Anästhesie in der Urologie – Aktuelle Strategien zur Minimierung von Blutverlusten bei radikaler Prostatektomie

Zusammenfassung

Das Prostatakarzinom ist ein häufig diagnostiziertes Karzinom des männlichen Patienten mit einer hohen Inzidenz. Trotz Weiterentwicklung der chirurgischen Techniken zur Prostatektomie ist der perioperative Blutverlust mit konsekutiver Gabe von Erythrozyten weiterhin die häufigste Komplikation. Die kontrollierte Hypotension (MAD 60–70mmHg) aus einer Kombination aus thorakaler Epiduralanästhesie und restriktiver Flüssigkeitstherapie ist ein sicheres Verfahren, um den Blutverlust zu minimieren. Die 25°-Trendelenburglagerung unterstützt die multimodale Behandlung zur Hypotension. Tranexamsäure ist ein sicheres Medikament, um die Hyperfibrinolyse unter Prostataresektion zu behandeln.

Abstract

Prostate cancer is a frequently diagnosed cancer in men with a high incidence. Despite enhancements of surgical techniques in prostatectomyperioperative blood loss is still the most frequent complication. Controlled hypotension (MAP 60–70mmHg) consisting of thoracal epidural anaesthesia und restrictive fluid management is a safe method to minimize blood loss. 25 degrees Trendelenburg position supports the multimodal treatment of controlled hypotension. Tranexamic acid is a safe drug to treat hyperfibrinolysis during prostate resection.

Kernaussagen

• Das Prostatakarzinom ist das zweithäufigste diagnostizierte Karzinom des männlichen Patienten.

• Trotz Weiterentwicklung der operativen Methoden ist die perioperative Blutung eine der wichtigsten Komplikationen der radikalen retropubischen Prostatektomie.

• Kontrollierte Hypotension ist ein sicheres Verfahren um den Blutverlust bei ASA-1-und ASA-2-Patienten unter Prostatektomie einzudämmen.

• Richtwert des mittleren arteriellen Drucks der kontrollierten Hypotension sind beim gesunden Patienten 60–70mmHg.

• Die Anlage eines thorakalen Epiduralkatheters ist empfehlenswert zur intraoperativen kontrollierten Hypotension und postoperativen Schmerztherapie.

• Eine restriktive Flüssigkeitstherapie weist einen Vorteil bezüglich des Blutverlusts gegenüber der liberalen Flüssigkeitstherapie auf.

• Infusionslösungen sollten möglichst nach der Präparationsphase der Prostata gegeben werden.

• Die Trendelenburglagerung bis 25–30° scheint einen positiven Einfluss auf den perioperativen Blutverlust zu haben.

• Vorsicht ist geboten bei der Rücklagerung von steilen Trendelenburglagerungen aufgrund der Umverteilung des Blutvolumens mit konsekutiver hämodynamischer Instabilität.

• Die Prostata ist ein fibrinolytisch aktives Organ.

• Tranexamsäure ist ein sicheres und preiswertes Medikament um die Hyperfibrinolyse zu behandeln.

• Tranexamsäure kann auch bei ASA-Patienten der Klassen 3 und 4 angewendet werden, um dem Blutverlust zu minimieren.

Schlüsselwörter:

Prostataresektion - Blutverlust - kontrollierte Hypotension - Tranexamsäure

Key words:

