Topische Anwendung von Tranexamsäure zur Prophylaxe von Nachblutungen nach Tonsillektomie

Zusammenfassung

Hintergrund: Nachblutungen nach Tonsillektomie (TE) gehören zu den häufigsten Komplika­tionen dieses Eingriffs. Ziel dieser Studie war festzu­stellen, ob die postoperative topische Applikation von Tranexamsäure (TXA) eine Reduktion der Nachblutungsrate nach TE bewirkt.

Material und Methoden: Zwischen November 2011 und April 2013 wurde TXA postoperativ topisch zur Prophylaxe von Nachblutungen eingesetzt (n=246). Es wurde 1 Ampulle TXA in 300 ml Wasser von Tag 5–10 nach TE zum Gurgeln oder Besprühen der Tonsillenlogen angewendet. Verglichen wurde retrospektiv mit einer Kontrollgruppe ohne TXA (n=248) im Zeitraum Dezember 2010–November 2011.

Ergebnisse: Bei der Studiengruppe betrug die Nachblutungsrate gesamthaft 19,1% und bei der Kontrollgruppe 22,2%. Die Rate von interven­tionspflichtigen Nachblutungen mit Revision in Intubationsnarkose lag bei 8,9% in der Studiengruppe und bei 11,3% in der Kontrollgruppe. Die Unterschiede waren nicht signifikant.

Schlussfolgerung: Die topische Applikation von TXA in einer Konzentration von 0,2% bewirkte keine signifikante Reduktion von Nachblutungen nach TE. Lediglich bei Patienten ≥ 12 Jahre zeigt sich eine schwache Tendenz zu weniger interventionspflichtigen Nachblutungen in Intuba­tionsnarkose.

Abstract

Topical Application of Tranexamic Acid to Prevent Post-tonsillectomy Haemorrhage

Background: Haemorrhage after tonsillectomy (TE) is a frequent and possibly major complication. The aim of the present study was to examine, if the rate of haemorrhage after tonsillectomy could be reduced by the topical application of Tranexamic acid (TXA) postoperatively.

Material and Methods: Between November 2011 and April 2013, all patients (n=246) received TXA postoperatively to prevent haemorrhage after TE. The patients were instructed to dilute 1 ampulla of TXA in 300 ml of tap water (concentration 0.2%) from postoperative day 5–10 and to gargle or spray the tonsillar fossae 5–6 times daily. The study group was compared retrospectively with a control group of patients undergoing TE with­out postoperative application of TXA from December 2010 to November 2011 (n=248).

Results: The overall rate of postoperative haemorrhage was 19% and 22% in the study and control group, respectively. The rate of postoperative bleeding that needed surgical intervention was at 8.9% and 11.3% in the study and control group, respectively. Topical application of TXA did not significantly reduce the rate of postoperative haemorrhage after TE.

Conclusion: Topically applied TXA did not reduce postoperative haemorrhage after TE. However, a slight tendency to less bleeding which needed surgical intervention was found in pa­tients older than ≥ 12 years.

Schlüsselwörter

Tonsillektomie - Tranexamsäure - Nachblutung - Operationstechnik - Nachblutungsklassifikation - Nachblutungsintensität

Key words

tonsillectomy - tranexamic acid - haemorrhage - operation technique - classification of bleeding episodes - severity of bleeding episodes

