Zusammenfassung
Blutprodukte werden in der Intensivmedizin oft eingesetzt. Die Evidenz hinsichtlich einer Verbesserung des klinischen Ausgangs ist jedoch meist gering. Der Trigger für eine Erythrozytentransfusion bei nicht blutenden kritisch Kranken ist aktuell ein Hämoglobinwert von 7,0 g/dl. Vor der Gabe von Thrombozytenkonzentraten müssen die Ursache der Thrombozytopenie, der klinische Zustand und der erwartete Effekt kritisch geprüft werden. Plasma sollte ebenfalls kritisch eingesetzt werden, insbesondere aufgrund der Volumenbelastung. Prothrombinkomplexkonzentrate sind bei Warfarinantagonisierung effektiver als Plasma. Albumin wird bei massiver Parazentese sowie bei der Therapie des hepatorenalen Syndroms Typ 1 und der spontanen bakteriellen Peritonitis mit guter Evidenz eingesetzt. Bei schwerer Sepsis und septischem Schock kann Albumin positive Effekte haben. Insgesamt sollten Blutprodukte restriktiv eingesetzt werden. Die Therapieentscheidung basiert auf einer kritischen Prüfung der Evidenzlage.
Abstract
Blood products are frequently used in intensive care medicine although there is little evidence of improvement in clinical outcome. The threshold for erythrocyte transfusion in non-bleeding critically ill patients is currently a hemoglobin level of 7.0 g/dl. The indications for platelet transfusion must be assessed after evaluation of the cause of thrombocytopenia, the clinical condition and the expected effect. The use of plasma should also be critically viewed, mainly due to hypervolemia. Prothrombin complex concentrates are better than plasma for warfarin reversal. There is good evidence for the use of albumin for massive paracentesis, in the treatment of hepatorenal syndrome type 1 and spontaneous bacterial peritonitis. Albumin infusion can have favorable effects in severe sepsis and septic shock. A restrictive strategy should be favored in the use of blood products and the decision should be based on a critical appraisal of the available evidence.
Literatur
Hebert PC, Wells G, Blajchman MA et al (1999) A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 340:409–417
Holst LB, Haase N, Wetterslev J et al (2014) Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med 371:1381–1391
Querschnitts-Leitlinien (BÄK) zur Therapie mit Blutkomponenten und Plasmaderivaten. 4. überarbeitete und aktualisierte Auflage. http://www.bundesaerztekammer.de/fileadmin/user_upload/downloads/QLL_Haemotherapie_2014.pdf. Zugegriffen: 16. Juli 2015
Carson JL, Grossman BJ, Kleinman S et al (2012) Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med 157:49–58
Bracey AW, Radovancevic R, Riggs SA et al (1999) Lowering the hemoglobin threshold for transfusion in coronary artery bypass procedures: effect on patient outcome. Transfusion 39:1070–1077
Carson JL, Terrin ML, Noveck H et al (2011) Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med 365:2453–2462
Hardy JF (2004) Current status of transfusion triggers for red blood cell concentrates. Transfus Apher Sci 31:55–66
Villanueva C, Colomo A, Bosch A et al (2013) Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 368:11–21
Hanson SR, Slichter SJ (1985) Platelet kinetics in patients with bone marrow hypoplasia: evidence for a fixed platelet requirement. Blood 66:1105–1109
Slichter SJ (2004) Relationship between platelet count and bleeding risk in thrombocytopenic patients. Transfus Med Rev 18:153–167
Slichter SJ (2007) Evidence-based platelet transfusion guidelines. Hematology Am Soc Hematol Educ Program 2007:172–178
Kaufman RM, Djulbegovic B, Gernsheimer T et al (2015) Platelet transfusion: a clinical practice guideline from the AABB. Ann Intern Med 162:205–213
Diedrich B, Remberger M, Shanwell A et al (2005) A prospective randomized trial of a prophylactic platelet transfusion trigger of 10 × 10(9) per L versus 30 × 10(9) per L in allogeneic hematopoietic progenitor cell transplant recipients. Transfusion 45:1064–1072
Heckman KD, Weiner GJ, Davis CS et al (1997) Randomized study of prophylactic platelet transfusion threshold during induction therapy for adult acute leukemia: 10,000/microL versus 20,000/microL. J Clin Oncol 15:1143–1149
Zumberg MS, Del Rosario ML, Nejame CF et al (2002) A prospective randomized trial of prophylactic platelet transfusion and bleeding incidence in hematopoietic stem cell transplant recipients: 10,000/L versus 20,000/microL trigger. Biol Blood Marrow Transplant 8:569–576
Murad MH, Stubbs JR, Gandhi MJ et al (2010) The effect of plasma transfusion on morbidity and mortality: a systematic review and meta-analysis. Transfusion 50:1370–1383
