Die aktuelle S3-Leitlinie zur Prophylaxe der venösen Thromboembolie und ihre Implikation für die Plastische Chirurgie

Zusammenfassung

Evidenzbasierte Leitlinien zur perioperativen Thromboembolieprophylaxe in der Plastischen Chirurgie existieren in Deutschland bislang nicht. Die zunehmende Komplexität mikrochirurgisch-rekonstruktiver Eingriffe und der technische Fortschritt in der Medizin machen die Formulierung einer evidenzbasierten Leitlinie zu diesem Thema jedoch erforderlich, zumalältere Patienten mit Komorbiditäten und hieraus resultierendem erhöhten Thromboembolierisiko zunehmend das Patientengut in der Plastischen Chirurgie widerspiegeln. Aus diesem Grund haben wir die aktuelle S3-Leitlinie zur venösen Thromboembolieprophylaxe der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) mit Stand vom April 2009 auf ihre Relevanz für die plastische Chirurgie geprüft und in körperregionsbezogene Eingriffe unterteilt.

Abstract

Introduction: In Germany, clinically and experimentally proven, evidence-based guidelines for the perioperative prophylaxis of thromboembolism in plastic surgery have not yet been developed. The ever-expanding complexity of microsurgical reconstructive procedures associated with the immense technical progress in the medical field have once more highlighted the urgent need for evidence-based guidelines. Moreover, this urgency is underlined by more and more complex reconstructive procedures needing to be performed in elderly patients presenting with grave comorbidities and the related high risk for thromboembolic events. These facts prompted us to review and discuss the relevance of the updated S3-guidelines on prophylaxis of venous thromboembolic events for the field of plastic and reconstructive surgery[41].

Material and Methods: The existing S3-guidelines represent the result of a consensus between 27 medical societies and organisations. Delegates of the German Society of Plastic, Reconstructive and Aesthetic Surgery (DGPRAEC) also participated in this consensus process and the development of the guidelines, which provide evidence-based and clinically oriented recommendations for the prophylaxis of venous thromboembolism for operative and non-operative as well as outpatient and inpatient settings. In the results section of this paper, general and specific recommendations with regard to plastic and reconstructive surgery are outlined.

Results: Indications for the pharmacological prophylaxis of thromboembolic events are oriented on the specific risk categories for surgical interventions with regard to the dispositional individual risk factors. Furthermore, the recommendations for the field of plastic and reconstructive surgery are subdivided into the various regions of the body.

Discussion: Evidence-based recommendations for perioperative prophylaxis of venous thromboembolism in plastic surgery are not available yet. The establishment of an algorithm to screen and estimate the procedure-associated risks for thromboembolism is needed. The discussed S3-guidelines of the AWMF Society on the prophylaxis of venous thromboembolism meet these formal requirements. Gathering of evidence-based data and the generation of recommendations leading to a reduction of the perioperative risk of thromboembolic events is a pivotal element to improve patient outcomes and safety in microsurgery.

