Advertisement

Der Chirurg

, Volume 89, Issue 2, pp 90–94 | Cite as

Perioperativer Umgang mit Thrombozytenaggregationshemmern

  • J. Wagner
  • J. F. Lock
  • V. Luber
  • U. A. Dietz
  • S. Lichthardt
  • N. Matthes
  • K. Krajinovic
  • C.-T. Germer
  • S. Knop
  • A. Wiegering
Leitthema
  • 878 Downloads

Zusammenfassung

Pro Jahr werden in Deutschland ca. 16 Mio. operative Eingriffe durchgeführt. Eine nicht unerhebliche Anzahl an Patienten nehmen Thrombozytenaggregationshemmer als Primär- oder Sekundärprophylaxe ein, um das Risiko kardiovaskulärer Ereignisse zu reduzieren. Besonders in der perioperativen Phase ist diese Risikoreduktion relevant, da perioperative Myokardinfarkte in bis zu 6,2 % der Operationen festgestellt wurden. Andererseits wird aufgrund des mutmaßlich erhöhten Blutungsrisikos die Einnahme der Thrombozytenaggregationshemmer perioperativ häufig pausiert. Im klinischen Alltag ist der operativ tätige Arzt mit der Frage konfrontiert, ob diese Medikation perioperativ fortgeführt werden kann oder pausiert werden sollte und wenn ja, mit welchem Risiko. Ist die Indikation zur Acetylsalicylsäure(ASS)-Therapie die Primärprophylaxe, so kann die Einnahme perioperativ pausiert werden, wohingegen ASS, welches im Rahmen der Sekundärprophylaxe eingenommen wird, nur bei Operationen in engen Räumen pausiert werden sollte. Wichtig ist es, beim Absetzen auf einen ausreichenden Abstand zur Operation und dem „ASS-withdrawal-Syndrom“ mit erhöhter Koagulationsneigung zu achten. Des Weiteren ist der perioperative Umgang mit einer dualen Plättchenaggregationshemmung, die nach Koronarstentimplantation notwendig ist, zu beachten. Aufgrund des erhöhten Risikos einer In-Stent-Thrombose wird die duale Plättchenaggregationshemmung ungerne pausiert. Kann eine Operation nicht verschoben werden, so muss im Notfall unter der dualen Plättchenaggregationshemmung operiert werden. Ist jedoch das operative Blutungsrisiko hoch und das Risiko einer In-Stent-Thrombose vergleichsweise gering, so sollte der P2Y12-Inhibitor (z. B. Clopidogrel) pausiert und die Operation unter ASS-Monotherapie durchgeführt werden.

Schlüsselwörter

Dauermediaktion Duale Plättchenaggregationshemmmung Thrombozytenfunktionsmessung Perioperatives Blutungsrisiko Acetylsalicylsäure-withdrawal-Syndrom 

The use of platelet aggregation inhibitors in the perioperative period

Abstract

Every year 16 million operations are performed in Germany. Many patients take platelet aggregation inhibitors as a primary or secondary prevention to reduce the risk of cardiovascular events. Especially during the perioperative period, this risk reduction is relevant due to an increased risk for cardiac events (in approximately 6.2% of operations). As a result of a presumed increased risk of bleeding, platelet aggregation inhibitors are often paused perioperatively. Thus, doctors must decide on a risk-adapted basis whether the medication can be continued perioperatively and, if so, with what risks. If acetylsalicylic acid (ASA) treatment is solely used as primary prevention it can be paused during the perioperative period, whereas ASA treatment for secondary prevention should only be paused for operations within narrow confines. When pausing ASA, a sufficient time interval should be maintained before the operation. Furthermore, the ASA withdrawal syndrome with an increased predisposition for clotting is an important phenomenon to be considered. Additionally, the perioperative handling of dual platelet aggregation inhibition needed after coronary stent implantation should be addressed. Due to an increased risk for in-stent thrombosis, dual platelet aggregation inhibition is only reluctantly paused. Emergency surgery must, if not otherwise possible, be carried out even if the dual platelet aggregation inhibition is not paused; however, if the risk for intraoperative bleeding is too high and the risk of an in-stent thrombosis is lower in comparison, P2Y12 inhibitors (e.g. clopidogrel) should be paused and the operation carried out solely with ASA therapy.