prostate resection - blood loss - controlled hypotension - tranexamic acid

• Literatur

• 1 Ferlay J, Parkin DM, Steliarova-Foucher E. Estimates of cancer incidence and mortality in Europe in 2008. Eur J Cancer 2010; 46: 765-781
• 2 Crescenti A, Borghi G, Bignami E et al. Intraoperative use of tranexamic acid to reduce transfusion rate in patients undergoing radical retropubic prostatectomy: double blind, randomised, placebo controlled trial. BMJ 2011; 343
• 3 Ferlay J, Steliarova-Foucher E, Lortet-Tieulent J et al. Cancer incidence and mortality patterns in Europe: Estimates for 40 countries in 2012. Eur J Cancer 2013; 49: 1374-1403
• 4 Resnick MJ et al. Long-term functional outcomes after treatment for localized prostate cancer. N Engl J Med 2013; 368: 436-445
• 5 Bill-Axelson A, Holmberg L, Filén F et al. Radical prostatectomy versus watchful waiting in localized prostate cancer: the Scandinavian prostate cancer group-4 randomized trial. J Natl Cancer Inst 2008; 100: 1144-1154
• 6 Tewari A, Sooriakumaran P, Bloch DA et al. Positive surgical margin and wperioperative complication rates of primary surgical treatments for prostate cancer: a systematic review and meta-analysis comparing retropubic, laparoscopic, and robotic prostatectomy. Eur Urol 2012; 62: 1-15
• 7 Vickers AJ, Bianco FJ, Serio AM et al. The surgical learning curve for prostate cancer control after radical prostatectomy. J Natl Cancer Inst 2007; 99: 1171-1177
• 8 Chang SS, Duong DT, Wells N et al. Predicting blood loss and transfusion requirements during radical prostatectomy: the significant negative impact of increasing body mass index. J Urol 2004; 171: 1861-1865
• 9 Schostak M, Matischak K, Müller M et al. New perioperative management reduces bleeding in radical retropubic prostatectomy. BJU Int 2005; 96: 316-319
• 10 Friederich PW, Henny CP, Messelink EJ et al. Effect of recombinant activated factor VII on perioperative blood loss in patients undergoing retropubic prostatectomy: a double-blind placebo-controlled randomised trial. Lancet 2003; 361: 201-205
• 11 McCullough TC, Roth JV, Ginsberg PC, Harkaway RC. Estimated blood loss underestimates calculated blood loss during radical retropubic prostatectomy. Urol Int 2004; 72: 13-16
• 12 Shir Y, Raja SN, Frank SM, Brendler CB. Intraoperative blood loss during radical retropubic prostatectomy: epidural versus general anesthesia. Urology 1995; 45: 993-999
• 13 Wang JK, Klein HG. Red blood cell transfusion in the treatment and management of anaemia: the search for the elusive transfusion trigger. Vox Sang 2010; 98: 2-11
• 14 Walker RH. Special report: transfusion risks. Am J Clin Pathol 1987; 88: 374-378
• 15 Hendrickson JE, Hillyer CD. Noninfectious serious hazards of transfusion. Anesth Analg 2009; 108: 759-769
• 16 Quillen K, Murphy K. Reducing the risk of mistransfusion. Arch Pathol Lab Med 2009; 133: 176-176
• 17 Perkins HA, Busch MP. Transfusion-associated infections: 50 years of relentless challenges and remarkable progress. Transfusion 2010; 50: 2080-2099
• 18 Engoren M, Mitchell E, Perring P et al. The effect of erythrocyte blood transfusions on survival after surgery for hip fracture. J Trauma 2008; 65: 1411-1415
• 19 Surgenor SD, Kramer RS, Olmstead EM et al. Northern New England Cardiovascular Disease Study Group. The association of perioperative red blood cell transfusions and decreased long-term survival after cardiac surgery. Anesth Analg 2009; 108: 1741-1746
• 20 Benjamin RJ, Whitaker BI. Boom or bust? Estimating blood demand and supply as the baby boomers age. Transfusion 2011; 51: 670-673
• 21 Gurusamy KS, Li J, Sharma D, Davidson BR. Cardiopulmonary interventions to decrease blood loss and blood transfusion requirements for liver resection. Cochrane Database Syst Rev CD 007338 2009; 51
• 22 Dragan S, Kulej M, Krawczyk A et al. Methods of reducing allogeneic blood demand in orthopedic surgery. Ortop Traumatol Rehabil 2012; 14: 199-214
