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Zeitschrift für Herz-,Thorax- und Gefäßchirurgie
Erschienen in: Zeitschrift für Herz-,Thorax- und Gefäßchirurgie 4/2017

17.07.2017 | Direkte orale Antikoagulanzien | CME

Patient Blood Management in der Herzchirurgie

verfasst von: Prof. Dr. P. Meybohm, R. M. Muellenbach, H. Keller, S. Fichtlscherer, N. Papadopoulos, D. R. Spahn, A. Greinacher, K. Zacharowski

Erschienen in: Zeitschrift für Herz-,Thorax- und Gefäßchirurgie | Ausgabe 4/2017

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Zusammenfassung

Patient Blood Management (PBM) ist ein patientenzentriertes und multidisziplinäres Konzept mit der Zielsetzung, eine Anämie zu vermeiden oder zu therapieren, die Hämostase zu optimieren, den iatrogenen Blutverlust zu minimieren und die Toleranz einer Anämie medizinisch sinnvoll auszunutzen. Der vorliegende CME-Beitrag geht auf besondere Herausforderungen im Bereich der Herzchirurgie ein, u. a. auf das Management der präoperativen Anämie, das präoperative Management von oralen Antikoagulanzien und Thrombozytenaggregationshemmern, das Management der intra- und der postoperativen Koagulopathie, die Vermeidung unnötiger Blutverluste sowie vermeidbare Transfusionen allogener Blutprodukte.
Literatur
1.
2.
Rohde JM, Dimcheff DE, Blumberg N et al (2014) Health care-associated infection after red blood cell transfusion: a systematic review and meta-analysis. JAMA 311:1317–1326PubMedPubMedCentralCrossRef
3.
4.
5.
AABB (2014) Standards for a patient blood management program
6.
7.
8.
9.
10.
11.
12.
Spahn DR, Moch H, Hofmann A et al (2008) Patient blood management: the pragmatic solution for the problems with blood transfusions. Anesthesiology 109:951–953PubMedCrossRef
13.
Goodnough LT, Maggio P, Hadhazy E et al (2014) Restrictive blood transfusion practices are associated with improved patient outcomes. Transfusion 54:2753–2759PubMedCrossRef
14.
Goodnough LT, Shieh L, Hadhazy E et al (2014) Improved blood utilization using real-time clinical decision support. Transfusion 54:1358–1365PubMedCrossRef
15.
Gross I, Seifert B, Hofmann A et al (2015) Patient blood management in cardiac surgery results in fewer transfusions and better outcome. Transfusion 55:1075–1081PubMedCrossRef
16.
Leahy MF, Roberts H, Mukhtar SA et al (2014) A pragmatic approach to embedding patient blood management in a tertiary hospital. Transfusion 54:1133–1145PubMedCrossRef
17.
Moskowitz DM, McCullough JN, Shander A et al (2010) The impact of blood conservation on outcomes in cardiac surgery: Is it safe and effective? Ann Thorac Surg 90:451–458PubMedCrossRef
18.
Oliver JC, Griffin RL, Hannon T et al (2014) The success of our patient blood management program depended on an institution-wide change in transfusion practices. Transfusion 54:2617–2624PubMedCrossRef
19.
Roubinian NH, Escobar GJ, Liu V et al (2014) Trends in red blood cell transfusion and 30-day mortality among hospitalized patients. Transfusion 54:2678–2686PubMedPubMedCentralCrossRef
20.
Theusinger OM, Kind SL, Seifert B et al (2014) Patient blood management in orthopaedic surgery: a four-year follow-up of transfusion requirements and blood loss from 2008 to 2011 at the Balgrist University Hospital in Zurich, Switzerland. Blood Transfus 12:195–203PubMedPubMedCentral
21.
Leahy MF, Hofmann A, Towler S et al (2017) Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: a retrospective observational study in four major adult tertiary-care hospitals. Transfusion 57(6):1347–1358PubMedCrossRef
22.
Honemann C, Bierbaum M, Heidler J et al (2013) Costs of delivering allogenic blood in hospitals. Chirurg 84:426–432PubMedCrossRef
23.
