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DOI: 10.1055/s-0031-1291317
Perioperatives Gerinnungsmanagement in der Mikrochirurgie – Bericht der Konsensus-Workshops im Rahmen der 31. und 32. Jahrestagung der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße (DAM) im November 2009 in Erlangen und November 2010 in Basel
Perioperative Coagulation Management in Microsurgery – Report of the Consensus Workshops in the Course of the 31st and 32nd Annual Meeting of the German-language Working Group for Microsurgery of the Peripheral Nerves and Vessels (DAM) November 2009 in Erlangen and November 2010 in BaselPublication History
eingereicht 17 April 2011
akzeptiert 06 October 2011
Publication Date:
17 November 2011 (online)
![](https://www.thieme-connect.de/media/hamipla/201106/lookinside/thumbnails/10.1055-s-0031-1291317-1.jpg)
Zusammenfassung
Die Mikrochirurgie ist ein zunehmend wichtiger Bestandteil der rekonstruktiven Chirurgie. In diesem Zusammenhang gewinnt die Antikoagulation immer mehr an Bedeutung. Bis dato gibt es keinerlei Studien oder allgemeingültige Regimes, die als evidenzbasierte Leitlinie zur antithrombotischen Prophylaxe in der Mikrochirurgie dienen. Während der Jahrestagungen der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie (DAM) 2009 und 2010 wurde im Rahmen von interdisziplinär besetzten Workshops ein erster Konsensus der deutschsprachigen Mikrochirurgen in der Plastischen Chirurgie angestrebt. Dieser Artikel fasst die besprochenen Aspekte als Zwischenbericht der Entwicklung eines allgemeingültigen Antikoagulationsregimes zusammen. Grundsätzlich werden auf der Basis der aktuellen Literatur verschiedene Empfehlungen und Erfahrungsberichte zu 3 Hauptfaktoren der Thromboseprophylaxe zusammengefasst: Heparingabe, Verwendung von Kolloidallösungen und Plättchenaggregationshemmung. Im Rahmen der Workshops wurde keine Empfehlung für die allgemeine Gabe des Plättchenaggregationshemmers Acetylsalicylsäure zur Thromboseprophylaxe ausgesprochen. Auch die Gabe von Kolloiden (z. B. HES 6%/Dextran) wurde aufgrund fehlender Evidenz und der Gefahr erheblicher Nebenwirkungen nicht als Routineverfahren empfohlen. Die Antikoagulation sollte nach derzeitigem Konsensus in erster Linie mit Heparin erfolgen. Dabei sind niedermolekulare Heparine (NMH) dem unfraktionierten Heparin (UFH) überlegen. Lediglich bei Revisionsfällen, Niereninsuffizienz und in seltenen Konstellationen im Rahmen der Rekonstruktion der unteren Extremität wurde von der Mehrzahl der Teilnehmer die PTT-gesteuerte intravenöse kontinuierliche Antikoagulation mit UFH als sinnvoll erachtet. Zum Zeitpunkt der Anastomosenfreigabe erscheint eine single-shot Dosis UFH in ausgewählten Fällen weiterhin empfehlenswert, wenngleich dies nicht in allen Zentren durchgeführt wird und diesbezüglich keine evidenzbasierte Studienlage besteht. Zukünftige prospektive Studien zu diesem Thema sind genauso erfoderlich wie letztendlich die Entwicklung einer allgemeingültigen evidenzbasierten Leitlinie zum perioperativen Gerinnungsmanagement in der Mikrochirurgie.
Abstract
Microsurgery is a very relevant component of reconstructive surgery. In this context anticoagulation plays an increasing role. At the moment there are no unanimously accepted prospective studies or generally accepted regimes available that could serve as evidence-based guidelines for the prevention of thrombosis in microsurgery. With regard to this problem the aim of a series of workshops during the annual meetings of the German-speaking group for microsurgery in 2009 and 2010 was to establish a first possible consensus. This article reflects the main aspects of the ongoing development of a generally acceptable guideline for anticoagulation in microsurgery as interim report of these consensus workshops. Basically there are 3 main agents in thromboprophylaxis available: antiplatelet drugs, dextran and heparin. In the course of the workshops no general use of aspirin or dextran for anticoagulation in microsurgery was recommended. The use of heparin as anticoagulation agent is advisable for different indications. Low molecular heparins (LMH) have certain advantages in comparison to unfractionated heparins (UFH) and are therefore preferred by most participants. Indications for UFH are still complex microsurgical revisions, renal failure and some specific constellations in patients undergoing reconstruction of the lower extremity, where the continuous administration of heparin is recommended. At the moment of clamp release a single-shot of UFH is still given by many microsurgeons, despite a lack of scientific evidence. Future prospective clinical trials and the establishment of a generally accepted evidence-based guideline regarding anticoagulation treatment in microsurgery are deemed necessary.
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