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Anästhesiol Intensivmed Notfallmed Schmerzther 2010; 45(4): 254-262
DOI: 10.1055/s-0030-1253094
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Topthema: Perioperative Organprotektion
© Georg Thieme Verlag Stuttgart · New York

Perioperative Organprotektion – Organprotektion durch Konditionierung

Organ protection by conditioningBerthold Bein, Patrick Meybohm
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Publication History

Publication Date:
12 April 2010 (online)

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Zusammenfassung

Die demografische Entwicklung führt dazu, dass sich zunehmend ältere Patienten mit kardiovaskulären Vorerkrankungen auch größeren, operativen Eingriffen unterziehen müssen. Interventionen, die zu einer höheren Ischämietoleranz vitaler Organe führen, sind daher von großem Interesse. Unter Konditionierung versteht man in diesem Zusammenhang einen Mechanismus, der es einem Organismus durch Anpassungsprozesse ermöglicht, eine Ischämie besser zu verkraften. Je nachdem, in welchem zeitlichen Zusammenhang zur Ischämie die protektive Intervention erfolgt, kann man Präkonditionierung (Intervention vor der Ischämie) und Postkonditionierung (Intervention nach der Ischämie während der Reperfusion) voneinander unterscheiden. Wenn die Ischämie in einem vom Zielorgan entfernten Gewebe ausgelöst wird, spricht man von Remote- (Fern-) Konditionierung. Sowohl kurzzeitige Ischämien als auch volatile Anästhetika und Opioide sind in der Lage, Konditionierung auszulösen. Auf zellulärer Ebene sind ATP-abhängige Kaliumkanäle und Kanäle, die die mitochondriale Permeabilität steuern, wichtige Effektoren. Die Effektivität der Konditionierung wurde für viele Organe in tierexperimentellen Arbeiten überzeugend gezeigt. Im klinischen Kontext gibt es zahlreiche Hinweise für eine Organprotektion durch Konditionierung bei herzchirurgischen Patienten. Große, randomisierte und multizentrische Studien sind aber noch erforderlich.

Abstract

Recent demographic developments challenge anaesthesiologists with an increasing number of elderly patients with cardiovascular comorbidities undergoing major surgery. Interventions that are capable to increase tissue tolerance against ischemia are of paramount importance. In this context, conditioning is defined as a mechanism that fosters tissue by specific adaptive processes to develop tolerance against a subsequent ischaemia. Dependent upon the temporal relationship between the intervention and the index ischaemia, preconditiong (intervention before ischaemia) is differentiated from postconditioning (intervention upon reperfusion).

Ischaemia induced in tissue remote from the target organ is called remote preconditioning. Both brief periods of ischaemia as well as volatile anaesthetics and opioids are able to trigger conditioning. On a cellular level, ATP-dependent potassium channels and the mitochondrial permeability transition pore are thought to be key effectors. Effective conditioning has been unequivocal demonstrated for various tissues in animal experiments. Clinical trials in patients undergoing cardiac surgery have provided evidence for organ protection by conditioning. Large scale multicenter randomised trials, however, are still needed.

Schlüsselwörter:

ischämische Präkonditionierung - anästhetikainduzierte Präkonditionierung - Fern-Präkonditionierung - klinische Studien - Anästhesie

Keywords:

ischemic preconditioning - anesthetic preconditioning - remote preconditioning - clinical studies - anaesthesia

Kernaussagen

  • Konditionierung stellt einen angeborenen, universellen und ubiquitären Schutzmechanismus gegen Organischämie dar.

  • Ischämische, anästhetikainduzierte und Remote-Präkonditionierung haben sowohl tierexperimentell als auch klinisch organprotektive Effekte.

  • Die zugrunde liegenden Mechanismen sind noch nicht vollständig geklärt. Auf zellulärer Ebene sind u. a. KATP - Kanäle, mPTP, NO und ROS an der Vermittlung der Protektion beteiligt.

  • Tierexperimentell sind protektive Effekte in praktisch allen relevanten Organsystemen gezeigt worden.

  • Klinische Studien lassen einen vorteilhaften Effekt für herzchirurgische Patienten und Patienten in der Leberchirurgie vermuten.

  • In der klinischen Praxis kann die Effektivität der Konditionierung durch Alter, Begleiterkrankungen (Hyperglykämie) und Co-Medikation (β-Blocker) abgeschwächt bzw. aufgehoben werden.

  • Die Remote-Konditionierung stellt eine interessante Option dar, bei Patienten praktisch ohne Nebenwirkungen und Komplikationen eine potente Protektion wichtiger Organe perioperativ zu realisieren.

Weiteres Material zum Artikel

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PD Dr. med. Berthold Bein
Dr. med. Patrick Meybohm

Email: bein@anaesthesie.uni-kiel.de

Email: meybohm@anaesthesie.uni-kiel.de

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