Klinischer Nutzen des PFA-100 als präoperativer Screeningtest zum Erkennen von Störungen der primären Hämostase bei Patienten mit komplizierten, elektiven intrakraniellen Eingriffen aufgrund raumfordernder Prozesse

Das menschliche Gehirn ist durch den umgebenden Liquor und die Schädelkalotte geschützt. Eine schnelle intrakranielle Drucksteigerung führt aufgrund der engen Verhältnisse allerdings frühzeitig zu teils irreversiblen Parenchymschäden. Blutungen stellen neben dem Hirnödem eine Haupt¬ursache für Hirnd...

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Bibliographic Details
Main Author: Reuter, Karoline
Contributors: Karger,Ralf (Dr.) (Thesis advisor)
Format: Doctoral Thesis
Published: Philipps-Universität Marburg 2011
Online Access:PDF Full Text
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Background: Based on the clinical experience perioperative bleeding in complex neurosurgery can be related to an unidentified impairment of primary haemostasis. The Platelet Function Analyzer (PFA-100) has been evaluated as a screening tool for disorders of primary haemostasis. This study investigates whether the inclusion of the PFA-100 in the preoperative screening of neurosurgery patients might help reducing perioperative bleeding complications. Methods: Beginning in April 2006, patients with intracranial space occupying lesions who were scheduled for complex neurosurgical interventions underwent routine preoperative PFA-100 testing. Patients suffering from vascular mal-formations or intracranial aneurysms were excluded. In case of abnormal PFA, patients were further evaluated and/or received prophylactic treatment with desmopressin. Post-operative outcomes were compared to patients operated before introduction of PFA testing. The patients were enrolled consecutively over an 18-month period. Preoperative PFA-testing was introduced after 9 months. Inclusion criteria remained unchanged during the study period. Results: 102 patients were enrolled in the 9-month period before PFA introduction (non-PFA group), and 93 patients were enrolled thereafter (PFA group). The groups were highly comparable in terms of basic patient characteristics (age, gender, height, weight, BMI, ASA, Hb) and the spectrum of intracranial pathologies. Duration of anaesthesia or surgery, as well as experience of the operating surgeons were not significantly different between the two groups. Four patients (3.9 %) in the non-PFA group and six patients (6.5 %) in the PFA group experienced an increased intraoperative bleeding tendency according to a subjective assessment of the respective surgeon (p = 0.42). Two patients (2.0 %) in the non-PFA group and two patients (2.2 %) in the PFA group experienced a clinically relevant intracranial bleeding complication confirmed by postoperative computed tomography (odds ratio (OR) 1.05, 95% confidence intervall (95%-CI) 0.39-2.82; p = 1.0). Red blood cell, plasma or platelet transfusions were not significantly different between the two groups. Administration of coagulation factors (only fibrinogen concentrate was administered) or antifibrinolytic agents was also not significantly different between the groups. Five patients (4.9 %) in the non-PFA group and thirteen patients (14.0 %) in the PFA-group received desmopressin infusions perioperatively (OR 3.2, 95%-CI 1.1-9.2; p = 0.045). Conclusion: Prophylactic haemostatic treatment based on preoperative screening with the PFA-100 did not reduce the occurrence of perioperative bleeding complications related to complex intracranial surgical interventions, but resulted in a significant increase in the administration of desmopressin. A larger prospective randomized trial is needed to definitely determine the real clinical benefit of this approach.