Gerinnungsmanagement bei traumatisch bedingter Massivblutung – Empfehlungen der Arbeitsgruppe für perioperative Gerinnung der ÖGARI

 

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Zusammenfassung

Zu den Haupttodesursachen polytraumatisierter Patienten zählt der hämorrhagische Schock. Die „Trauma induzierte Koagulopathie“ (TIC) beschreibt eine Kombination aus Verlust von Gerinnungsfaktoren und Thrombozyten, Hämodilution (Dilutionskoagulopathie), Steigerung der Fibrinolyse sowie Hypothermie, Azidose und Hypokalzämie. Neue Erkenntnisse zur Pathophysiologie der TIC und der weit verbreitete Einsatz viskoelastischer Messmethoden haben während den letzten Jahren zur Entwicklung alternativer Behandlungskonzepte geführt. Ebenso wie für die bisher empfohlene Therapie mit Frischplasma und Thrombozytenkonzentraten sind derzeit auch für diese alternativen Konzepte keine Daten von großen randomisierten Studien verfügbar. Durch die zunehmende Verwendung Point-of-Care tauglicher viskoelastische Messverfahren können einzelne Faktorenmangelzustände jedoch schnell erkannt und zielgerichtet bei entsprechender klinischer Blutungsneigung mit Gerinnungsfaktoren-konzentraten behandelt werden.

Abstract

Even nowadays and at specialized centers, one of the leading causes of death is exsanguination. Trauma-induced coagulopathy (TIC) occuring with massive blood loss primarily results from loss of coagualtion factors and platelets and is aggravated by hemodilution. In addition, hyperfibrinolysis, hypothermia, acidosis and hypocalcaemia also contribute to the development of severe haemostatic derangement. During the past few years new insights into the pathophysiology of TIC and the widespread use of viscoelastic coagulation monitoring provoked the development of alternative treatment concepts. As for the previously recommended standard therapy using fresh frozen plasma and platelet concentrates also for alternative strategies no data from large prospective randomized studies are available until now, however, the evidence is growing favoring the use of coagulation factor concentrates guided by viscoelastic measurements.

Kernaussagen

• Um einen ausreichenden Volumeneffekt zu erzielen, ist eine Kombination aus kristalloiden und kolloidalen Volumenersatzmitteln angezeigt.

• Bereits bei klinischem Verdacht auf eine Hyperfibrinolyse ist eine antifibrinolytische Therapie angezeigt; Tranexamsäure in einer Dosis von 15–20 mg/kg kann eingesetzt werden.

• Wird im Rahmen einer Massivblutung eine prokoagulatorische Substitutionstherapie durchgeführt, soll ein pH von > 7,2 mittels Puffertherapie angestrebt werden.

• Bei Kalziumwerten unter 0,8–0,9 mmol/l sollte Kalziumglukonat (10–20 ml) oder Kalziumchlorid (5 ml) verabreicht werden.

• Im Rahmen einer Massivtransfusion mit anhaltender aktiver Blutung sollten niedrige Transfusionstrigger vermieden und ein Hämoglobinwert von 8–10 g/dl angestrebt werden.

• Laut Datenlage kann für Thrombozyten kein eindeutiger Transfusionstrigger definiert werden. Nach Meinung der Autoren sind bei Massivblutung Thrombozytenkonzentrate bei Werten unter 100 000 / μl indiziert.

• Hohe Fibrinogenspiegel haben eine protektive Wirkung bezüglich perioperativer Blutverluste.

• Steht kein Fibrinogenkonzentrat zur Verfügung, müssen Frischplasmen (mindestens 30 ml/kg) transfundiert werden.

• Bei pathologischen Gerinnungstests und erhöhter Blutungsneigung wird die Gabe von PPSB (20–30 I.E./kg KG) empfohlen. Alternativ können Frischplasmen (mindestens 30 ml/kg) transfundiert werden. Als Sonderfall sind polytraumatisierte Patienten unter oraler Antikoagulantientherapie zu sehen. In diesen Fällen wird die Gabe von PPSB und Vitamin K an erster Stelle notwendig sein.

• Bei einer FXIII-Aktivität < 60 % und anhaltender Blutung kann FXIII-Konzentrat eingesetzt werden. Alternativ kann Frischplasma transfundiert werden.

• rFVIIa sollte bei Blutungen, die konventionell, chirurgisch oder interventionell radiologisch nicht sanierbar sind, oder bei Versagen einer umfassend durchgeführten Gerinnungstherapie in Erwägung gezogen werden.

• Besteht eine relevante Gerinnungsstörung mit Transfusionspflichtigkeit und nachgewiesenen oder zu erwartenden Einzelfaktorenmangelzuständen, sollten diese zunächst mit Konzentraten ausgeglichen werden. Der Einsatz von Frischplasma wird erst bei Blutverlusten ≥ 150 % des totalen Blutvolumens mit einem zu erwartenden Mangel verschiedener Gerinnungsfaktoren empfohlen.

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Dietmar Fries
Petra Innerhofer
Peter Perger
Manfred Gütl
Sabine Heil
Nikolaus Hofmann
Werner Kneifel
Ludwig Neuner
Thomas Pernerstorfer
Georg Pfanner
Herbert Schöchl
Bernhard Ziegler
Camillo Kölblinger
Sibylle Kozek-Langenecker

• Supplementary Material