Präinterventionelles Hämostasemanagement – Risikoevaluation und therapeutische Konsequenzen

Zusammenfassung

Hämostasestörungen können das periinterventionelle Blutungs- und Thromboserisiko erhöhen. Zur Eingriffsvorbereitung gehört deswegen eine Risikoevaluation, um potenzielle Risikopatienten zu erkennen und gezielte therapeutische Maßnahmen einzuleiten. Das entscheidende Element der Risikoevaluation ist die Blutungs- und Thromboseanamnese. Eine unauffällige Anamnese macht das Vorliegen einer Hämostasestörung unwahrscheinlich. In diesen Fällen wird keine zusätzliche Gerinnungsanalytik empfohlen. Ergibt die Anamnese einen Hinweis auf ein erhöhtes Blutungs- oder Thromboserisiko, wird eine differenzierte laboranalytische Abklärung empfohlen. In Abhängigkeit vom Ergebnis kann durch spezifische Therapiemaßnahmen oder allgemeine hämostyptische Maßnahmen das Blutungsrisiko gesenkt werden. Im Fall eines erhöhten Thromboserisikos kann eine forcierte antithrombotische Therapie die übliche Thromboseprophylaxe ergänzen. Ein besonderes Risikokollektiv bilden Patienten, die mit Antikoagulanzien oder Thrombozytenfunktionshemmern behandelt werden. Diese iatrogenen Risikopatienten erfordern ein Hämostasemanagement, das es ermöglicht, das eingriffsassoziierte Blutungsrisiko zu senken, ohne das Thromboserisiko überproportional zu steigern.

Abstract

Coagulation disorders may predispose patients to an increased risk of haemorrhage or thrombosis during diagnostic or therapeutic interventions. Pre-interventional haemostatic assessment is therefore recommended in order to identify potential high-risk patients and to introduce targeted therapeutic interventions. A detailed patient interview to determine any personal or family history of haemorrhagic diathesis plays a central role in determining the perioperative bleeding risk. Patients with no history of haemorrhagic complications are at low risk for peri-interventional haemorrhage and should not undergo routine pre-interventional haemostasis testing. Patients showing a positive history should undergo a detailed haemostasis testing and should receive appropriate medical and surgical treatment. Patients with an increased risk of thrombosis should receive an intensified antithrombotic prophylaxis. Patients treated with antithrombotic agents are at high risk of peri-interventional haemorrhage and require a haemostatic management that lowers the risk of bleeding without increasing the risk of thrombosis significantly.

Schlüsselwörter

präinterventionelles Screening - Blutungsrisiko - präinterventionelles Management - Screening-Tests - Risikoevaluation

Key words

preinterventional assessment - bleeding risk - preinterventional management - screening tests - risk evaluation

