for peripheral nerve blockade.  Br J Anaesth. 2009;  103 773-774
  PubMedGoogle Scholar
• 48 Beach ML, Sites BD, Gallagher JD. Use of a nerve stimulator does not improve the efficacy of ultrasound-guided supraclavicular nerve blocks.  J Clin Anesth. 2006;  18 580-584
  CrossrefPubMedGoogle Scholar
• 49 Benumof JL. Permanent loss of cervical spinal cord function associated with interscalene block performed under general anesthesia.  Anesthesiology. 2000;  93 1541-1544
  CrossrefPubMedGoogle Scholar
• 50 Neal JM, Bernards CM, Hadzic A et al.. ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine.  Reg Anesth Pain Med. 2008;  33 404-415
  PubMedGoogle Scholar
• 51 Bogdanov A, Loveland R. Is there a place for interscalene block performed after induction of general anaesthesia?.  Eur J Anaesthesiol. 2005;  22 107-110
  PubMedGoogle Scholar
• 52 Borgeat A, Aguirre J, Curt A. Case scenario: neurologic complication after continuous interscalene block.  Anesthesiology. 2010;  112 742-745
  CrossrefPubMedGoogle Scholar
• 53 Wallach SG. Cannulation injury of the radial artery: diagnosis and treatment algorithm.  Am J Crit Care. 2004;  13 315-319
  PubMedGoogle Scholar
• 54 Slogoff S, Keats AS, Arlund C. On the safety of radial artery cannulation.  Anesthesiology. 1983;  59 42-47
  CrossrefPubMedGoogle Scholar
• 55 Bhananker SM, Liau DW, Kooner PK et al.. Liability related to peripheral venous and arterial catheterization: a closed claims analysis.  Anesth Analg. 2009;  109 124-129
  CrossrefPubMedGoogle Scholar
• 56 Singleton RJ, Webb RK, Ludbrook GL, Fox MA. The Australian Incident Monitoring Study. Problems associated with vascular access: an analysis of 2000 incident reports.  Anaesth Intensive Care. 1993;  21 664-669
  PubMedGoogle Scholar
• 57 Debnath D, Wallace S, Mylona E, Myint F. Aneurysm of antecubital vein: an unusual complication of peripheral intravenous cannulation.  BMC Surg. 2007;  7 9
  CrossrefPubMedGoogle Scholar
• 58 Liau DW. Injuries and liability related to periphereal catheters: A closed Claims Analysis.  ASA Newsletter. 2006;  70
  PubMedGoogle Scholar
• 59 Horlocker TT, Bishop AT. Compartment syndrome of the forearm and hand after brachial artery cannulation.  Anesth Analg. 1995;  81 1092-1094
  CrossrefPubMedGoogle Scholar
• 60 Martin C, Saux P, Papazian L, Gouin F. Long-term arterial cannulation in ICU patients using the radial artery or dorsalis pedis artery.  Chest. 2001;  119 901-906
  CrossrefPubMedGoogle Scholar
• 61 Karacalar S, Ture H, Baris S, Karakaya D, Sarihasan B. Ulnar artery versus radial artery approach for arterial cannulation: a prospective, comparative study.  J Clin Anesth. 2007;  19 209-213
  CrossrefPubMedGoogle Scholar
• 62 Dashkoff N, Dashkoff PB, Zizzi Sr. JA, Wadhwani J, Zizzi Jr. JA. Ulnar artery cannulation for coronary angiography and percutaneous coronary intervention: case reports and anatomic considerations.  Catheter Cardiovasc Interv. 2002;  55 93-96
  CrossrefPubMedGoogle Scholar
• 63 Bazaral MG, Welch M, Golding LA, Badhwar K. Comparison of brachial and radial arterial pressure monitoring in patients undergoing coronary artery bypass surgery.  Anesthesiology. 1990;  73 38-45
  CrossrefPubMedGoogle Scholar
• 64 Barnes RW, Foster EJ, Janssen GA, Boutros AR. Safety of brachial arterial catheters as monitors in the intensive care unit--prospective evaluation with the Doppler ultrasonic velocity detector.  Anesthesiology. 1976;  44 260-264
  CrossrefPubMedGoogle Scholar
• 65 Maki DG, Ringer M. Risk factors for infusion-related phlebitis with small peripheral venous catheters. A randomized controlled trial.  Ann Intern Med. 1991;  114 845-854
  PubMedGoogle Scholar
• 66 Oexmann B. Juristische Aspekte bei intraoperativ bedingten Lagerungsschäden / Abgrenzung der Verantwortlichkeit zwischen Anästhesist und Operateur.  Hamm. 2008; 
  PubMedGoogle Scholar
• 67 Adam C, Quabach R, Standl T. Neurological complications following anesthesia – Perioperative stroke, postoperative visual loss, anticholingeric syndrom.  Anästhesiol Intensivmed Notfallmed Schmerzther. 2010;  45 440-447
  Article in Thieme ConnectPubMedGoogle Scholar

Dr. med. Ralf Quabach
Dr. med. Christian Adam
Prof. Dr. med. Thomas Standl

Email: ralf.quabach@med.uni-duesseldorf.de

Email: adam@klinikumsolingen.de

Email: standl@klinikumsolingen.de

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