• 23 Schostak M, Matischak K, Schafer M et al. New concept minimizes bleeding in radical retropubic prostatectomy. Urologe A 2005; 44: 1332-1336
• 24 Menkis AH, Martin J, Cheng DC et al. Drug, devices, technologies, and techniques for blood management in minimally invasive and conventional cardiothoracic surgery: a consensus statement from the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) 2011. Innovations (Phila) 2012; 7: 229-241
• 25 Wang G, Liu S, Liu G. Effects of infusion of different fluids during controlled hypotension on gastric intramucosal pH and postoperative gastroenterological function. J Biomed Res 2011; 25: 191-196
• 26 Han SH et al. The effect of esmolol-induced controlled hypotension in combination with acute normovolemic hemodilution on cerebral oxygenation. Acta Anaesthesiol Scand 2006; 50: 863-868
• 27 Chari P et al. Comparative evaluation of cardiovascular effects of sevoflurane and isoflurane in patients with ischaemic heart disease undergoing non-cardiac surgery. Ann Card Anaesth 1999; 2: 28-31
• 28 Rolf N, Van Aken H. Kardiovaskuläre Effekte von Sevofluran. Anaesthesist 1998; 47 (Suppl. 01) 11-18
• 29 Ervens J, Marks C, Hechler M et al. Effect of induced hypotensive anaesthesia vs isovolaemic haemodilution on blood loss and transfusion requirements in orthognathic surgery: a prospective, single-blinded, randomized, controlled clinical study. Int J Oral Maxillofac Surg 2010; 39: 1168-1174
• 30 Djavan B, Agalliu I, Laze J et al. Blood loss during radical prostatectomy: impact on clinical, oncological and functional outcomes and complication rates. BJU Int 2012; 110: 69-75
• 31 Degoute CS. Controlled hypotension: a guide to drug choice. Drugs 2007; 67: 1053-1076
• 32 Rodgers A, Walker N, Schug S et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000; 321: 1493-1493
• 33 Rigg JR, Jamrozik K, Myles PS et al. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet 2002; 359: 1276-1282
• 34 Popping DM, Elia N, Marret E et al. Protective effects of epidural analgesia on pulmonary complications after abdominal and thoracic surgery: a meta-analysis. Arch Surg 2008; 143
• 35 Turunen P, Carpelan-Holmström M, Kairaluoma P et al. Epidural analgesia diminished pain but did not otherwise improve enhanced recovery after laparoscopic sigmoidectomy: a prospective randomized study. Surg Endosc 2009; 23: 31-37
• 36 Salonia A, Crescenti A, Suardi N et al. General versus spinal anesthesia in patients undergoing radical retropubic prostatectomy: results of a prospective, randomized study. Urology 2004; 64: 95-100
• 37 Salonia A, Suardi N, Crescenti A et al. General versus spinal anesthesia with different forms of sedation in patients undergoing radical retropubic prostatectomy: results of a prospective, randomized study. Int J Urol 2006; 13: 1185-1190
• 38 Nakano M et al. Comparison of radical retropubic prostatectomy under combined lumbar spinal and epidural anesthesia with that under combined general and epidural anesthesia. Nihon Hinyokika Gakkai Zasshi 2005; 96: 11-16
• 39 O'Connor PJ, Hanson J, Finucane BT. Induced hypotension with epidural/general anesthesia reduces transfusion in radical prostate surgery. Can J Anaesth 2006; 53: 873-880
• 40 Tikuisis R, Miliauskas P, Samalavicius NE et al. Epidural and general anesthesia versus general anesthesia in radical prostatectomy. Medicina (Kaunas) 2009; 45: 772-777
• 41 Cwik J. Postoperative considerations of neuraxial anesthesia. Anesthesiol Clin 2012; 30: 433-443
• 42 Johnson M, Mannar R, Wu AV. Correlation between blood loss and inferior vena caval pressure during liver resection. Br J Surg 1998; 85: 188-190
• 43 Shaftan GW, Chiu CJ, Dennis C et al. Fundamentals of physiologic control of arterial hemorrhage. Surgery 1965; 58: 851-856
• 44 Bickell WH, Bruttig SP, Millnamow GA et al. Use of hypertonic saline/dextran versus lactated Ringer's solution as a resuscitation fluid after uncontrolled aortic hemorrhage in anesthetized swine. Ann Emerg Med 1992; 21: 1077-1085
