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Prophylaktische Anwendung von Tranexamsäure in der nichtkardialen Chirurgie

Update 2017

Prophylactic use of tranexamic acid in noncardiac surgery

Update 2017

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Zusammenfassung

Hintergrund

Die Vermeidung perioperativer Blutungen ist ein zentrales Ziel des „patient blood management“. Ein entsprechender Baustein ist die Hemmung der Fibrinolyse mittels Proteaseinhibitoren, z. B. der Tranexamsäure (TXA). TXA hemmt die Plasminogenaktivierung und somit den Abbau von Fibrin.

Ziele der Arbeit

Der vorliegende Beitrag gibt einen Überblick über die vorhandene Literatur und sich hieraus ergebende Einsatzbereiche von TXA in der Prophylaxe perioperativer Blutungen.

Methoden

Literaturrecherche in PubMed/MEDLINE (U.S. National Library of Medicine®, Bethesda, MD, USA).

Ergebnisse

Randomisierte kontrollierte Studien (RCT) sowie Metaanalysen zeigen, dass TXA den perioperativen Blutverlust und Transfusionsbedarf im Bereich der Hüft- und Knieendoprothetik senkt. Dies gilt für die intravenöse und topische Anwendung. Auch für den Einsatz in der Wirbelsäulenchirurgie und der rekonstruktiven Chirurgie (kindliche Kraniosynostosen) existiert gute Evidenz. Einzelne RCT zeigen einen Nutzen von TXA für abdominale Hysterektomien, die offene Prostatachirurgie, die Tumorchirurgie der Leber und blutende Traumapatienten. Zur Prophylaxe von peripartalen Hämorrhagien (PPH) bei vaginaler Geburt oder Kaiserschnitt wird TXA derzeit nicht generell empfohlen – es existieren jedoch Hinweise auf einen potenziellen Nutzen. Bei aktiver PPH wird der Einsatz empfohlen. Zur prophylaktischen perioperativen Gabe wird für Erwachsene eine Bolusgabe von 1 g bzw. 10–15 mg/kg KG i. v. empfohlen, ggf. wiederholt (nach 6 h) oder ergänzt durch eine Infusion über 8 h. Perioperative Lungenembolien oder tiefe Beinvenenthrombosen treten nach derzeitiger Datenlage nicht gehäuft auf.

Schlussfolgerung

Die prophylaktische Anwendung der TXA unter Beachtung der Kontraindikationen senkt für ausgewählte chirurgische Indikationen den perioperativen Blutverlust sowie den Transfusionsbedarf.

Abstract

Background

Minimising perioperative bleeding is a key goal of “patient blood management” programs. One component of respective strategies includes preventive inhibition of fibrinolysis using protease inhibitors, such as tranexamic acid (TXA). TXA inhibits plasminogen activation and plasmin-induced fibrin degradation.

Objectives

The present article provides an overview of the existing literature and TXA applications in the prophylaxis of perioperative bleeding.

Methods

Literature search in PubMed/MEDLINE (U.S. National Library of Medicine®, Bethesda, MD, USA).

Results

TXA reduces perioperative blood loss and transfusion requirements in several randomized controlled trials (RCTs) and meta-analyses in the field of hip and knee arthroplasty for both intravenous and topical use. Moreover, evidence favours use of TXA in complex spine surgery and reconstructive surgery (e. g. craniosynostosis in children). Single RCTs showed benefits of TXA in abdominal hysterectomy, open prostatectomy, liver surgery and actively bleeding trauma patients. For prophylaxis of peripartum haemorrhage (PPH) following vaginal delivery or Caesarean section, TXA cannot be routinely recommended, although evidence points to benefits in actively bleeding patients. A recommendation exists for the treatment of (active) PPH. For prophylactic perioperative administration, different dosage regimens exist for adults. Most often an initial i. v. bolus of 1 g or 10–15 mg/kg body weight with/without repetition after 6 h or continuous infusions over 8 h is administered. Increased rates of thromboembolic events were not noted.

Conclusion

Protease inhibitors such as TXA reduce perioperative blood loss and transfusion requirements in selected surgical fields.

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  1. Universitätsklinik für Anästhesiologie und Schmerztherapie, Inselspital, Universitätsspital Bern, Universität Bern, 3010, Bern, Schweiz

    J. Waskowski & F. Stueber

  2. Universitätsklinik für Intensivmedizin, Inselspital, Universitätsspital Bern, Universität Bern, 3010, Bern, Schweiz

    J. C. Schefold

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Waskowski, J., Schefold, J.C. & Stueber, F. Prophylaktische Anwendung von Tranexamsäure in der nichtkardialen Chirurgie. Med Klin Intensivmed Notfmed 114, 642–649 (2019). https://doi.org/10.1007/s00063-018-0402-5

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