Patient Blood Management – Der Patient im Krankenhaus

Zusammenfassung

Das multimodale Konzept des Patient Blood Managements tangiert zahlreiche Aspekte der Krankenhausbehandlung eines Patienten. Hauptaugenmerk liegt darauf, patienteneigene Ressourcen zu schonen und zu stärken. Dies kann v.a. durch akribische Minimierung des perioperativen Blutverlusts und den Ausbau und die Ausschöpfung der individuellen Anämietoleranz erreicht werden. Blutprodukte sollen erst nach Optimierung aller anderen Aspekte leitliniengerecht zur Anwendung kommen, um die mit allogenen Bluttransfusionen verbundenen Risiken zu vermeiden. Das vorgeschlagene Maßnahmenbündel besitzt großes Potenzial zur Steigerung der Patientensicherheit!

Abstract

The multimodal concept of Patient Blood Management touches many aspects of in-hospital treatment. The goals are to preserve and strengthen the patients' own resources in order to avoid transfusion-associated adverse events. This can be achieved by meticulous minimization of perioperative blood loss and the enhancement and full utilization of individual anaemia tolerance. The transfusion of allogeneic blood products shall be guideline-based only. The proposed package of measures has immense potential to increase patient safety!

Kernaussagen

• Allogene Bluttransfusionen steigern dosisabhängig Morbidität und Letalität und haben möglicherweise Einfluss auf den Verlauf von Krebserkrankungen.

• Durch Schonung und Stärkung patienteneigener Ressourcen können Situationen umgangen werden, in denen Bluttransfusionen notwendig werden.

• Blutprodukte sind Medikamente mit relevantem Nebenwirkungsspektrum, die leitliniengerecht angewandt werden müssen.

• Die interdisziplinäre Optimierung perioperativer Prozesse erhöht die Qualität der Patientenversorgung und hat das Potenzial, Komplikationsraten und Letalität nachhaltig zu senken.

• Die Steigerung der Patientensicherheit durch Verbesserung der Heilungsverläufe ist das Ziele des Patient Blood Managements!

• Jeder oben genannte Baustein kann einen wichtigen Beitrag leisten, doch summativ hat das vorgeschlagene Maßnahmenbündel den größten Effekt.

Schlüsselwörter:

Patient Blood Management - blood alternatives - Patientensicherheit - Versorgungsforschung - krankenhauserworbene Anämie

Key words:

patient blood management - blood alternatives - patient safety - health services research - hospital-acquired anaemia

