Perioperative Gerinnungsstörungen, perioperatives Gerinnungsmanagement

Zusammenfassung

Das Management von Problemen der perioperativen Hämostase fängt mit der Anamnese an. Klassische Globaltests (Quick-Test, aPTT) haben keinen prädiktiven Wert hinsichtlich einer erworbenen intra- oder postoperativen Blutungsneigung, neue Assays zur Risikostratifizierung sind in klinischer Entwicklung. Ein wesentliches Qualitätsmerkmal eines guten perioperativen Hämostasemangements ist die frühzeitige interdisziplinäre Beurteilung. Bei Antikoagulation bzw. antithrombozytärer Therapie ist das perioperative Bridging sorgfältig zu planen. Kardiovaskuläre Risikopatienten haben bei Absetzen der antithrombozytären Therapie ein erhöhtes Morbiditäts- und Mortalitätsrisiko. Bei bekannter hämorrhagischer Diathese sollte früh präoperativ eine spezifische Therapie festgelegt werden. Bei intra- und postoperativer Blutungsneigung kann die Point-of-care-Diagnostik zur raschen Beurteilung der Pathologie hilfreich sein. Ein validiertes algorithmisches Vorgehen reduziert den Verbrauch von Blutprodukten. Die Festlegung eines evidenzbasierten Einsatzes von Blutkomponenten und anderer prokoagulanter Substanzen intraoperativ bedarf prospektiver klinischer Studien. Erkenntnisse zur Pathophysiologie (z. B. Quervernetzungsdefekte durch Kolloide, Dilution durch Volumentherapie und bei wiederholtem Einsatz von FFP, Verwendung von Antifibrinolytika, Häufigkeit unerwünschter Wirkungen) sollten berücksichtigt werden.

Summary

Managing perioperative haemostasis starts with the diligently taken patient history. Unfortunately, classic global tests such as the PT and aPTT have no predictive value with regard to an acquired intra- or postoperative bleeding diathesis. However, new assays for preoperative risk stratification are in clinical development. An attribute of good perioperative haemostasis management is the early, multidisciplinary problem assessment. With a preoperatively existing anticoagulation or antiplatelet therapy, perioperative bridging therapy needs to be carefully planned as cardiovascular risk patients have an increased risk of morbidity and mortality when their current anticoagulative therapy is simply stopped. If a haemorrhagic diathesis is known, a specific therapy should be scheduled early preoperatively. When excessive intra- and postoperative bleeding occurs, point of care diagnostics can help to determine the underlying pathophysiology. A predefined validated algorithm reduces the need for blood products. To establish an evidence based approach for the use of blood components and other pro coagulants in such a situation requires prospective clinical trials. The actual knowledge on the pathophysiology of such incidents (e. g. cross linking defects by use of colloids, dilutional effects of volume therapy, repeated use of FFP, of antifibrinolytics, frequency of unwanted effects) should also be considered.

Schlüsselwörter

Hämostase - Operation - Blutung - Thrombozyten - Verbrauch - Dilutionskoagulopathie - Gerinnungsfaktoren

Keywords

Haemostasis - surgery - bleeding - platelets - consumption - dilutional coagulopathy - coagulation factors

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