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Empfehlungen für die Anwendung konventioneller und neuer Antithrombotika aus anästhesiologischer Sicht

Recommendations for the administration of conventional and new antithrombotic agents from the perspective of anesthesiology

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Zusammenfassung

Rückenmarknahe Regionalanästhesien weisen in der postoperativen Schmerztherapie erhebliche Vorteile für Patienten auf, die Analgesiequalität wird verbessert, die Rate an respiratorischen Komplikationen und die Dauer des postoperativen Ileus werden gesenkt. Bei Patienten mit unfallchirurgischen Eingriffen wird in der Regel aufgrund der effektiven Schmerztherapie eine verbesserte Mobilisierbarkeit beobachtet. Bei rückenmarknahen Regionalanästhesien ist die schwerwiegendste Komplikation ein spinales epidurales Hämatom mit dem Risiko der bleibenden Querschnittslähmung. Dieses Risiko wird durch den gleichzeitigen Einsatz von Antithrombotika erhöht. Aus diesem Grund wurden in nationalen Empfehlungen Zeitintervalle zwischen der Gabe von Antithrombotika und einer rückenmarknahen Punktion anhand der Pharmakokinetik und -dynamik entwickelt, um das Risiko einzugrenzen. Aus anästhesiologischer Sicht ist es zum Einhalten von Zeitintervallen hilfreich, wenn die medikamentöse Thromboembolieprophylaxe möglichst erst postoperativ erfolgt, einheitlich am Abend verabreicht und die Anzahl der eingesetzten Substanzen begrenzt gehalten wird. Die Sicherheit rückenmarknaher Regionalanästhesien beim oralen Antithrombotikum Rivaroxaban kann aufgrund der limitierten Datenlage nicht abschließend beurteilt werden, Dabigatran gilt nach Herstellerinformationen bei Epiduralanästhesien als kontraindiziert.

Abstract

Neuraxial blockade confers benefits to surgical patients not only due to the high analgesic quality but also through a reduction in postoperative complications, such as respiratory insufficiency and a shortening of postoperative paralytic ileus. In orthopedic surgery peripheral and neuraxial blockades are extensively used to enhance postoperative mobilization. The most serious complication of neuraxial blockade is spinal epidural hematoma, which may lead to permanent paraplegia if left untreated. The risk is enhanced in patients receiving thromboembolism prophylaxis. Most national societies have issued guidelines with specific time intervals between application of antithrombotic drugs and subsequent neuraxial blockade to minimize this risk. From the viewpoint of an anesthesiologist it is preferable to start with chemical thromboembolism prophylaxis postoperatively as opposed to preoperatively, to administer all drugs in the evening and to limit the number of available drugs at each site. The safety of neuraxial blockade in the presence of the new oral anticoagulant rivaroxaban is currently unknown due to limited experience and dabigatran is considered contraindicated with indwelling epidural catheters according to the manufacturer.

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Interessenkonflikt

Die korrespondierende Autorin weist auf folgende Beziehungen hin: Aufwandsentschädigungen für Berater- oder Vortragstätigkeit, Tätigkeit in einem wissenschaftlichen Beirat oder Teilnahme an Studien von folgenden Industrieunternehmen erhalten: Bayer Healthcare, Boehringer-Ingelheim, GlaxoSmithKline, Bristol Myer Squibb.

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Authors and Affiliations

  1. Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Klinikum Harlaching, Städtisches Klinikum München GmbH, Sanatoriumsplatz 2, 81545, München, Deutschland

    W. Gogarten & K. Hoffmann

  2. Klinik und Poliklinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Münster, Münster, Deutschland

    H. Van Aken

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  1. W. Gogarten
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  3. H. Van Aken
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Correspondence to W. Gogarten.

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Gogarten, W., Hoffmann, K. & Van Aken, H. Empfehlungen für die Anwendung konventioneller und neuer Antithrombotika aus anästhesiologischer Sicht. Unfallchirurg 113, 908–914 (2010). https://doi.org/10.1007/s00113-010-1881-x

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