Trentino KM, Farmer SL, Swain SG et al (2015) Increased hospital costs associated with red blood cell transfusion. Transfusion 55:1082–1089PubMedCrossRef
24.
Froessler B, Palm P, Weber I et al (2016) The important role for intravenous iron in perioperative patient blood management in major abdominal surgery: a randomized controlled trial. Ann Surg 264:41–46PubMedPubMedCentralCrossRef
25.
Mehra T, Seifert B, Bravo-Reiter S et al (2015) Implementation of a patient blood management monitoring and feedback program significantly reduces transfusions and costs. Transfusion 55:2807–2815PubMedCrossRef
26.
Fischer DP, Zacharowski KD, Muller MM et al (2015) Patient blood management implementation strategies and their effect on physicians’ risk perception, clinical knowledge and perioperative practice – the Frankfurt experience. Transfus Med Hemother 42:91–97PubMedPubMedCentralCrossRef
27.
Mbanya D (2012) Barriers and enablers to introducing comprehensive patient blood management in the hospital. Biologicals 40:205–208PubMedCrossRef
28.
Munoz M, Gomez-Ramirez S, Kozek-Langeneker S et al (2015) „Fit to fly“: overcoming barriers to preoperative haemoglobin optimization in surgical patientsdagger. Br J Anaesth 115:15–24PubMedCrossRef
29.
Vamvakas EC (2013) Reasons for moving toward a patient-centric paradigm of clinical transfusion medicine practice. Transfusion 53:888–901PubMedCrossRef
30.
31.
Meybohm P, Richards T, Isbister J et al (2017) Patient blood management bundles to facilitate implementation. Transfus Med Rev 31:62–71PubMedCrossRef
32.
Kulier A, Levin J, Moser R et al (2007) Impact of preoperative anemia on outcome in patients undergoing coronary artery bypass graft surgery. Circulation 116:471–479PubMedCrossRef
33.
Loor G, Rajeswaran J, Li L et al (2013) The least of 3 evils: exposure to red blood cell transfusion, anemia, or both? J Thorac Cardiovasc Surg 146(6):1480–1487.e6PubMedCrossRef
34.
von Heymann C, Kaufner L, Sander M et al (2016) Does the severity of preoperative anemia or blood transfusion have a stronger impact on long-term survival after cardiac surgery? J Thorac Cardiovasc Surg 152:1412–1420CrossRef
35.
Basora M, Colomina MJ, Tio M et al (2013) Optimizing preoperative haemoglobin with intravenous iron. Br J Anaesth 110:488–490PubMedCrossRef
36.
Goodnough LT, Maniatis A, Earnshaw P et al (2011) Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth 106:13–22PubMedPubMedCentralCrossRef
37.
38.
Spivak JL, Gascon P, Ludwig H (2009) Anemia management in oncology and hematology. Oncologist 14(Suppl 1):43–56PubMedCrossRef
39.
Theusinger OM, Leyvraz PF, Schanz U et al (2007) Treatment of iron deficiency anemia in orthopedic surgery with intravenous iron: efficacy and limits: a prospective study. Anesthesiology 107:923–927PubMedCrossRef
40.
Munoz M, Gomez-Ramirez S, Cuenca J et al (2014) Very-short-term perioperative intravenous iron administration and postoperative outcome in major orthopedic surgery: a pooled analysis of observational data from 2547 patients. Transfusion 54:289–299PubMed
41.
Na HS, Shin SY, Hwang JY et al (2011) Effects of intravenous iron combined with low-dose recombinant human erythropoietin on transfusion requirements in iron-deficient patients undergoing bilateral total knee replacement arthroplasty. Transfusion 51:118–124PubMedCrossRef
42.
Weltert L, Rondinelli B, Bello R et al (2015) A single dose of erythropoietin reduces perioperative transfusions in cardiac surgery: results of a prospective single-blind randomized controlled trial. Transfusion 55:1644–1654PubMedCrossRef
43.
Yoo YC, Shim JK, Kim JC et al (2011) Effect of single recombinant human erythropoietin injection on transfusion requirements in preoperatively anemic patients undergoing valvular heart surgery. Anesthesiology 115:929–937PubMedCrossRef
44.
