Moderne Anästhesieverfahren unter Antikoagulation

Zusammenfassung

Die Möglichkeiten der medikamentösen Antikoagulation werden vielfältiger. Anästhesisten und Schmerztherapeuten werden mit Patienten konfrontiert, die im Rahmen einer koronaren Herzkrankheit, nach zerebralem Insult oder bei peripheren Gefäßerkrankungen mit hochwirksamen Antikoagulanzien und/oder neuen Thrombozytenfunktionshemmern behandelt werden. Gerade diese Patienten profitieren bei kardiochirurgischen Eingriffen, desobliterierenden Gefäßoperationen oder Amputationen von einem rückenmarksnahen, regionalanästhesiologischen Verfahren. Der Anästhesist muss Pharmakologie, Indikationen und unerwünschte Arzneimittelwirkungen der gerinnungswirksamen Medikamente kennen und zur Vermeidung von Blutungskomplikationen in das Behandlungskonzept integrieren. In dieser Übersicht werden Grundlagen der Gerinnung, Wirkorte der modernen Antikoagulanzien und österreichische Standards zur Durchführung von modernen zentralen und peripheren Blockaden unter antithrombotischer Medikation dargestellt. Auch bei Allgemeinanästhesien ist die präoperative Evaluation hinsichtlich bestehender Antikoagulanzientherapie von großer Bedeutung, da davon Maßnahmen des perioperativen Gerinnungsmanagements abzuleiten sind. Zur Vermeidung von Blutungskomplikationen bei antithrombotisch behandelten Patienten werden Empfehlungen zu folgenden Fragestellungen gegeben: Einhaltung von Zeitintervallen zwischen der Verabreichung der gerinnungshemmenden Medikation und einer Punktion bzw. Katheterentfernung oder Allgemeinanästhesie / Operation; Wahl des lokoregionalanästhesiologischen Verfahrens und intraoperativen Gerinnungstests; Reversierung der Gerinnungshemmung in Akutsituationen.

Summary

The variety of possibilities for medicamentous anticoagulation is constantly growing. Anesthesiologists and pain therapists are confronted with patients being treated with highly effective anticoagulatory or new antiaggregatory substances due to coronary heart disease, stroke or peripheral arterial disease. Especially these patients benefit from neuraxial blockades when undergoing cardiac surgery, revascularization surgery or amputations. The anaesthesiologist needs an overview concerning pharmacology, indications and side-effects of the anti- and procoagulatory substances and has to integrate this knowledge in the treatment concept to prevent haemorrhagic complications.

This review depicts basics of coagulation, sites of action of currently applied anticoagulants and Austrian standards for performing modern central and peripheral nerve blocks under anticoagulatory medication. In general anaesthesia, too, the preoperative evaluation of preexisting anticoagulatory therapy is of high significance concerning the derivation of procedures for perioperative coagulation management. To prevent haemorrhagic complications in patients treated with anticoagulatory agents, recommendations concerning the following questions are given: time intervals between the application of anticoagulatory substances and punction, removal of catheters or general anaesthesia and operation; the choice and perfomance of the locoregional anaesthesiologic method and intraoperative coagulation analysis method; reversion of anticoagulation in acute situations.

Schlüsselwörter

Allgemeinanästhesie - Antikoagulation - Blutung - Gerinnung - Lokoregionalanästhesie

Keywords

Anticoagulation - bleeding - coagulation - general anaesthesia - locoregional anaesthesia

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