Schlüsselwörter

Heparin - Antikoagulation - Thrombose - Thromboembolie - Plastische Chirurgie

Key words

heparin - anticoagulation - thrombosis - thromboembolism - plastic surgery

Literatur

• 1 Antiplatelet Trialists’ Collaboration. . Collaborative overview of randomised trials of antiplatelet therapy--III: Reduction in venous thrombosis and pulmonary embolism by antiplatelet prophylaxis among surgical and medical patients.  BMJ. 1994;  308 235-246
• 2 Bottaro FJ, Elizondo MC, Doti C. et al . Efficacy of extended thrombo-prophylaxis in major abdominal surgery: What does the evidence show?.  A metaanalysis. Thromb Haemost. 2008;  99 1104-1111
• 3 Bounameaux H, Miron MJ, Blanchard J. et al . Measurement of plasma D-dimer is not useful in the prediction or diagnosis of postoperative deep vein thrombosis in patients undergoing total knee arthroplasty.  Blood Coagul Fibrinolysis. 1998;  9 749-752
• 4 Broughton G, Rios JL, Rohrich RJ. et al . Deep venous thrombosis prophylaxis practice and treatment strategies among plastic surgeons: survey results.  Plast Reconstr Surg. 2007;  119 (1) 157-174
• 5 Caprini JA, Arcelus JI, Reyna JJ. Effective risk stratification of surgical and nonsurgical patients for venous thrombembolic disease.  Semin Hematol. 2001;  38 12
• 6 Chen CM, Disa JJ, Mehrara BJ. The incidence of venous thromboembolism in head and neck reconstruction.  Presented at the 24th Annual Meeting of the Northeastern Society of Plastic Surgeons, Bermuda. October;  3-7 2007
• 7 Davison SP, Venturi ML, Attinger CE. et al . Prevention of venous thromboembolism in the plastic surgery patient.  Plast Reconstr Surg. 2004;  114 43e
• 8 Douketis JD, Eikelboom JW, Quinlan DJ. et al . Short-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of prospective studies investigating symptomatic outcomes.  Arch Intern Med. 2002;  162 1465-1471
• 9 Dries DJ. Activation of the clotting system and complement after trauma.  New Horiz. 1996;  4 276-288
• 10 Dujon DG, Chatzis LA, Hart NB. Thromboembolic prophylaxis in plastic surgery: an appraisal.  Br J Plast Surg. 1992;  45 418-420
• 11 Fecher AM, O’Mara MS, Goldfarb IW. et al . Analysis of deep vein thrombosis in burn patients.  Burns. 2004;  30 591-593
• 12 Geerts WH, Bergqvist D, Pineo GF. et al .Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8^th Edition). Chest. 2008 133: S381-S453
• 13 Geerts WH, Jay RM, Code KI. et al . A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma.  N Engl J Med. 1996;  335 701-707
• 14 Geerts WH, Pineo GF, Heit JA. et al . Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.  Chest. 2004;  126 338S-400S
• 15 Green D. VTE prophylaxis in aesthetic surgery patients.  Aesthet Surg J. 2006 May-Jun;  26 (3) 317-324
• 16 Gutt CN, Oniu T, Wolkener F. et al . Prophylaxis and treatment of deep vein thrombosis in general surgery.  Am J Surg. 2005;  189 14-22
• 17 Harrington DT, Mozingo DW, Cancio L. et al . Thermally injured patients are at significant risk for thromboembolic complications.  J Trauma. 2001;  50 (3) 495-499
• 18 Hatef DA, Kenkel JM, Nguyen MQ. et al . Thromboembolic risk assessment and the efficacy of enoxaparin prophylaxis in excisional body contouring surgery.  Plast Reconstr Surg. 2008;  122 (1) 269-279
• 19 Johnson RL, Hemigton-Gorse SJ, Dhital SK. Do cosmetic surgeons consider estrogen-containing drugs to be of significant risk in the development of thromboembolism?.  Aesth Plast Surg. 2008;  32 743-747
• 20 Kock HJ, Schmit-Neuerburg KP, Hanke J. et al . Thromboprophylaxis with low molecular-weight heparin in outpatients with plaster-cast immobilisation of the leg.  Lancet. 1995;  346 459-461
