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DOI: 10.5482/ha-1180
Anticoagulation for venous thromboembolism
What if they bleed?Anticoagulation bei venöser ThromboembolieWas tun bei einer Blutung?Publication History
received:
02 October 2011
accepted:
06 October 2011
Publication Date:
28 December 2017 (online)
![](https://www.thieme-connect.de/media/10.1055-s-00034925/201201/lookinside/thumbnails/10-5482-ha-1180_de-1.jpg)
Summary
Acute venous thromboembolism (VTE) is treated with parenteral administration of heparin or derivatives, in conjunction with oral vitamin K antagonists (VKAs) to reach and maintain INR values between 2.0 and 3.0 for at least 3 months; the duration of a further period of treatment for secondary prevention of recurrences is still matter of debate. If bleeding occurs during treatment the decision will be based on: a) type of bleeding (major or minor), and b) thrombotic risk if anticoagulation is withheld (characteristics of patients and time elapsed from the index VTE). In case of major bleeding anticoagulation should be stopped and reversed. A first but insufficient measure is i.v. vitamin K administration. Fresh frozen plasma is widely used; however, large volumes are needed (at least 15 mL/kg body weight) with risk for fluid overload. Prothrombin complex concentrate infusion, with 3 or (better) the 4 pro-coagulant factors, is a more efficient (fast and safe) measure. In patients at high thrombotic risk (first month or other conditions) and absolute contraindication for anticoagulation a caval filter is recommended, to avoid as much as possible lifethreatening pulmonary embolism.
Zusammenfassung
Die Behandlung der akuten venösen Thromboembolie (VTE) besteht in der parenteralen Gabe von Heparin bzw. -derivaten, zusammen mit oralen Vitamin-K-Antagonisten (VKA), um INR-Werte zwischen 2,0 und 3,0 zu erreichen und für mindestens drei Monate aufrecht zu erhalten. Über die Dauer einer anschließenden sekundären Rezidivprophylaxe wird noch diskutiert. Falls während der Behandlung eine Blutung auftritt, richtet sich die Entscheidung nach: a) Art der Blutung (leichte oder schwere) und b) Thromboserisiko bei Absetzen der Antikoagulation (Patientencharakteristika und Zeitraum seit der Index-VTE). Im Falle einer großen Blutung sollte die Antikoagulation beendet und antagonisiert werden. Eine erste, jedoch unzureichende Maßnahme ist die i.v.- Gabe von Vitamin K. Gefrorenes Frischplasma wird häufig verwendet; es werden jedoch große Mengen benötigt (mindestens 15 ml/kg Körpergewicht), mit dem Risiko der Volumenüberlastung. Die Infusion eines Prothrombinkomplex-Konzentrats mit drei oder (besser) vier Gerinnungsfaktoren ist das effizientere Verfahren (schnell und sicher). Bei Patienten mit einem hohen Thromboserisiko (im ersten Monat oder bei Vorliegen anderer Erkrankungen) und einer absoluten Kontraindikation für eine Antikoagulation wird ein Vena-cava-Filter empfohlen, um möglichst eine lebensbedrohliche Lungenembolie zu vermeiden
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