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DOI: 10.1055/a-0808-4970
Postoperative Blutung nach thoraxchirurgischen Eingriffen
Postoperative Haemothorax Following Thoracic SurgeryPublication History
Publication Date:
05 February 2019 (online)
Zusammenfassung
Die postoperative Nachblutung nach thoraxchirurgischen Eingriffen ist eine seltene, aber mit einer hohen Mortalität verknüpfte Komplikation. In der Literatur wird die Häufigkeit mit 0,6 – 2% bzw. 3 – 4,6% angegeben bei einer Mortalität von 5,1 bis zu 17,8%. Bei leichten Blutungen kann der Abfluss über die Thoraxdrainagen, Substitution von Gerinnungsprodukten (Fresh frozen Plasma, Tranexamsäure) und die Transfusion von Erythrozytenkonzentraten (EK) ausreichend sein, um diese zu kontrollieren. Bei ausgeprägten Blutungen ist jedoch meist eine Rethorakotomie erforderlich. Die Ursache der Nachblutung liegt meist in einem Bronchial- oder Interkostalgefäß (21 und 16%) oder an der Thoraxwand bei ausgedehnter Pleurolyse (10,5%). Die Pulmonalarterie oder -vene war nur in 16% Ursache der Blutung und in den meisten Fällen (37%) konnte keine aktive Blutungsquelle mehr identifiziert werden. Einen günstigen Effekt auf das postoperative Outcome nach Nachblutung scheint die rasche Revisionsoperation zu haben.
Abstract
Postoperative haemothorax following thoracic surgery is a rare complication, but associated with a high mortality. In the literature, this complication occurs in 0.6 to 4.6% of patients and with a mortality of 5.1 to 17.8%. In minor cases, chest tube placement, application of fresh frozen plasma (FFP) or transfusion can be sufficient to control the situation. In severe cases, re-thoracotomy is mandatory. The most frequent origin of bleeding is a bronchial or intercostal vessel (21 and 16%) or the area of pleural adhesions that were separated (10.5%). The pulmonal artery or vein were the origin of bleeding in 16% of cases while in most cases (37%) active bleeding could no longer be detected. A positive effect on postoperative outcome is observed after an early reoperation.
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Literatur
- 1 Sirbu H, Busch T, Aleksic I. et al. Chest re-exploration for complications after lung surgery. Thorac Cardiovasc Surg 1999; 47: 73-76 doi:10.1055/s-2007-1013114
- 2 Dai W, Yang XJ, Zhuang X. et al. Reoperation for hemostasis within 24 hours can get a better short-term outcome when indicated after lung cancer surgery. J Thorac Dis 2017; 9: 3677-3683 doi:10.21037/jtd.2017.09.85
- 3 Lardinois D, De Leyn P, Van Schil P. et al. ESTS guidelines for intraoperative lymph node staging in non-small cell lung cancer. Eur J Cardiothorac Surg 2006; 30: 787-792 doi:10.1016/j.ejcts.2006.08.008
- 4 Sørensen JB, Badsberg JH. Prognostic factors in resected stages I and II adenocarcinoma of the lung. A multivariate regression analysis of 137 consecutive patients. J Thorac Cardiovasc Surg 1990; 99: 218-226
- 5 Izbicki JR, Thetter O, Habekost M. et al. Radical systematic mediastinal lymphadenectomy in non-small cell lung cancer: a randomized controlled trial. Br J Surg 1994; 81: 229-235
- 6 Lardinois D, Suter H, Hakki H. et al. Morbidity, survival, and site of recurrence after mediastinal lymph-node dissection versus systematic sampling after complete resection for non-small cell lung cancer. Ann Thorac Surg 2005; 80: 268-274 doi:10.1016/j.athoracsur.2005.02.005
- 7 Onaitis MW, Petersen RP, Balderson SS. et al. Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients. Ann Surg 2006; 244: 420-425 doi:10.1097/01.sla.0000234892.79056.63
- 8 McKenna jr. RJ, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg 2006; 81: 421-425 doi:10.1016/j.athoracsur.2005.07.078
- 9 Huth JH, Diwok K. [Intra- and postoperative complications in pulmonary surgery (authorʼs transl)]. Z Erkrank Atmungsorg 1978; 151: 231-238
- 10 Vanʼt Westeinde SC, Horeweg N, De Leyn P. et al. Complications following lung surgery in the Dutch-Belgian randomized lung cancer screening trial. Eur J Cardiothorac Surg 2012; 42: 420-429 doi:10.1093/ejcts/ezs081
- 11 Foroulis CN, Kleontas A, Karatzopoulos A. et al. Early reoperation performed for the management of complications in patients undergoing general thoracic surgical procedures. J Thorac Dis 2014; 6 (Suppl. 01) S21-S31 doi:10.3978/j.issn.2072-1439.2014.02.22
