Thromboseprophylaxe bei chirurgischen und nicht chirurgischen Patienten^[*]

Zusammenfassung

Eine routinemäßige Thromboseprophylaxe ist fester Bestandteil der Versorgung chirurgischer und orthopädischer Patienten und gewinnt bei internistischen Patienten an Bedeutung. Trotzdem sind Fragen zur Indikation, zu Art und Umfang der Prophylaxe sowie zu den Möglichkeiten der Verbesserung offen. Zur Indikationsstellung hat sich eine klinisch orientierte Risikoabschätzung bewährt, die expositionelle und dispositionelle Risikofaktoren berücksichtigt. Das expositionelle Risiko ist durch Art und Umfang des chirurgischen Eingriffs bzw. des Traumas charakterisiert, das dispositionelle Risiko hingegen durch patientenbezogene Faktoren. Dies wird auch in nationalen und internationalen Leitlinien beschrieben. Die Wahl der Prophylaxe resultiert aus der Kombination der expositionellen und dispositionellen Risikofaktoren.

Zur VTE-Prophylaxe stehen physikalische und medikamentöse Maßnahmen zur Verfügung. Die tragenden Säulen der medikamentösen Prophylaxe waren bisher einmal tägliche subkutane Verabreichungen von niedermolekularen Heparinpräparaten oder Fondaparinux. Seit kurzem stehen für Hochrisikopatienten mit elektiven Hüft- oder Kniegelenkersatzoperationen auch orale direkte Thrombin- und Faktor- Xa-Inhibitoren zur Verfügung.

Summary

Prevention of deep vein thrombosis has become standard of care in surgical and orthopaedic patients and it is gaining in attention in medical patients. However, there are still open questions related to its indication, to type and extent of prophylaxis and how to improve its efficacy and safety. In order to facilitate decision making to provide or to withhold prophylaxis, clinical risk assessment considering exposing and predisposing risk factors has proved to be of value. The exposing risk is characterised by type and extent of surgery or trauma, respectively, whereas the predisposing risk is determined by patient related risk factors. This has also been acknowledged in national and international guidelines. The choice of prophylactic modalities should be based on the combination of exposing and predisposing risk factors.

Physical and pharmacological methods are available for primary prevention of VTE. The cornerstones of pharma -cological prophylaxis have been subcutaneous injections of low molecular weight heparins or fondaparinux. Recently, also oral direct thrombin- and factor Xa-inhibitors have become available for patients undergoing hip or knee replacement surgery who always are at high risk for VTE complications .

Schlüsselwörter

Thromboembolieprophylaxe - Risikofaktoren - Heparine - Fondaparinux - Thrombininhibitoren - Faktor-Xa-Inhibitoren

Keywords

Prevention of thromboembolism - risk factors - heparins - fondaparinux - thrombin inhibitors - factor Xa inhibitors

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