Keywords

Chronic medication Dual platelet aggregation inhibitors Platelet function measurement Perioperative bleeding risk Acetylsalicylic acid withdrawal syndrome 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

J. Wagner, J.F. Lock, V. Luber, U.A. Dietz, S. Lichthardt, N. Matthes, K. Krajinovic, C.‑T. Germer, S. Knop und A. Wiegering geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Literatur

  1. 1.
    Oscarsson A, Gupta A, Fredrikson M, Jarhult J, Nystrom M, Pettersson E, Darvish B, Krook H, Swahn E, Eintrei C (2010) To continue or discontinue aspirin in the perioperative period: a randomized, controlled clinical trial. Br J Anaesth.  https://doi.org/10.1093/bja/aeq003 PubMedGoogle Scholar
  2. 2.
    Devereaux PJ, Mrkobrada M, Sessler DI, Leslie K, Alonso-Coello P, Kurz A, Villar JC, Sigamani A, Biccard BM, Meyhoff CS, Parlow JL, Guyatt G, Robinson A, Garg AX, Rodseth RN, Botto F, Lurati Buse G, Xavier D, Chan MTV, Tiboni M, Cook D, Kumar PA, Forget P, Malaga G, Fleischmann E, Amir M, Eikelboom J, Mizera R, Torres D, Wang CY, VanHelder T, Paniagua P, Berwanger O, Srinathan S, Graham M, Pasin L, Le Manach Y, Gao P, Pogue J, Whitlock R, Lamy A, Kearon C, Baigent C, Chow C, Pettit S, Chrolavicius S, Yusuf S (2014) Aspirin in patients undergoing noncardiac surgery. N Engl J Med.  https://doi.org/10.1056/NEJMoa1401105 Google Scholar
  3. 3.
    Duceppe E, Mrkobrada M, Thomas S, Devereaux PJ (2015) Role of aspirin for prevention and treatment of perioperative cardiovascular events. J Thromb Haemost.  https://doi.org/10.1111/jth.12975 PubMedGoogle Scholar
  4. 4.
    Ryan A, Saad T, Kirwan C, Keegan DJ, Acheson RW (2013) Maintenance of perioperative antiplatelet and anticoagulant therapy for vitreoretinal surgery. Clin Exp Ophthalmol.  https://doi.org/10.1111/ceo.12017 Google Scholar
  5. 5.
    Park HJ, Kwon KY, Woo JH (2014) Comparison of blood loss according to use of aspirin in lumbar fusion patients. Eur Spine J.  https://doi.org/10.1007/s00586-014-3294-y Google Scholar
  6. 6.
    Kang SB, Cho KJ, Moon KH, Jung JH, Jung SJ (2011) Does low-dose aspirin increase blood loss after spinal fusion surgery? Spine J.  https://doi.org/10.1016/j.spinee.2011.02.006 Google Scholar
  7. 7.
    Barequet IS, Sachs D, Shenkman B, Priel A, Wasserzug Y, Budnik I, Moisseiev J, Salomon O (2011) Risk assessment of simple phacoemulsification in patients on combined anticoagulant and antiplatelet therapy. J Cataract Refract Surg.  https://doi.org/10.1016/j.jcrs.2011.02.035 PubMedGoogle Scholar
  8. 8.
    Jacob M, Smedira N, Blackstone E, Williams S, Cho L (2011) Effect of timing of chronic preoperative aspirin discontinuation on morbidity and mortality in coronary artery bypass surgery. Circulation.  https://doi.org/10.1161/CIRCULATIONAHA.110.957373 PubMedGoogle Scholar
  9. 9.
    Mantz J, Samama CM, Tubach F, Devereaux PJ, Collet JP, Albaladejo P, Cholley B, Nizard R, Barre J, Piriou V, Poirier N, Mignon A, Schlumberger S, Longrois D, Aubrun F, Farese ME, Ravaud P, Steg PG (2011) Impact of preoperative maintenance or interruption of aspirin on thrombotic and bleeding events after elective non-cardiac surgery: the multicentre, randomized, blinded, placebo-controlled, STRATAGEM trial. Br J Anaesth.  https://doi.org/10.1093/bja/aer274 PubMedGoogle Scholar
  10. 10.
    Alghamdi AA, Moussa F, Fremes SE (2007) Does the use of preoperative aspirin increase the risk of bleeding in patients undergoing coronary artery bypass grafting surgery? Systematic review and meta-analysis. J Card Surg.  https://doi.org/10.1111/j.1540-8191.2007.00402.x PubMedGoogle Scholar