• Literatur

• 1 Krishna P, Lee D. Post-tonsillectomy bleeding: a meta-analysis. Laryngoscope 2001; 111: 1358-1361
• 2 Keay L et al. Routine preoperative medical testing for cataract surgery. Cochrane Database Syst Rev 2009; (2) CD007293
• 3 Lind SE. The bleeding time does not predict surgical bleeding. Blood 1991; 77: 2547-2552
• 4 Munro J et al. Routine preoperative testing: a systematic review of the evidence. Health Technol Assess 1997; 1: 1-62
• 5 Eckman MH et al. Screening for the risk for bleeding or thrombosis. Ann Intern Med 2003; 138: W15-W24
• 6 Chee YL, Greaves M. Role of coagulation testing in predicting bleeding risk. Hematol J 2003; 4: 373-378
• 7 Harrison P. The role of PFA-100 testing in the investigation and management of haemostatic defects in children and adults. Br J Haematol 2005; 130: 3-10
• 8 Segal JB, Dzik WH. Transfusion Medicine/Hemostasis Clinical Trials Network. Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence- based review. Transfusion 2005; 45: 1413-1425
• 9 Wahlberg T et al. Application of indicators, predictors and diagnostic indices in coagulation disorders. I. Evaluation of a self-administered questionnaire with binary questions. Methods Inf Med 1980; 19: 194-200
• 10 Blery C et al. Evaluation of a protocol for selective ordering of preoperative tests. Lancet 1986; 1: 139-141
• 11 Gorman M et al. Preoperative prediction of hyphemas. Ophthalmic Surg 1986; 17: 490-492
• 12 Janvier G et al. Value of the activated partial thromboplastin time for preoperative detection of coagulation disorders not revealed by a specific questionnaire. Anesthesiology 1991; 75: 920-921
• 13 Nosek-Cenkowska B et al. Bleeding/bruising symptomatology in children with and without bleeding disorders. Thromb Haemost 1991; 65: 237-241
• 14 Macpherson CR et al. Abnormal peri-operative haemorrhage in asymptomatic patients is not predicted by laboratory testing. S Afr Med J 1993; 83: 106-108
• 15 Houry S et al. A prospective multicenter evaluation of preoperative hemostatic screening tests. The French Associations for Surgical Research. Am J Surg 1995; 170: 19-23
• 16 Gabriel P et al. Relationship between clinical history, coagulation tests, and perioperative bleeding during tonsillectomies in pediatrics. J Clin Anesth 2000; 12: 288-291
• 17 Biss TT et al. Use of a quantitative pediatric bleeding questionnaire to assess mucocutaneous bleeding symptoms in children with a platelet function disorder. J Thromb Haemost 2010; 8: 1416-1419
• 18 Barber A et al. The bleeding time as a preoperative screening test. Am J Med 1985; 78: 761-764
• 19 Licameli GR et al. Use of a preoperative bleeding questionnaire in pediatric patients who undergo adenotonsillectomy. Otolaryngol Head Neck Surg 2008; 139: 546-550
• 20 Koscielny J et al. A practical concept for preoperative identification of patients with impaired primary hemostasis. Clin Appl Thromb Hemost 2004; 10: 195-204
• 21 Eika C et al. The value of preoperative haemostatic screening. Scand J Haematol 1978; 21: 349-354
• 22 Rohrer MJ et al. A prospective evaluation of the efficacy of preoperative coagulation testing. Ann Surg 1988; 208: 554-557
• 23 Gewirtz AS, Miller ML, Keys TF. The clinical usefulness of the preoperative bleeding time. Arch Pathol Lab Med 1996; 120: 353-356
• 24 Burk CD et al. Preoperative history and coagulation screening in children undergoing tonsillectomy. Pediatrics 1992; 89: 691-695
• 25 Kang J et al. Coagulation profile as a predictor for post-tonsillectomy and adenoidectomy (T + A) hemorrhage. Int J Pediatr Otorhinolaryngol 1994; 28: 157-165
• 26 Watel A et al. [Successes and failures of the activated partial thromboplastin time in the preoperative evaluation]. Ann Fr Anesth Reanim 1986; 5: 35-39
• 27 McKee RF, Scott EM. The value of routine preoperative investigations. Ann R Coll Surg Engl 1987; 69: 160-162
• 28 Johnson H et al. Are routine preoperative laboratory screening tests necessary to evaluate ambulatory surgical patients?. Surgery 1988; 104: 639-645
• 29 Close HL et al. Hemostatic assessment of patients before tonsillectomy: a prospective study. Otolaryngol Head Neck Surg 1994; 111: 733-738
• 30 Darcy MD et al. Evaluation of coagulation tests as predictors of angiographic bleeding complications. Radiology 1996; 198: 741-744
• 31 Simon L et al. Pre-anaesthetic assessment of coagulation abnormalities in obstetric patients: usefulness, timing and clinical implications. Br J Anaesth 1997; 78: 678-683
• 32 Suchman AL, Mushlin AI. How well does the activated partial thromboplastin time predict postoperative hemorrhage?. JAMA 1986; 256: 750-753
• 33 Manning SC. Re: Coagulation profile as a predictor for post-tonsillectomy and adenoidectomy (T + A) hemorrhage. Int J Pediatr Otorhinolaryngol 1995; 32: 261-263
• 34 Erban SB et al. Routine use of the prothrombin and partial thromboplastin times. JAMA 1989; 262: 2428-2432
• 35 Myssiorek D, Alvi A. Post-tonsillectomy hemorrhage: an assessment of risk factors. Int J Pediatr Otorhinolaryngol 1996; 37: 35-43
• 36 Ng KFJ et al. Value of preoperative coagulation tests: reappraisal of major noncardiac surgery. World J Surg 2002; 26: 515-520
• 37 Cariappa R et al. Comparison of PFA-100 and bleeding time testing in pediatric patients with suspected hemorrhagic problems. J Pediatr Hematol Oncol 2003; 25: 474-479
• 38 Roschitz B et al. PFA-100 closure times in preoperative screening in 500 pediatric patients. Thromb Haemost 2007; 98: 243-247
• 39 Bonhomme F et al. for the French anaesthetic and intensive care committee on evaluation of routine preoperative testing. Pre-interventional haemostatic assessment: Guidelines from the French Society of Anaesthesia and Intensive Care. Eur J Anaesthesiol 2013; Feb 21. [Epub ahead of print]
• 40 Schein OD et al. The value of routine preoperative medical testing before cataract surgery. Study of medical testing for cataract surgery. N Engl J Med 2000; 342: 168-175
• 41 American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice advisory for preanesthesia evaluation: a report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2002; 96: 485-496
• 42 Chee YL et al. Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. British Committee for Standards in Haematology. Br J Haematol 2008; 140: 496-504
• 43 Cosmi B et al. Assessment of the risk of bleeding in patients undergoing surgery or invasive procedures: Guidelines of the Italian Society for Haemostasis and Thrombosis (SISET). Thrombosis Research 2009; 124: e6-e12
• 44 Mannucci PM et al. Recessively inherited coagulation disorders. Blood 2004; 104: 1243-1252
• 45 Oldenburg J et al. Angeborener Faktorenmangel. In: Pötzsch B, Madlener K, Hrsg. Hämostaseologie – Grundlagen, Diagnostik, Therapie. Berlin: Springer; 2010: 335-345
• 46 Sadler JE et al. Impact, diagnosis and treatment of von Willebrand disease. Thromb Haemost 2000; 84: 160-174
• 47 Paolo F et al. Blood loss, predictors of bleeding, transfusion practice and strategies of blood cell salvaging during liver transplantation. World J Hepatol 2013; 5: 1-15
• 48 Eerenberg ES et al. Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate – a randomized, placebo-controlled, crossover study in healthy subjects. Circulation 2011; 124: 1573-1579