• Literatur

• 1 Windfuhr JP. Serious complications following tonsillectomy: how frequent are they really?. ORL J Otorhinolaryngol Relat Spec 2013; 75: 166-173
• 2 Windfuhr JP, Chen YS, Remmert S. Hemorrhage following tonsillectomy and adenoidectomy in 15,218 patients. Otolaryngol Head Neck Surg 2005; 132: 281-286
• 3 Evans AS, Khan AM, Young D, Adamson R. Assessment of secondary haemorrhage rates following adult tonsillectomy – a telephone survey and literature review. Clin Otolaryngol Allied Sci 2003; 28: 489-491
• 4 Sarny S, Ossimitz G, Habermann W, Stammberger H. Austrian Tonsil Study Part 3: Surgical Technique and Postoperative Haemorrhage after Tonsillectomy. Laryngo-Rhino-Otol 2013; 92: 92-96
• 5 Wei JL, Beatty CW, Gustafson RO. Evaluation of posttonsillectomy hemorrhage and risk factors. Otolaryngol Head Neck Surg 2000; 123: 229-235
• 6 Verstraete M, Vermylen J, Tyberghein J. Double blind evaluation of the haemostatic effect of adrenochrome monosemicarbazone, conjugated oestrogens and epsilonaminocaproic acid after adenotonsillectomy. Acta Haematol 1968; 40: 154-161
• 7 Verstraete M, Tyberghein J, De Greef Y, Daems L, Van Hoof A. Double-blind trials with ethamsylate, batroxobin or tranexamic acid on blood loss after adenotonsillectomy. Acta Clin Belg 1977; 32: 136-141
• 8 Vitale W. Initial notes on the use of AMCHA (trans-4-aminomethylcyclohexancarbonic acid) in otorhinolaryngologic surgery. Minerva Otorinolaringol 1971; 21: 224-228
• 9 Ali G, Ascanelli L, Pagliuso G. Preventive use of AMCHA in tonsillectomies under general anesthesia. Clinical evaluation. Minerva Anestesiol 1976; 42: 675-677
• 10 Taborelli G, Bastiani G, Lercari G, Pallestrini EA. Action of tranexamic acid (AMCHA) on posttonsillectomy fibrinolysis. Valsalva 1974; 50: 34-50
• 11 Mazauric FX, Boudon A, Rheingold C. Value of tranexamic acid in extracapsular tonsillectomy in adults. JFORL J Fr Otorhinolaryngol Audiophonol Chir Maxillofac 1973; 22: 165-168
• 12 Castelli G, Vogt E. Der Erfolg einer antifibrinolytischen Behandlung mit Tranexamsäure zur Reduktion des Blutverlustes während und nach Tonsillektomien. Schweiz Med Wochenschr 1977; 107: 780-784
• 13 George A, Kumar R, Kumar S, Shetty S. A randomized control trial to verify the efficacy of pre-operative intra venous tranexamic acid in the control of tonsillectomy bleeding. Indian J. Otolaryngol Head Neck Surg 2011; 63: 20-26
• 14 Brum MR, Miura MS, Castro SF, Machado GM, Lima LH, Lubianca Neto JF. Tranexamic acid in adenotonsillectomy in children: a double-blind randomized clinical trial. Int J Pediatr Otorhinolaryngol 2012; 76: 1401-1405
• 15 Verstraete M. Clinical application of inhibitors of fibrinolysis. Drugs 1985; 29: 236-261
• 16 Overbosch HC, Hart HC. Local application of epsilon-aminocaproic acid (E.A.C.A.) in the prevention of haemorrhage after tonsillectomy. J Laryngol Otol 1970; 84: 905-908
• 17 Falbe-Hansen Jr J, Jacobsen B, Lorenzen E. Local application of an antifibrinolytic in tonsillectomy. A double-blind study. J Laryngol Otol 1974; 88: 565-568
• 18 Carter G, Goss A, Lloyd J, Tocchetti R. Tranexamic acid mouthwash versus autologous fibrin glue in patients taking warfarin undergoing dental extractions: a randomized prospective clinical study. J Oral Maxillofac Surg 2003; 61: 1432-1435
• 19 Abrams J. Die lokale Anwendung von Tranexamsäure in der HNO-Chirurgie. HNO 2012; 60: 1014-1018
• 20 Chan CC, Chan YY, Tanweer F. Systematic review and meta-analysis of the use of tranexamic acid in tonsillectomy. Eur Arch Otorhinolaryngol 2013; 270: 735-748
• 21 Ker K, Edwards P, Perel P, Shakur H, Roberts I. Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. BMJ 2012; 344: e3054
• 22 Günzel T, Zenev E, Heinze N, Schwager K. Tonsillektomienachblutungen im Zeitraum von 1985 bis 2001 und Erfahrungen bei der Anwendung der Lasertonsillotomie bei Kleinkindern. Laryngo-Rhino-Otologie 2004; 83: 579-584
• 23 Windfuhr J, Seehafer M. Classification of haemorrhage following tonsillectomy. J Laryngol Otol 2001; 115: 457-461
• 24 Walner DL, Karas A. Standardization of reporting post-tonsillectomy bleeding. Ann Otol Rhinol Laryngol 2013; 122: 277-282
• 25 Windfuhr JP, Wienke A, Chen YS. Electrosurgery as a risk factor for secondary post-tonsillectomy hemorrhage. Eur Arch Otorhinolaryngol 2009; 266: 111-116
• 26 Lowe D, van der Meulen J. Tonsillectomy technique as a risk factor for postoperative haemorrhage. Lancet 2004; 364: 697-702
• 27 Kim DW, Koo JW, Ahn SH, Ch Lee, Kim JW. Difference of delayed post-tonsillectomy bleeding between children and adults. Auris Nasus Larynx 2010; 37: 456-460
• 28 Windfuhr JP, Deck JC, Krabs C, Sadra R, Remmert S. Coblation-Tonsillektomie. Ergebnisse einer Pilotstudie. HNO 2006; 54: 190-197