Antifibrinolytika und Blutgerinnung in der Kinderchirurgie – Was ist anders als beim erwachsenen Patienten?

Zusammenfassung

Das System der Blutgerinnung ist altersabhängig unterschiedlich bei Kindern im Vergleich zu Erwachsenen. Bedeutsam ist dieser Unterschied insbesondere bei Kindern unter sechs Monaten. Die Konzentrationen von Gerinnungsfaktoren und Inhibitoren weisen im Blut bei Kindern eine Altersabhängigkeit auf. Das bedeutet auch, dass sich bekannte Referenzwerte für Erwachsene für Blutgerinnungsparameter nicht auf alle Altersgruppen übertragen lassen. Sobald bei kinderchirurgischen Eingriffen mit einem signifikanten Blutverlust zu rechnen ist, wird auch das System der Blutgerinnung beeinflusst. Um die fibrinolytische Aktivität des Gerinnungssystems zu hemmen, werden auch und besonders bei Kindern Antifibrinolytika eingesetzt. Während zahlreiche Studien bei erwachsenen Patienten zu diesem Thema publiziert wurden, ist die Datenlage in der Pädiatrie begrenzt. Dieser Artikel fasst die wesentlichen Unterschiede des Gerinnungssystems von Kindern zu dem erwachsener Patienten zusammen und stellt die Indikationen, Medikamente und Nebenwirkungen der verfügbaren Antifibrinolytika beim Einsatz in der pädiatrischen Chirurgie dar.

Abstract

More than 30 years ago the pioneering work of Andrew and co-workers showed that the coagulation system of children is different than from adult. They have introduced the term of “developmental hemostasis” to describe this phenomenon. They were able to show that the concentration of coagulation factors and inhibitors are age-dependent and therefore reference limits from adult practice cannot be transferred to children one to one. Numerous studies showed that the perioperative loss of blood, and thus the use of homologous blood could be limited by administering antifibrinolytic substances such as aprotinin. Other antifibrinolytics acting substances like Epsilon-aminocaproic acid (EACA) or tranexamic acid (TXA) tended to be misfits in routine clinical practice. In 2006, the publication of a retrospective study carried out by Mangano et al, in which considerable safety concerns were expressed with regard to aprotinin led to a significant rethinking of its clinical use. Two years later the results of the BART (Blood Conservation using antifibrinolytics in a Randomized Trial) study confirmed that there was an increased postoperative mortality associated with the use of aprotinin compared to TXA and EACA.

In a few adult studies so far tranexamic acid was found to be comparably as effective as aprotinin. Although TXA is a long known drug available on the market for more than 50 years, the studies connecting factors of indication, dosage regimen and safety are limited especially in children and infants. This article highlights the differences in the coagulation system in children compared to adult as well as indication, dosage regimens and possible side effects of antifibrinolytic agents in children.

Kernaussagen

• Das Blutgerinnungssystem bei Kindern unterscheidet sich im Vergleich zu Erwachsenen je nach Alter: Die Konzentrationen von Gerinnungsfaktoren und Inhibitoren variieren altersabhängig. Darum lassen sich bekannte Referenzwerte für Blutgerinnungsparameter für Erwachsene nicht auf alle Altersgruppen übertragen.

• Derzeit ist Tranexamsäure das einzige in Deutschland für pädiatrische Patienten zugelassene Antifibrinolytikum.

• Bisher publizierte Daten unterstützen die Anwendung von Antifibrinolytika bei komplexen herzchirurgischen Operationen von Neugeborenen, bei Patienten mit zyanotischen Vitien und bei Rethorakotomien.

• Aufgrund der begrenzten und heterogenen Daten zur Anwendung von Antifibrinolytika in der pädiatrischen Chirurgie können noch keine gesicherten Aussagen zur optimalen Dosierung sowie zu möglichen Risiken und Nebenwirkungen gemacht werden.

Schlüsselwörter:

Blutgerinnung - Kinderchirurgie - Anifibrinolytika - Tranexamsäure - Kinderanästhesie

Key words:

pediatric surgery - hemostasis - antifibrinolytic therapy - tranexamic acid

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