- 12 Hong A, King CS, Brown AW. et al. Hemothorax following lung transplantation: incidence, risk factors, and effect on morbidity and mortality. Multidiscip Respir Med 2016; 11: 40 doi:10.1186/s40248-016-0075-y
- 13 Mahmood K, Shofer SL, Moser BK. et al. Hemorrhagic complications of thoracentesis and small-bore chest tube placement in patients taking clopidogrel. Ann Am Thorac Soc 2014; 11: 73-79 doi:10.1513/AnnalsATS.201303-050OC
- 14 Dammert P, Pratter M, Boujaoude Z. Safety of ultrasound-guided small-bore chest tube insertion in patients on clopidogrel. J Bronchology Interv Pulmonol 2013; 20: 16-20 doi:10.1097/LBR.0b013e31828194f9
- 15 Abouzgheib W, Shweihat YR, Meena N. et al. Is chest tube insertion with ultrasound guidance safe in patients using clopidogrel?. Respirology 2012; 17: 1222-1224 doi:10.1111/j.1440-1843.2012.02230.x
- 16 Cannon CP, Mehta SR, Aranki SF. Balancing the benefit and risk of oral antiplatelet agents in coronary artery bypass surgery. Ann Thorac Surg 2005; 80: 768-779 doi:10.1016/j.athoracsur.2004.09.058
- 17 Cerfolio RJ, Minnich DJ, Bryant AS. General thoracic surgery is safe in patients taking clopidogrel (Plavix). J Thorac Cardiovasc Surg 2010; 140: 970-976 doi:10.1016/j.jtcvs.2010.07.051
- 18 Sziklavari Z, Neu R, Hofmann HS. et al. [Persistent pleural effusion following thoracic surgery]. Chirurg 2015; 86: 432-436 doi:10.1007/s00104-014-2863-2
- 19 Dienemann H. [Postoperative complications in thoracic surgery. Special aspects]. Chirurg 2009; 80: 807-813 doi:10.1007/s00104-009-1688-x
- 20 Ortmann E, Besser MW, Klein AA. Antifibrinolytic agents in current anaesthetic practice. Br J Anaesth 2013; 111: 549-563 doi:10.1093/bja/aet154
- 21 Later AF, Maas JJ, Engbers FH. et al. Tranexamic acid and aprotinin in low- and intermediate-risk cardiac surgery: a non-sponsored, double-blind, randomised, placebo-controlled trial. Eur J Cardiothorac Surg 2009; 36: 322-329 doi:10.1016/j.ejcts.2008.11.038
- 22 Greilich PE, Jessen ME, Satyanarayana N. et al. The effect of epsilon-aminocaproic acid and aprotinin on fibrinolysis and blood loss in patients undergoing primary, isolated coronary artery bypass surgery: a randomized, double-blind, placebo-controlled, noninferiority trial. Anesth Analg 2009; 109: 15-24 doi:10.1213/ane.0b013e3181a40b5d
- 23 Wang G, Xie G, Jiang T. et al. Tranexamic acid reduces blood loss after off-pump coronary surgery: a prospective, randomized, double-blind, placebo-controlled study. Anesth Analg 2012; 115: 239-243 doi:10.1213/ANE.0b013e3182264a11
- 24 Adler Ma SC, Brindle W, Burton G. et al. Tranexamic acid is associated with less blood transfusion in off-pump coronary artery bypass graft surgery: a systematic review and meta-analysis. J Cardiothorac Vasc Anesth 2011; 25: 26-35 doi:10.1053/j.jvca.2010.08.012
- 25 Horrow JC, Van Riper DF, Strong MD. et al. The dose-response relationship of tranexamic acid. Anesthesiology 1995; 82: 383-392
- 26 Hiippala ST, Myllyla GJ, Vahtera EM. Hemostatic factors and replacement of major blood loss with plasma-poor red cell concentrates. Anesth Analg 1995; 81: 360-365
- 27 Chowdary P, Saayman AG, Paulus U. et al. Efficacy of standard dose and 30 ml/kg fresh frozen plasma in correcting laboratory parameters of haemostasis in critically ill patients. Br J Haematol 2004; 125: 69-73
- 28 Fenger-Eriksen C, Jensen TM, Kristensen BS. et al. Fibrinogen substitution improves whole blood clot firmness after dilution with hydroxyethyl starch in bleeding patients undergoing radical cystectomy: a randomized, placebo-controlled clinical trial. J Thromb Haemost 2009; 7: 795-802 doi:10.1111/j.1538-7836.2009.03331.x
- 29 Strasser E. [The new hemotherapy guideline]. Unfallchirurg 2018; 121: 423-428 doi:10.1007/s00113-018-0489-4
- 30 Loscertales J, Quero Valen Zuela F, Congregado M. et al. Video-assisted thoracic surgery lobectomy: results in lung cancer. J Thorac Dis 2010; 2: 29-35
- 31 Yim AP, Ko KM, Chau WS. et al. Video-assisted thoracoscopic anatomic lung resections. The initial Hong Kong experience. Chest 1996; 109: 13-17
- 32 Roviaro G, Varoli F, Vergani C. et al. Video-assisted thoracoscopic major pulmonary resections: technical aspects, personal series of 259 patients, and review of the literature. Surg Endosc 2004; 18: 1551-1558
- 33 Bollen EC, van Duin CJ, Theunissen PH. et al. Mediastinal lymph node dissection in resected lung cancer: morbidity and accuracy of staging. Ann Thorac Surg 1993; 55: 961-966