Zusammenfassung
Patient Blood Management (PBM) ist spätestens seit seiner Implementierung in 4 deutschen Universitätskliniken und der Gründung des Deutschen PBM Netzwerks in aller Munde. Inwieweit sich das PBM im Bereich der Herzchirurgie umsetzen lässt, ist Gegenstand dieses Übersichtsbeitrags. Er diskutiert die Indikation zur Transfusion anhand der aktuellen Leitlinien und die zu diesem Thema publizierten Studien. Prä-, intra- und postoperative Maßnahmen des PBMs werden in Bezug auf die speziellen Bedürfnisse der Herzchirurgie herausgearbeitet und Empfehlungen in Form des „Fazits für die Praxis“ am Beitragsende gegeben. Die Indikation zur Transfusion ist bei Zeichen einer anämischen Hypoxie jederzeit gegeben. Bei akutem Koronarsyndrom und einem Hämoglobin(Hb)-Wert < 7 g/dl sollte transfundiert werden, ansonsten im Bereich zwischen 6 und 8 g/dl. Eine präoperative i.v.-Anämietherapie mit Eisen kann nach aktueller Datenlage empfohlen werden. Wünschenswert ist ein längerer, präoperativer Zeitraum von mindestens 4 Tagen, der sich im herzchirurgischen Bereich allerdings praktisch schwer umsetzen lässt. Die postoperative i.v. Eisengabe kann nach aktueller Datenlage für die herzchirurgische Patientenklientel nicht empfohlen werden. Studien an herzchirurgischen Patienten haben gezeigt, dass diese ineffektiv ist und zu keinem Hb-Wert-Anstieg bzw. nicht zur Reduktion der Transfusionsrate führt. Perioperative Maßnahmen des PBMs wie Cell Saver®, Tranexamsäuregabe und „Point-of-care“-Diagnostik zur Optimierung der Gerinnungssituation sind empfehlenswerte Bausteine des PBMs, die gut in der Herzchirurgie umsetzbar sind. Daher lässt sich zusammenfassen, dass das PBM und die Herzchirurgie keine Kontradiktion darstellen, sondern gut miteinander vereinbar sind.
Abstract
Patient blood management (PBM) is well known since its implementation in four German university hospitals and the foundation of the German PBM network. To what extent PBM can be performed in cardiac surgery is the main topic of this review article. The indications for red blood cell transfusions according to current guidelines and recently published studies are discussed. Preoperative, intraoperative and postoperative PBM measures are set in the specific context of cardiac surgery and treatment recommendations are given at the end of the article. Signs of anemic hypoxia are always an indication for transfusion of red blood cells. Guidelines recommend a red blood cell transfusion in patients with acute coronary syndrome and hemoglobin (Hb) levels <7 g/dl, otherwise within the range of 6–8 g/dl. Preoperative therapy of anemia with intravenous iron can be recommended according to current evidence. The time between intravenous iron substitution and surgery should be as long as possible with a minimum of 4 days, a duration that is hardly practicable in cardiac surgery. In contrast, postoperative intravenous iron substitution cannot be recommended, as studies on cardiac surgery patients with postoperative substitution did not result in an increase in Hb levels or a reduction of the red blood cell transfusion rate. Perioperative measures of PBM, such as the use of Cell Saver®, tranexamic acid and point-of-care diagnostics to optimize coagulation are recommendable components of PBM that can easily be performed in cardiac surgery. To summarize, PBM and cardiac surgery do not represent a contradiction but show good compatibility.
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Steinbicker, A.U. Patient Blood Management in der Herzchirurgie – eine Kontradiktion?. Z Herz- Thorax- Gefäßchir 31, 46–53 (2017). https://doi.org/10.1007/s00398-016-0116-z
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DOI: https://doi.org/10.1007/s00398-016-0116-z