45.
46.
47.
48.
49.
Retter A, Wyncoll D, Pearse R et al (2013) Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients. Br J Haematol 160:445–464PubMedCrossRef
50.
51.
Avni T, Bieber A, Grossman A et al (2015) The safety of intravenous iron preparations: systematic review and meta-analysis. Mayo Clin Proc 90:12–23PubMedCrossRef
52.
Geiser P (2009) The pharmacology and safety profile of ferric carboxymaltose (Ferinject®): structure/reactivity relationships of iron preparations. Port J Nephrol Hypert 23:11–16
53.
Gasche C, Berstad A, Befrits R et al (2007) Guidelines on the diagnosis and management of iron deficiency and anemia in inflammatory bowel diseases. Inflamm Bowel Dis 13:1545–1553PubMedCrossRef
54.
Society of Thoracic Surgeons Blood Conservation Guideline Task F, Ferraris VA, Brown JR et al (2011) 2011 Update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 91:944–982CrossRef
55.
56.
Kristensen SD, Knuuti J, Saraste A et al (2014) 2014 ESC/ESA guidelines on non-cardiac surgery: cardiovascular assessment and management: the Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur J Anaesthesiol 35(35):2383–2431. doi:10.​1093/​eurheartj/​ehu282
57.
Giebl A, Gurtler K (2014) New oral anticoagulants in perioperative medicine. Anaesthesist 63:347–362 (quiz 363–364)PubMedCrossRef
58.
Von Heymann C, Kaufner L, Korber M (2014) Perioperative management and therapy of bleeding complications. Anasthesiol Intensivmed Notfallmed Schmerzther 49:196–204 (quiz 205)CrossRef
59.
Arzneimittelkommission der deutschen Ärzteschaft (AkdÄ) (2016) Orale Antikoagulation bei nicht valvulärem Vorhofflimmern – Empfehlungen zum Einsatz der direkten oralen Antikoagulanzien Dabigatran (Pradaxa®), Apixaban (Eliquis®), Edoxaban (Lixiana®) und Rivaroxaban (Xarelto®), 2. Aufl., S 1–52
60.
Gomez-Outes A, Suarez-Gea ML, Lecumberri R et al (2015) Direct-acting oral anticoagulants: pharmacology, indications, management, and future perspectives. Eur J Haematol 95:389–404PubMedCrossRef
61.
Mar PL, Familtsev D, Ezekowitz MD et al (2016) Periprocedural management of anticoagulation in patients taking novel oral anticoagulants: review of the literature and recommendations for specific populations and procedures. Int J Cardiol 202:578–585PubMedCrossRef
62.
Roffi M, Patrono C, Collet JP et al (2016) 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 37:267–315PubMedCrossRef
63.
Amour J, Garnier M, Szymezak J et al (2016) Prospective observational study of the effect of dual antiplatelet therapy with tranexamic acid treatment on platelet function and bleeding after cardiac surgery. Br J Anaesth 117:749–757PubMedCrossRef
64.
Kong R, Trimmings A, Hutchinson N et al (2015) Consensus recommendations for using the Multiplate((R)) for platelet function monitoring before cardiac surgery. Int J Lab Hematol 37:143–147PubMedCrossRef
65.
Petricevic M, Kopjar T, Biocina B et al (2015) The predictive value of platelet function point-of-care tests for postoperative blood loss and transfusion in routine cardiac surgery: a systematic review. Thorac Cardiovasc Surg 63:2–20PubMed
66.
Windecker S, Kolh P et al (2014) 2014 ESC/EACTS guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 35:2541–2619PubMedCrossRef
67.
Angiolillo DJ, Firstenberg MS, Price MJ et al (2012) Bridging antiplatelet therapy with cangrelor in patients undergoing cardiac surgery: a randomized controlled trial. JAMA 307:265–274PubMedPubMedCentralCrossRef
68.
Thiele T, Sumnig A, Hron G et al (2012) Platelet transfusion for reversal of dual antiplatelet therapy in patients requiring urgent surgery: a pilot study. J Thromb Haemost 10:968–971PubMedCrossRef
69.