  11. 11.
    Yang JK, Jimenez JC, Jabori S (2014) Antiplatelet therapy before, during, and after extremity revascularization. J Vasc Surg.  https://doi.org/10.1016/j.jvs.2014.07.006 PubMedCentralGoogle Scholar
  12. 12.
    Marzouk K, Lawen J, Kiberd BA (2013) Blood transfusion in deceased donor kidney transplantation. Transplant Res.  https://doi.org/10.1186/2047-1440-2-4 Google Scholar
  13. 13.
    Wolf AM, Pucci MJ, Gabale SD, McIntyre CA, Irizarry AM, Kennedy EP, Rosato EL, Lavu H, Winter JM, Yeo CJ (2014) Safety of perioperative aspirin therapy in pancreatic operations. Surgery.  https://doi.org/10.1016/j.surg.2013.05.031 PubMedGoogle Scholar
  14. 14.
    Culkin DJ, Exaire EJ, Green D, Soloway MS, Gross AJ, Desai MR, White JR, Lightner DJ (2014) Anticoagulation and antiplatelet therapy in urological practice: ICUD/AUA review paper. J Urol.  https://doi.org/10.1016/j.juro.2014.04.103 PubMedGoogle Scholar
  15. 15.
    Meier R, Marthy R, Saely CH, Kuster MS, Giesinger K, Rickli H (2016) Comparison of preoperative continuation and discontinuation of aspirin in patients undergoing total hip or knee arthroplasty. Eur J Orthop Surg Traumatol.  https://doi.org/10.1007/s00590-016-1830-7 PubMedGoogle Scholar
  16. 16.
    Kristensen SD, Knuuti J, Saraste A, Anker S, Botker HE, de Hert S, Ford I, Gonzalez Juanatey JR, Gorenek B, Heyndrickx GR, Hoeft A, Huber K, Iung B, Kjeldsen KP, Longrois D, Luescher TF, Pierard L, Pocock S, Price S, Roffi M, Sirnes PA, Uva MS, Voudris V, Funck-Brentano C (2014) 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur J Anaesthesiol.  https://doi.org/10.1097/EJA.0000000000000150 Google Scholar
  17. 17.
    Korte W, Cattaneo M, Chassot P‑G, Eichinger S, von Heymann C, Hofmann N, Rickli H, Spannagl M, Ziegler B, Verheugt F, Huber K (2011) Peri-operative management of antiplatelet therapy in patients with coronary artery disease: joint position paper by members of the working group on Perioperative Haemostasis of the Society on Thrombosis and Haemostasis Research (GTH), the working group on Perioperative Coagulation of the Austrian Society for Anesthesiology, Resuscitation and Intensive Care (OGARI) and the Working Group Thrombosis of the European Society for Cardiology (ESC). Thromb Haemost.  https://doi.org/10.1160/TH10-04-0217 Google Scholar
  18. 18.
    Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S, Neumann F‑J, Ardissino D, de Servi S, Murphy SA, Riesmeyer J, Weerakkody G, Gibson CM, Antman EM (2007) Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med.  https://doi.org/10.1056/NEJMoa0706482 PubMedGoogle Scholar
  19. 19.
    Soo CGKM, Torre DPK, Yolland TJ, Shatwell MA (2016) Clopidogrel and hip fractures, is it safe? A systematic review and meta-analysis. Bmc Musculoskelet Disord.  https://doi.org/10.1186/s12891-016-0988-9 PubMedPubMedCentralGoogle Scholar
  20. 20.
    Chu EW, Chernoguz A, Divino CM (2016) The evaluation of clopidogrel use in perioperative general surgery patients: a prospective randomized controlled trial. Am J Surg.  https://doi.org/10.1016/j.amjsurg.2015.05.036 Google Scholar
  21. 21.
    Strosberg DS, Corbey T, Henry JC, Starr JE (2016) Preoperative antiplatelet use does not increase incidence of bleeding after major operations. Surgery.  https://doi.org/10.1016/j.surg.2016.05.031 Google Scholar
  22. 22.
    Herman CR, Buth KJ, Kent BA, Hirsch GM (2010) Clopidogrel increases blood transfusion and hemorrhagic complications in patients undergoing cardiac surgery. Ann Thorac Surg.  https://doi.org/10.1016/j.athoracsur.2009.10.051 PubMedGoogle Scholar