• Literaturverzeichnis

• 1 Wang Y, Eldridge N, Metersky M et al. National trends in patient safety for four common conditions, 2005–2011. N Engl J Med 2014; 370: 341-351
• 2 Koch CG, Li L, Sun Z et al. Hospital-acquired anemia: Prevalence, outcomes, and healthcare implications. J Hosp Med 2013; 8: 506-512
• 3 Schlitt A, Jambor C, Spannagl M et al. The perioperative management of treatment with anticoagulants and platelet aggregation inhibitors. Dt Arztebl Int 2013; 110: 525-532
• 4 Siegal D, Yudin J, Kaatz S et al. Periprocedural heparin bridging in patients receiving vitamin K antagonists: systematic review and meta-analysis of bleeding and thromboembolic rates. Circ 2012; 126: 1630-1639
• 5 Camm AJ, Lip GY, De Caterina R et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012; 33: 2719-2747
• 6 Odum LE, Cochran KA, Aistrope DS, Snella KA. The CHADS(2)versus the new CHA2DS2-VASc scoring systems for guiding antithrombotic treatment of patients with atrial fibrillation: review of the literature and recommendations for use. Pharmacotherapy 2012; 32: 285-296
• 7 Trappe HJ. Atrial fibrillation: established and innovative methods of evaluation and treatment. Dt Arztebl Int 2012; 109: 1-7
• 8 Weber CF, Zacharowski K, Brun K et al. Basisalgorithmus für „Point-of-Care“ basierte Hämotherapie. Der Anaesthesist 2013; 62: 464-472
• 9 Schellong SM, Haas S. Perioperative Thromboseprophylaxe – Neue orale Antikoagulanzien und ihre Anwendung im Umfeld operativer Eingriffe. Anasthesiol Intensivmed Notfallmed Schmerzther 2012; 47: 266-272
• 10 Angiolillo DJ, Firstenberg MS, Price MJ et al. Bridging antiplatelet therapy with cangrelor in patients undergoing cardiac surgery: a randomized controlled trial. JAMA 2012; 307: 265-274
• 11 Poldermans D, Bax JJ, Boersma E et al. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Eur Heart J 2009; 30: 2769-2812
• 12 Bechstein WO, Strey C. Möglichkeiten der lokalen und systemischen Blutstillung bei chirurgischen Eingriffen. Der Chirurg 2007; 78: 95-100
• 13 Choi WS, Samman N. Risks and benefits of deliberate hypotension in anaesthesia: a systematic review. Int J Oral Maxillofac Surg 2008; 37: 687-703
• 14 Ashworth A, Klein AA. Cell salvage as part of a blood conservation strategy in anaesthesia. Br J Anaesth 2010; 105: 401-416
• 15 Bundesärztekammer Hrsg. Querschnitts-Leitlinien zur Therapie mit Blutkomponenten und Plasmaderivaten. 4. Aufl. Köln: Deutscher Ärzte-Verlag; 2009
• 16 Pape A, Kertscho H, Stein P et al. Neuromuscular blockade with rocuronium bromide increases the tolerance of acute normovolemic anemia in anesthetized pigs. European Surgical Research 2012; 48: 16-25
• 17 Polderman KH. Mechanisms of action, physiological effects, and complications of hypothermia. Crit Care Med 2009; 37 (Suppl. 07) 186-202
• 18 S3-Leitlinie "Vermeidung von ungeplanter perioperativer Hypothermie". http://www.awmf.org/leitlinien/detail/anmeldung/1/ll/001-018.html
• 19 Dietrich W, Faraoni D, von Heymann C et al. ESA guidelines on the management of severe perioperative bleeding: Comments on behalf of the Subcommittee on Transfusion and Haemostasis of the European Association of Cardiothoracic Anaesthesiologists. Eur J Anaesthesiol 2014; 31: 239-41
• 20 Weber CF, Gorlinger K, Meininger D et al. Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology 2012; 117: 531-547
• 21 Bollinger DTK. Roles of Thrombelastography and Thromboelastometry for Patient Blood Management in Cardiac Surgery. Transf Med Rev 2013; 27: 213-220
• 22 CRASH-2 trial collaborators. Shakur H, Roberts I, Bautista R et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; 376: 23-32
• 23 http://www.ains24.de/haemostase/downloads/bleedcard.pdf
• 24 Statistische Bundesamt. Verbrauch von Blutprodukten durch Transfusionen. http://www.gbe-bund.de
• 25 Hourfar MK, Jork C, Schottstedt V et al. Experience of German Red Cross blood donor services with nucleic acid testing: results of screening more than 30 million blood donations for human immunodeficiency virus-1, hepatitis C virus, and hepatitis B virus. Transfusion 2008; 48: 1558-1566
• 26 Vamvakas EC. Reasons for moving toward a patient-centric paradigm of clinical transfusion medicine practice. Transfusion 2013; 53: 888-901
• 27 Ferraris VA, Davenport DL, Saha SP et al. Surgical outcomes and transfusion of minimal amounts of blood in the operating room. Arch Surg 2012; 147: 49-55
• 28 Lee JS, Gladwin MT. Bad blood: the risks of red cell storage. Nat Med 2010; 16: 381-382
• 29 Cata JP, Wang H, Gottumukkala V et al. Inflammatory response, immunosuppression, and cancer recurrence after perioperative blood transfusions. Br J Anaesth 2013; 110: 690-701
• 30 Acheson AG, Brookes MJ, Spahn DR. Effects of allogeneic red blood cell transfusions on clinical outcomes in patients undergoing colorectal cancer surgery: a systematic review and meta-analysis. Ann Surg 2012; 256: 235-244
• 31 Loor G, Rajeswaran J, Li L et al. The least of 3 evils: Exposure to red blood cell transfusion, anemia, or both?. J Thorac Cardiovasc Surg 2013; 146
• 32 Carson JL, Carless PA, Hebert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev CD 002042 2012; 4
• 33 Hamm CW, Bassand JP, Agewall S et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011; 32: 2999-3054
• 34 Nguyen BV, Bota DP, Melot C, Vincent JL. Time course of hemoglobin concentrations in nonbleeding intensive care unit patients. Crit Care Med 2003; 31: 406-410
• 35 Harber CR, Sosnowski KJ, Hegde RM. Highly conservative phlebotomy in adult intensive care – a prospective randomized controlled trial. Anaesth Intensive Care 2006; 34: 434-437
• 36 Sanchez-Giron F, Alvarez-Mora F. Reduction of blood loss from laboratory testing in hospitalized adult patients using small-volume (pediatric) tubes. Arch Pathol Lab Med 2008; 132: 1916-1919
• 37 Frasca D, Dahyot-Fizelier C, Catherine K et al. Accuracy of a continuous noninvasive hemoglobin monitor in intensive care unit patients. Crit Care Med 2011; 39: 2277-2282
• 38 O'Reilly M. Understanding noninvasive and continuous hemoglobin monitoring. Crit Care Med 2013; 41
• 39 National Blood Authority, Australia. Patient blood management guidelines. http://www.nba.gov.au/guidelines/review.html