Vorstand der Bundesärztekammer auf Empfehlung des wissenschaftlichen Beirats (2014) Querschnitts-Leitlinien (BÄK) zur Therapie mit Blutkomponenten und Plasmaderivaten, 4. Aufl.
70.
Koch CG, Reineks EZ, Tang AS et al (2015) Contemporary bloodletting in cardiac surgical care. Ann Thorac Surg 99:779–784PubMedCrossRef
71.
Branco BC, Inaba K, Doughty R et al (2012) The increasing burden of phlebotomy in the development of anaemia and need for blood transfusion amongst trauma patients. Injury 43:78–83PubMedCrossRef
72.
Lasocki S, Krauspe R, von Heymann C et al (2015) PREPARE: the prevalence of perioperative anaemia and need for patient blood management in elective orthopaedic surgery: a multicentre, observational study. Eur J Anaesthesiol 32:160–167PubMedCrossRef
73.
Sanchez-Giron F, Alvarez-Mora F (2008) Reduction of blood loss from laboratory testing in hospitalized adult patients using small-volume (pediatric) tubes. Arch Pathol Lab Med 132:1916–1919PubMed
74.
Hiscock R, Simmons S, Carstensen B et al (2014) Comparison of Massimo Pronto-7 and HemoCue Hb 201+ with laboratory haemoglobin estimation: a clinical study. Anaesth Intensive Care 42:608–613PubMed
75.
Meybohm P, von Heymann C, Kleinerüschkamp A, Weber C (2015) Patient Blood Management auf der Intensivstation. DIVI 6:158–164
76.
Meybohm P, Choorapoikayil S, Wessels A et al (2016) Washed cell salvage in surgical patients: a review and meta-analysis of prospective randomized trials under PRISMA. Medicine (Baltimore) 95:e4490CrossRef
77.
Varghese R, Myers ML (2010) Blood conservation in cardiac surgery: let’s get restrictive. Semin Thorac Cardiovasc Surg 22:121–126PubMedCrossRef
78.
Kozek-Langenecker SA, Afshari A, Albaladejo P et al (2013) Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 30:270–382PubMedCrossRef
79.
Myles PS, Smith JA, Forbes A et al (2017) Tranexamic acid in patients undergoing coronary-artery surgery. N Engl J Med 376:136–148PubMedCrossRef
80.
81.
Gorlinger K, Shore-Lesserson L, Dirkmann D et al (2013) Management of hemorrhage in cardiothoracic surgery. J Cardiothorac Vasc Anesth 27:S20–S34PubMedCrossRef
82.
Rahe-Meyer N, Solomon C, Hanke A et al (2013) Effects of fibrinogen concentrate as first-line therapy during major aortic replacement surgery: a randomized, placebo-controlled trial. Anesthesiology 118:40–50PubMedCrossRef
83.
Bilecen S, De Groot JA, Kalkman CJ et al (2017) Effect of fibrinogen concentrate on Intraoperative blood loss among patients with intraoperative bleeding during high-risk cardiac surgery: a randomized clinical trial. JAMA 317:738–747PubMedCrossRef
84.
Weber CF, Gorlinger K, Meininger D et al (2012) Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology 117:531–547PubMedCrossRef
85.
Corredor C, Wasowicz M, Karkouti K et al (2015) The role of point-of-care platelet function testing in predicting postoperative bleeding following cardiac surgery: a systematic review and meta-analysis. Anaesthesia 70:715–731PubMedCrossRef
86.
Wikkelso A, Wetterslev J, Moller AM et al (2016) Thromboelastography (TEG) or thromboelastometry (ROTEM) to monitor haemostatic treatment versus usual care in adults or children with bleeding. Cochrane Database Syst Rev. doi:10.​1002/​14651858.​cd007871.​pub3 PubMed
87.
Lazarus MG, Smul TM, Roewer N et al (2014) Coagulation disorders in the context of cardiac surgery – clinical basics and mechanism based therapy. Anasthesiol Intensivmed Notfallmed Schmerzther 49:50–57 (quiz 58)PubMedCrossRef
88.
