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Präoperative Anämie in der Orthopädie

Klinische Relevanz, Diagnostik und Therapie

Preoperative anemia in orthopedic surgery

Clinical impact, diagnostics and treatment

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Zusammenfassung

Etwa ein Drittel der Patienten, die sich einer elektiven Hüft- oder Kniegelenkendoprothesenoperation unterziehen, weist einen Hämoglobinwert unter 13 g/dl (Männer) bzw. unter 12 g/dl (Frauen) auf, was nach der gültigen WHO-Definition einer Anämie entspricht. Diese ist mit einer erhöhten postoperativen Morbidität- und Mortalität und mit häufigen Transfusionen verbunden. Transfundierte Patienten haben ebenfalls ein erhöhtes Risiko für Mortalität und Infektionen und verweilen länger im Krankenhaus. Entsprechend dem Transfusionsgesetz und den Richtlinien der Bundesärztekammer sind Patienten mit einer Transfusionswahrscheinlichkeit von mindestens 10% auf die Möglichkeit autologer Hämotherapieverfahren hinzuweisen. Die Eigenblutspende als ein gängiges autologes Verfahren zur Vermeidung allogener Transfusionen wird in Deutschland in vielen Kliniken angewendet, kann jedoch unter bestimmten Bedingungen eine präoperative Anämie noch verstärken. Deswegen, aber auch weil die Ressource Fremdblut zunehmend knapper wird, besteht die Notwendigkeit neuer Standards in der Diagnostik und Therapie der präoperativen Anämie. In aktuellen internationalen Leitlinien wird empfohlen, den Hämoglobinwert spätestens 28 Tage vor dem Eingriff zu bestimmen und entsprechend der Definition der WHO bei Männern auf > 13 g/dl und bei Frauen auf > 12 g/dl anzuheben. Als Ursache für eine Anämie sollten eine chronische Niereninsuffizienz, eine maligne Erkrankung und eine chronische Entzündung abgeklärt und ein Mangel an Eisen, Vitamin B12 und/oder Folsäure ausgeglichen werden. Für Patienten, bei denen keine Mangelerkrankung vorliegt oder eine Substitutionstherapie keine ausreichende Therapie der Anämie erzielt, wird vorgeschlagen, eine Therapie mit erythropoesestimulierenden Substanzen durchzuführen.

Abstract

In a national audit of elective orthopedic surgery conducted in the US, 30% of patients were found to have hemoglobin (Hgb) levels < 13 g/dl at preadmission testing. Preoperative anemia has been associated with increased mortality and morbidity after surgery, increased allogeneic blood transfusion therapy and increased rates of postoperative infection leading to a longer length of hospital stay. Because of the risks associated with allogeneic blood transfusions according to German law patients have to be offered the option of autologous transfusion if the risk associated with allogeneic blood transfusion is > 10%. However, one of these measures, the autologous blood donation, can exaggerate anemia and can increase the overall transfusion rates (allogeneic and autologous). As autologous procedures (autologous blood donation and cell salvage) are not always appropriate for anemic patients together with an expected shortage of blood and because preoperative anemia is associated with perioperative risks of blood transfusion, a standardized approach for the detection, evaluation and management of anemia in this setting was identified as an unmet medical need. A panel of multidisciplinary physicians was convened by the Society for Blood Management to develop a clinical care pathway for anemia management in elective surgery patients for whom blood transfusion is an option. In these guidelines elective surgery patients should have Hgb level determination at the latest 28 days before the scheduled surgical procedure. The patient target Hgb before elective surgery should be within the normal range (normal female ≥ 120 g/l, normal male ≥ 130 g/l). Laboratory testing should take place to further determine nutritional deficiencies, chronic renal insufficiency and/or chronic inflammatory diseases. Nutritional deficiencies should be treated and erythropoiesis-stimulating agent (ESA) therapy should be used for anemic patients in whom nutritional deficiencies have been ruled out and/or corrected.

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Interessenkonflikt

Im Einvernehmen mit der Autorengruppe weist die Schriftleitung darauf hin, dass für den Zweitautor der Publikation, Dr. J. Tomeczkowski, ein Interessenkonflikt bestehen kann. Herr Dr. Tomeczkowski ist Mitarbeiter der Firma Janssen-Cilag GmbH Health Economics & Reimbursement, die Produkte herstellt und vertreibt, deren Verwendung in der vorliegenden Arbeit empfohlen wird.

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  1. Orthopädische Chirurgie, ENDO-Klinik Hamburg GmbH, Holstenstr. 2, 22767, Hamburg, Deutschland

    D. Kendoff

  2. Health Economics & Reimbursement, Janssen-Cilag GmbH, Neuss, Deutschland

    J. Tomeczkowski

  3. Verband der privaten Krankenversicherung e.V., Köln, Deutschland

    J. Fritze

  4. Abt. Anästhesiologie und operative Intensivmedizin, AKH Linz, Linz, Österreich

    H. Gombotz

  5. Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum/Campus Mitte , Berlin, Deutschland

    C. von Heymann

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Kendoff, D., Tomeczkowski, J., Fritze, J. et al. Präoperative Anämie in der Orthopädie. Orthopäde 40, 1018–1028 (2011). https://doi.org/10.1007/s00132-011-1789-3

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