• 45 Davies BJ, Chung SY, Nelson JB. Delayed intraoperative hydration limits blood loss during radical retropubic prostatectomy. Urology 2004; 64: 712-716
• 46 Shigemura K et al. Limited hydration may reduce intraoperative blood loss in retropubic radical prostatectomy. Kobe J Med Sci 2010; 56: 18-23
• 47 Mercatello A. Changes in renal function induced by anesthesia]. Ann Fr Anesth Reanim 1990; 9: 507-524
• 48 Radtke FM, Franck M, Schust S et al. A comparison of three scores to screen for delirium on the surgical ward. World J Surg 2010; 34: 487-494
• 49 Fenger-Eriksen C, Hartig Rasmussen C, Kappel Jensen T et al. Renal effects of hypotensive anaesthesia in combination with acute normovolaemic haemodilution with hydroxyethyl starch 130/0.4 or isotonic saline. Acta Anaesthesiol Scand 2005; 49: 969-974
• 50 Choi WS, Samman N. Risks and benefits of deliberate hypotension in anaesthesia: a systematic review. Int J Oral Maxillofac Surg 2008; 37: 687-703
• 51 Wirth GJ, Psutka SP, Chapin BF et al. Midterm oncological outcomes of laparoscopic vs open radical prostatectomy (RP). BJU Int 2013; 112: 190-197
• 52 Choi DK, Lee IG, Hwang JH. Arterial to end-tidal carbon dioxide pressure gradient increases with age in the steep Trendelenburg position with pneumoperitoneum. Korean J Anesthesiol 2012; 63: 209-215
• 53 Kadono Y, Yaegashi H, Machioka K et al. Cardiovascular and respiratory effects of the degree of head-down angle during robot-assisted laparoscopic radical prostatectomy. Int J Med Robot 2013; 9: 17-22
• 54 Barre C, Pocholle P, Chauveau P. Minimal blood loss in patients undergoing radical retropubic prostatectomy. World J Surg 2002; 26: 1094-1098
• 55 Bhayani SB, Pavlovich CP, Hsu TS et al. Prospective comparison of short-term convalescence: laparoscopic radical prostatectomy versus open radical retropubic prostatectomy. Urology 2003; 61: 612-616
• 56 Cathelineau X, Cahill D, Widmer H et al. Transperitoneal or extraperitoneal approach for laparoscopic radical prostatectomy: a false debate over a real challenge. J Urol 2004; 171: 714-716
• 57 Gainsburg DM. Anesthetic concerns for robotic-assisted laparoscopic radical prostatectomy. Minerva Anestesiol 2012; 78: 596-604
• 58 Kiss T, Bluth T, Heller A. Anästhesie bei endourologischen und roboterassistierten Eingriffen. Anaesthesist 2012; 61: 745-747
• 59 Ziegler S, Ortu A, Reale C et al. Fibrinolysis or hypercoagulation during radical prostatectomy? An evaluation of thrombelastographic parameters and standard laboratory tests. Eur J Anaesthesiol 2008; 25: 538-543
• 60 Nielsen JD, Gram J, Holm-Nielsen A et al. Post-operative blood loss after transurethral prostatectomy is dependent on in situ fibrinolysis. Br J Urol 1997; 80: 889-893
• 61 McCormack PL. Tranexamic acid: a review of its use in the treatment of hyperfibrinolysis. Drugs 2012; 72: 585-617
• 62 CRASH-2 trial collaborators. Shakur H, Roberts I, Bautista R et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; 376: 23-32
• 63 Ferraris VA, Brown JR, Despotis GJ et al. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists Blood Conservation Clinical Practice Guidelines. Ann Thorac Surg 2011; 91: 944-982
• 64 Kagoma YK, Crowther MA, Douketis J et al. Use of antifibrinolytic therapy to reduce transfusion in patients undergoing orthopedic surgery: a systematic review of randomized trials. Thromb Res 2009; 123: 687-696
• 65 Molenaar IQ, Warnaara N, Groenb H et al. Efficacy and safety of antifibrinolytic drugs in liver transplantation: a systematic review and meta-analysis. Am J Transplant 2007; 7: 185-194
• 66 Henry DA, Carless PA, Moxey AJ et al. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev CD 001886 2011; 3
• 67 Fergusson DA, Hébert PC, Mazer CD et al. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery. N Engl J Med 2008; 358: 2319-2331
• 68 Levi M, Levy JH, Andersen HF, Truloff D. Safety of recombinant activated factor VII in randomized clinical trials. N Engl J Med 2010; 363: 1791-1800
• 69 Cardone D, Klein AA. Perioperative blood conservation. Eur J Anaesthesiol 2009; 26: 722-729