Perioperatives Management von Patienten mit gerinnungshemmenden Medikamenten in der Neurochirurgie

Zusammenfassung

Bei Patienten mit pharmakologischer Gerinnungshemmung in der perioperativen Phase handelt es sich um Risikopatienten. Das Management dieser Patienten in Notfallsituationen, z. B. bei ZNS-Blutungen oder SHT, erfordert ein differenziertes und risikoadjustiertes Vorgehen, das eine enge interdisziplinäre Absprache zwingend notwendig macht. Im klinischen Alltag stellt sich daher täglich die Frage nach dem Umgang mit dieser Problematik.

Da kontrollierte Studien nicht vorliegen, ist es notwendig, für jede neurochirurgische Abteilung ein Konzept für eine individualisierte Therapie für den jeweils konkreten Patienten zu erarbeiten. Grundlage für solche Konzepte bilden theoretische Überlegungen vor dem Hintergrund der pharmakologischen Eigenschaften der einzelnen Antikoagulanzien und Plättchenhemmer, die vorliegenden Ergebnisse von Registerstudien und klinische Erfahrungen.

Diese Übersicht versucht die verfügbaren Daten zusammenzutragen und daraus konkrete Vorschläge für den klinischen Alltag zu erarbeiten. Die Vorschläge geben Anhaltspunkte für ein sicheres Vorgehen bei den meisten Patienten in den meisten klinischen Situationen. Die letztlich konkrete Vorgehensweise muss aber vom behandelnden Arzt unter Berücksichtigung aller Umstände bei dem individuellen Patienten festgelegt werden.

Kernaussagen

Bedingt durch Änderungen in der Altersstruktur der Bevölkerung sowie die Zunahme von Begleiterkrankungen ist die Zahl der Patienten, die gerinnungsaktive Medikamente einnehmen und unter elektiven oder Notfallbedingungen operiert werden müssen, angestiegen und wird in den nächsten Jahren noch weiter ansteigen. Die Entwicklung und Zulassung neuer gerinnungshemmender Medikamente führte aufgrund ihrer Wirksamkeit und ihrer geringeren Behandlungskomplikationen zur zunehmenden Verordnung.

Bei Operationen von Patienten mit pharmakologischer Gerinnungshemmung besteht ein erhöhtes Risiko der Nachblutung, die insbesondere bei neurochirurgischen Patienten mit einer hohen Morbidität einhergeht. Das unkritische Absetzen kann ebenfalls schwerwiegende thromboembolische Folgen haben, und die Entscheidung über Fortsetzung oder Beendigung der Therapie bzw. des perioperativen Bridgings bedarf einer sorgfältigen präoperativen Risikoabwägung.

Material und Methoden

Anhand der aktuellen Literatur werden die verschieden Medikamentengruppen dargestellt und deren perioperatives Management bei neurochirurgischen Patienten erläutert. Im Allgemeinen ist die Datenlage relativ schwach, und die Empfehlungen für die Neurochirurgie sind aus anderen Fachgebieten abgeleitet oder beruhen auf Erfahrungswissen.

Schlussfolgerungen

Perioperative Blutungskomplikationen bei neurochirurgischen Patienten sind mit einer hohen Morbidität und unter Umständen Mortalität assoziiert. Die standardisierte Gerinnungsanamnese hilft, Blutungskomplikationen zu vermeiden sowie Patienten mit gerinnungshemmenden Medikamenten zu identifizieren, und hat somit eine besondere Bedeutung.

Das perioperative Management von Patienten mit pharmakologischer Gerinnungshemmung in der Neurochirurgie ist aufgrund der Komplexität (neue Antikoagulanzien, Komorbidität, Alter der Patienten) eine interdisziplinäre Aufgabe, die mit den Kardiologen, Neurologen und Gefäßmedizinern gemeinsam angegangen werden sollte.

Auch wenn hier Möglichkeiten im perioperativen Umgang mit Patienten unter Gerinnungshemmern aufgezeigt werden, muss die Entscheidung nach Abwägen des individuellen Risiko-Nutzen-Verhältnisses getroffen werden. Alle operativ tätigen Neurochirurgen sind im Alltag mit diesen Patienten zunehmend konfrontiert.

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