Patient Blood Management (Teil 2) – Praktisches Vorgehen: die 3 Säulen

Zusammenfassung

Patient Blood Management (PBM) ist ein multidisziplinäres, evidenzbasiertes Behandlungskonzept mit dem Ziel, das endogene Blutvolumen von Patienten weitgehend zu bewahren und – wo angezeigt – zu verbessern. PBM basiert auf 3 sich ergänzenden Säulen: erstens der Optimierung des (präoperativen) Erythrozytenvolumens, zweitens der Minimierung des diagnostischen, interventionellen und operativen Blutverlusts und drittens der Ausnützung und Unterstützung der individuellen, physiologischen Anämietoleranz bei strenger Indikationsstellung zur Bluttransfusion. Die Anwendung von PBM reduziert demnach systematisch den Einfluss von 3 Faktoren, die den Krankheitsverlauf negativ beeinflussen können: Anämie, Blutverlust und Transfusion. PBM ist besonders bei Patienten mit erhöhtem Anämie- und Transfusionsrisiko angezeigt und sorgt für individualisierte Behandlungsstrategien. Dadurch werden nicht nur diese Risiken reduziert, sondern auch Versorgungsengpässe verringert und stark steigende Kosten in Verbindung mit Transfusionen eingespart.

Abstract

Patient blood management (PBM) is a patient-specific multidisciplinary, multimodal, evidence-based concept to appropriately conserve and manage a patient's own blood as a vital resource. PBM is based on 3 pillars: the first is the optimization of the patient's endogenous red cell mass, the second is the minimization of bleeding and blood loss and the third involves harnessing and optimizing the patient-specific physiological tolerance of anemia, including adopting more restrictive transfusion thresholds. PBM primarily identifies patients at risk of transfusion and provides a management plan aimed at reducing or eliminating the need for allogeneic transfusion, thus reducing the inherent risks, inventory pressures and the escalating costs associated with transfusion. PBM is applicable to surgical and medical patients. The application of PBM systematically reduces the impact of 3 major contributors to negative outcome: anemia, blood loss and transfusion.

Kernaussagen

• Vor elektiven Eingriffen mit signifikantem Blutverlust werden über 90 % aller präoperativen Anämien nicht behandelt. Die Folge ist eine 3–4-fach höhere Transfusionrate.

• Patienten sollten mindestens 3–4 Wochen vor der Operation der Anästhesieambulanz vorgestellt werden, um Risikofaktoren wie eine päoperative Anämie zu identifizieren und entsprechend zu behandeln.

• Zur Optimierung des Erythrozytenvolumens (1. Säule) können präoperativ der Eisenstatus mit Eisen i. v. optimiert und der Hämoglobinspiegel mit Erythropoetin (POE) angehoben werden (unter Berücksichtigung aller Kontraindikationen).

• Der Blutverlust kann durch folgende Methoden reduziert werden: geeignete Anästhesieverfahren und chirurgische Techniken, Retransfusion von Wundblut sowie optimales Gerinnungsmanagement.

• Wenn keine akute Blutung besteht, entbehrt die immer wieder geübte Transfusion von 2 Erythrozytenkonzentraten jeder Grundlage. Vielmehr sollte nach jeder einzelnen Transfusion die Indikation zur Bluttransfusion erneut überprüft werden.

Schlüsselwörter:

Anämie - Transfusion - Blutverlust - präoperativ - Erythropoetin - Eisen - Patient Blood Management

Key words:

anemia - transfusion - blood loss - erythropoetin - iron - patient blood management

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