Zusammenfassung
Die neuen oralen Antikoagulanzien (NOAK) hemmen direkt den Faktor Xa (Stuart-Prower-Faktor) oder den Faktor IIa (Thrombin). Sie werden zur Thromboseprophylaxe bei elektivem Hüft- oder Kniegelenkersatz, zur Therapie der tiefen Venenthrombose und zur Schlaganfallprophylaxe bei Vorhofflimmern als Behandlungsalternative zu den Vitamin-K-Antagonisten eingesetzt. Patienten mit langfristiger NOAK-Einnahme stellen alle Beteiligten in der perioperativen Phase vor medizinisch-logistische Herausforderungen. Bei geplanten Operationen ist zur individuellen Festlegung der perioperativen hämostaseologischen Strategie, insbesondere des optimalen Operationszeitpunkts, die frühzeitige Vorstellung der Patienten beim Anästhesisten zu fordern. Die zeitliche Dringlichkeit bei „Notoperationen“ muss interdisziplinär gegen das Blutungsrisiko unter NOAK abgewogen werden. Die Bestimmung der Medikamentenspiegel erlaubt hierbei eine Abschätzung der aktuellen Antikoagulation. Ursächlich koagulopathisch bedingte Blutungsnotfälle werden mit Blutprodukten und Gerinnungsfaktorenkonzentraten unspezifisch therapiert.
Abstract
New oral anticoagulants (NOAC) inhibit factor Xa (Stuart-Prower factor) or factor IIa (thrombin) and are alternatives to vitamin K antagonists. Perioperative indications are deep vein thrombosis prophylaxis for prosthetic hip and knee replacement, therapeutic anticoagulation for deep vein thrombosis as well as the prophylaxis of stroke for patients with atrial fibrillation. Patients on NOACs pose multiple perioperative challenges for all medical disciplines involved. For non-emergency surgery, patients should be evaluated by an anesthesiolgist as early as possible to assess an optimal appointment for surgery and bridging strategy. Management of emergency procedures for patients on NOACs requires an interdisciplinary approach. The individual risk for uncontrolled bleeding versus the urgency for surgery needs to be evaluated on an individual basis. The determination of drug serum levels enables a rough estimation of anticoagulant activity. Emergency procedures in coagulopathy due to active bleeding are treated with the unspecific administration of blood products and coagulation factor concentrates.
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Interessenkonflikt. K. Gürtler: Vortrag für Bayer zum Thema Thromboseprophylaxe mit Rivaroxaban. A. Giebl gibt an, dass kein Interessenkonflikt besteht. Der Beitrag enthält keine Studien an Menschen oder Tieren.
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Giebl, A., Gürtler, K. Neue orale Antikoagulanzien in der perioperativen Medizin. Anaesthesist 63, 347–364 (2014). https://doi.org/10.1007/s00101-014-2314-y
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DOI: https://doi.org/10.1007/s00101-014-2314-y