  23. 23.
    Karon BS, Tolan NV, Koch CD, Wockenfus AM, Miller RS, Lingineni RK, Pruthi RK, Chen D, Jaffe AS (2014) Precision and reliability of 5 platelet function tests in healthy volunteers and donors on daily antiplatelet agent therapy. Clin Chem.  https://doi.org/10.1373/clinchem.2014.226332 Google Scholar
  24. 24.
    Velik-Salchner C, Maier S, Innerhofer P, Streif W, Klingler A, Kolbitsch C, Fries D (2008) Point-of-care whole blood impedance aggregometry versus classical light transmission aggregometry for detecting aspirin and clopidogrel: The results of a pilot study. Anesth Analg.  https://doi.org/10.1213/ane.0b013e31818524c1 Google Scholar
  25. 25.
    Sibbing D, Steinhubl SR, Schulz S, Schömig A, Kastrati A (2010) Platelet aggregation and its association with stent thrombosis and bleeding in clopidogrel-treated patients: Initial evidence of a therapeutic window. J Am Coll Cardiol.  https://doi.org/10.1016/j.jacc.2010.03.048 Google Scholar
  26. 26.
    Sibbing D, Morath T, Braun S, Stegherr J, Mehilli J, Vogt W, Schömig A, Kastrati A, von Beckerath N (2010) Clopidogrel response status assessed with Multiplate point-of-care analysis and the incidence and timing of stent thrombosis over six months following coronary stenting. Thromb Haemost.  https://doi.org/10.1160/TH09-05-0284 Google Scholar
  27. 27.
    Sibbing D, Braun S, Morath T, Mehilli J, Vogt W, Schömig A, Kastrati A, von Beckerath N (2009) Platelet reactivity after clopidogrel treatment assessed with point-of-care analysis and early drug-eluting stent thrombosis. J Am Coll Cardiol.  https://doi.org/10.1016/j.jacc.2008.11.030 PubMedGoogle Scholar
  28. 28.
    Wijeysundera DN, Wijeysundera HC, Yun L, Wasowicz M, Beattie WS, Velianou JL, Ko DT (2012) Risk of elective major noncardiac surgery after coronary stent insertion: a population-based study. Circulation.  https://doi.org/10.1161/CIRCULATIONAHA.112.102715 PubMedCentralGoogle Scholar
  29. 29.
    Kaluza GL, Joseph J, Lee JR, Raizner ME, Raizner AE (2000) Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol 35(5):1288–1294CrossRefPubMedGoogle Scholar
  30. 30.
    Waurick K, Riess H, Van Aken H, Kessler P, Gogarten W, Volk T (2014) S1-Leitlinie: Rückenmarksnahe Regionalanästhesien und Thrombembolieprophylaxe/ antithrombotische Medikation: 3. überarbeitete Empfehlung der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin. Anasth Intensivmed 5(5):464–492Google Scholar
  31. 31.
    Egholm G, Kristensen SD, Thim T, Olesen KKW, Madsen M, Jensen SE, Jensen LO, Sorensen HT, Botker HE, Maeng M (2016) Risk associated with surgery within 12 months after coronary drug-eluting Stent implantation. J Am Coll Cardiol.  https://doi.org/10.1016/j.jacc.2016.09.967 PubMedGoogle Scholar

Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2017

Authors and Affiliations

  • J. Wagner
    • 1
  • J. F. Lock
    • 1
  • V. Luber
    • 2
  • U. A. Dietz
    • 1
  • S. Lichthardt
    • 1
  • N. Matthes
    • 1
  • K. Krajinovic
    • 1
  • C.-T. Germer
    • 1
    • 3
  • S. Knop
    • 2
    • 3
  • A. Wiegering
    • 1
    • 4
  1. 1.Klinik für Allgemein‑, Viszeral‑, Gefäß- und KinderchirurgieUniversitätsklinikum WürzburgWürzburgDeutschland
  2. 2.Klinik für Innere Medizin IIUniversitätsklinikum WürzburgWürzburgDeutschland
  3. 3.Comprehensive Cancer Centre MainfrankenUniversitätsklinikum WürzburgWürzburgDeutschland
  4. 4.Institut für Biochemie und MolekularbiologieUniversität WürzburgWürzburgDeutschland

Personalised recommendations