Desborough MJ, Oakland KA, Landoni G et al (2017) Desmopressin for treatment of platelet dysfunction and reversal of antiplatelet agents: a systematic review and meta-analysis of randomized controlled trials. J Thromb Haemost 15:263–272PubMedCrossRef
89.
Bilgin YM, Van De Watering LM, Versteegh MI et al (2011) Postoperative complications associated with transfusion of platelets and plasma in cardiac surgery. Transfusion 51:2603–2610PubMedCrossRef
90.
Aubron C, Flint AW, Bailey M et al (2017) Is platelet transfusion associated with hospital-acquired infections in critically ill patients? Crit Care 21:2PubMedPubMedCentralCrossRef
91.
92.
Khadzhynov D, Wagner F, Formella S et al (2013) Effective elimination of dabigatran by haemodialysis. A phase I single-centre study in patients with end-stage renal disease. Thromb Haemost 109:596–605PubMedCrossRef
93.
Denino WF, Carter CB, Sievert A et al (2016) The effect of ultrafiltration with cardiopulmonary bypass on the removal of dabigatran from the circulation of adult pigs. Perfusion 31:424–430PubMedCrossRef
94.
Habler O, Meier J, Pape A et al (2006) Tolerance to perioperative anemia. Mechanisms, influencing factors and limits. Anaesthesist 55:1142–1156PubMedCrossRef
95.
Acheson AG, Brookes MJ, Spahn DR (2012) Effects of allogeneic red blood cell transfusions on clinical outcomes in patients undergoing colorectal cancer surgery: a systematic review and meta-analysis. Ann Surg 256:235–244PubMedCrossRef
96.
Bernard AC, Davenport DL, Chang PK et al (2009) Intraoperative transfusion of 1 U to 2 U packed red blood cells is associated with increased 30-day mortality, surgical-site infection, pneumonia, and sepsis in general surgery patients. J Am Coll Surg 208:931–937PubMedCrossRef
97.
Glance LG, Dick AW, Mukamel DB et al (2011) Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology 114:283–292PubMedCrossRef
98.
Murphy GJ, Reeves BC, Rogers CA et al (2007) Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation 116:2544–2552PubMedCrossRef
99.
Paone G, Likosky DS, Brewer R et al (2014) Transfusion of 1 and 2 units of red blood cells is associated with increased morbidity and mortality. Ann Thorac Surg 97:87–93 (discussion 93–84)PubMedCrossRef
100.
101.
Carson JL, Terrin ML, Noveck H et al (2011) Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med 365:2453–2462PubMedPubMedCentralCrossRef
102.
Hebert PC, Wells G, Blajchman MA et al (1999) A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion requirements in critical care investigators, Canadian critical care trials group. N Engl J Med 340:409–417PubMedCrossRef
103.
Holst LB, Haase N, Wetterslev J et al (2014) Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med 371:1381–1391PubMedCrossRef
104.
Murphy GJ, Pike K, Rogers CA et al (2015) Liberal or restrictive transfusion after cardiac surgery. N Engl J Med 372:997–1008PubMedCrossRef
105.
Robertson CS, Hannay HJ, Yamal JM et al (2014) Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury: a randomized clinical trial. JAMA 312:36–47PubMedPubMedCentralCrossRef
106.
Villanueva C, Colomo A, Bosch A et al (2013) Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 368:11–21PubMedCrossRef
107.
American Society of Anesthesiologists Task Force on Perioperative Blood Management (2015) Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists task force on perioperative blood management. Anesthesiology 122:241–275CrossRef
108.
Carson JL, Grossman BJ, Kleinman S et al (2012) Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med 157:49–58PubMedCrossRef
Metadaten
Titel
Patient Blood Management in der Herzchirurgie
verfasst von
Prof. Dr. P. Meybohm
R. M. Muellenbach
H. Keller
S. Fichtlscherer
N. Papadopoulos
D. R. Spahn
A. Greinacher
K. Zacharowski
Publikationsdatum
17.07.2017
Verlag
Springer Medizin
Erschienen in
Zeitschrift für Herz-,Thorax- und Gefäßchirurgie / Ausgabe 4/2017
Print ISSN: 0930-9225
Elektronische ISSN: 1435-1277
DOI
https://doi.org/10.1007/s00398-017-0168-8

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