• 21 Kowal-Vern A, Gamelli RL, Walenga JM. et al . The effect of burn wound size on hemostasis: a correlation of the hemostatic changes to the clinical state.  J Trauma. 1992;  33 50-57
• 22 Lignitz E, Lignitz G, Pueschel K. Todesursache Lungenembolie in der Rechtsmedizin.  Versicherungsmedizin. 1995;  47 203-207
• 23 Lyman S, Sherman S, Carter TI. et al . Prevalence and risk factors for symptomatic thromboembolic events after shoulder arthroplasty.  Clin Orthop Relat Res. 2006;  448 152-156
• 24 Martyn J. Clinical pharmacology and drug therapy in the burned patient.  Anesthesiology. 1986;  65 67-75
• 25 Naess IA, Christiansen SC, Romundstad P. et al . Incidence and mortality of venous thrombosis: a population-based study.  J Thromb Haemost. 2007;  5 692-699
• 26 Nimah M, Brilli RJ. Coagulation dysfunction in sepsis and multiple organ system failure.  Crit Care Clin. 2003;  19 441-458
• 27 Patronella CK, Ruiz-Razura A, Newall G. et al . Thromboembolism in high-risk aesthetic surgery: experience with 17 patients in a review of 3871 consecutive cases.  Aesth Surg J. 2008;  28 (6) 648-655
• 28 Roderick P, Ferris G, Wilson K. et al . Towards evidence-based guidelines for the prevention of venous thromboembolism: systematic reviews of mechanical methods, oral anticoagulation, dextran and regional anaesthesia as thromboprophylaxis.  Health Technol Assess. 2005;  9 1-94
• 29 Rosenkranz S. Lungenembolie und akutes Cor pulmonale.. In: Erdmann: Klinische Kardiologie. 7. Aufl. Berlin, Heidelberg: Springer; 2008: 271-290
• 30 Samama CM, Albaladejo P, Benhamou D. et al . Venous thromboembolism prevention in surgery and obstetrics: clinical practice guidelines.  Eur J Anaesthesiol. 2006;  23 95-116
• 31 Seruya M, Venturi ML, Iorio ML. et al . Efficacy and safety of venous thromboembolism prophylaxis in highest risk plastic surgery patients.  Plast Reconstr Surg. 2008;  122 (6) 1701-1708
• 32 Stein PD, Beemath A, Olson RE. Trends in the incidence of pulmonary embolism and deep venous thrombosis in hospitalized patients.  Am J Cardiol. 2005;  95 1525-1526
• 33 Thesenfitz S. Todesursache Lungenembolie – Eine Analyse der Sektionsprotokolle aus dem Institut für Rechtsmedizin des Universitätsklinikums Hamburg-Eppendorf in dem Zeitraum von 1993 bis einschließlich 2004.. Dissertation, Fachbereich Medizin der Universität Hamburg; 2008
• 34 Trevidic P. National survey of the deep vein thrombosis in plastic and aesthetic surgery, consequences and guidelines.  Ann Chir Plast Esthet. 2006;  51 163-169
• 35 Turpie AG, Bauer KA, Eriksson BI. et al . Fondaparinux vs enoxaparin for the prevention of venous thromboembolism in major orthopedic surgery: a meta-analysis of 4 randomized double-blind studies.  Arch Intern Med. 2002;  162 1833-1840
• 36 Vogt PM, Eichhorn-Sens J. Fettabsaugung – Möglichkeiten und Risiken des populärsten ästhetischen Eingriffs.  Plast Chir. 2002;  2 69-74
• 37 Wahl WL, Brandt MM. Potential risk factors for deep venous thrombosis in burn patients.  J Burn Care Rehabil. 2001;  22 (2) 128-131
• 38 Wahl WL, Brandt MM, Ahrns K. et al . The utility of D-dimer levels in screening for thromboembolic complications in burn patients.  J Burn Care Rehabil. 2002;  23 439-443
• 39 White RH, Zhou H, Murin S. et al . Effect of ethnicity and gender on the incidence of venous thromboembolism in a diverse population in California in 1996.  Thromb Haemost. 2005;  93 298-305
• 40 Wibbenmeyer LA, Hoballah JJ, Amelon MJ. et al . The prevalence of venous thromboembolism of the lower extremity among thermally injured patients determined by duplex sonography.  J Trauma. 2003;  55 1162-1167
• 41 http://www.leitlinie.net/003-001.pdf.

Korrespondenzadresse