Roback JD, Caldwell S, Carson J et al (2010) Evidence-based practice guidelines for plasma transfusion. Transfusion 50:1227–1239
De Pietri L, Bianchini M, Montalti R et al (2015) Thrombelastography-guided blood product use before invasive procedures in cirrhosis with severe coagulopathy. A randomized controlled trial. Hepatology (im Druck). doi:10.1002/hep.28148
Sarode R, Milling TJ Jr, Refaai MA et al (2013) Efficacy and safety of a 4-factor prothrombin complex concentrate in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma-controlled, phase IIIb study. Circulation 128:1234–1243
Goldstein JN, Refaai MA, Milling TJ Jr et al (2015) Four-factor prothrombin complex concentrate versus plasma for rapid vitamin K antagonist reversal in patients needing urgent surgical or invasive interventions: a phase 3b, open-label, non-inferiority, randomised trial. Lancet 385:2077–2087
Nienaber U, Innerhofer P, Westermann I et al (2011) The impact of fresh frozen plasma vs coagulation factor concentrates on morbidity and mortality in trauma-associated haemorrhage and massive transfusion. Injury 42:697–701
Refaai MA, Goldstein JN, Lee ML et al (2015) Increased risk of volume overload with plasma compared with four-factor prothrombin complex concentrate for urgent vitamin K antagonist reversal. Transfusion 55:2722–2729
Milling TJ Jr, Refaai MA, Goldstein JN et al (2016) Thromboembolic events after vitamin K antagonist reversal with 4-factor prothrombin complex concentrate: exploratory analyses of two randomized, plasma-controlled studies. Ann Emerg Med. 67:96–105.e5. doi:10.1016/j.annemergmed.2015.04.036
Hiippala ST, Myllyla GJ, Vahtera EM (1995) Hemostatic factors and replacement of major blood loss with plasma-poor red cell concentrates. Anesth Analg 81:360–365
Acharya SS, Dimichele DM (2008) Rare inherited disorders of fibrinogen. Haemophilia 14:1151–1158
Spahn DR, Bouillon B, Cerny V et al (2013) Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care 17:R76
Rahe-Meyer N, Solomon C, Hanke A et al (2013) Effects of fibrinogen concentrate as first-line therapy during major aortic replacement surgery: a randomized, placebo-controlled trial. Anesthesiology 118:40–50
Ranucci M, Baryshnikova E, Crapelli GB et al (2015) Randomized, double-blinded, placebo-controlled trial of fibrinogen concentrate supplementation after complex cardiac surgery. J Am Heart Assoc 4:e002066
Dickneite G, Herwald H, Korte W et al (2015) Coagulation factor XIII: a multifunctional transglutaminase with clinical potential in a range of conditions. Thromb Haemost 113:686–697
Mishima Y, Nagao F, Ishibiki K et al (1984) [Factor XIII in the treatment of postoperative refractory wound-healing disorders. Results of a controlled study]. Chirurg 55:803–808
Bregenzer N, Caesar I, Andus T et al (1999) Lack of clinical efficacy of additional factor XIII treatment in patients with steroid refractory colitis. The Factor XIII Study Group. Z Gastroenterol 37:999–1004
Korte WC, Szadkowski C, Gahler A et al (2009) Factor XIII substitution in surgical cancer patients at high risk for intraoperative bleeding. Anesthesiology 110:239–245
Rasche H, Haghou F, Gaus W et al (1982) [Blood clotting factor XIII substitution in acute leukaemia: result of a randomized and controlled study]. Dtsch Med Wochenschr 107:1882–1886
Monroe DM, Hoffman M, Oliver JA et al (1997) Platelet activity of high-dose factor VIIa is independent of tissue factor. Br J Haematol 99:542–547
Friederich PW, Henny CP, Messelink EJ et al (2003) Effect of recombinant activated factor VII on perioperative blood loss in patients undergoing retropubic prostatectomy: a double-blind placebo-controlled randomised trial. Lancet 361:201–205
Boffard KD, Riou B, Warren B et al (2005) Recombinant factor VIIa as adjunctive therapy for bleeding control in severely injured trauma patients: two parallel randomized, placebo-controlled, double-blind clinical trials. J Trauma 59:8–15
Lodge JP, Jonas S, Jones RM et al (2005) Efficacy and safety of repeated perioperative doses of recombinant factor VIIa in liver transplantation. Liver Transpl 11:973–979
Raobaikady R, Redman J, Ball JA et al (2005) Use of activated recombinant coagulation factor VII in patients undergoing reconstruction surgery for traumatic fracture of pelvis or pelvis and acetabulum: a double-blind, randomized, placebo-controlled trial. Br J Anaesth 94:586–591
Pihusch M, Bacigalupo A, Szer J et al (2005) Recombinant activated factor VII in treatment of bleeding complications following hematopoietic stem cell transplantation. J Thromb Haemost 3:1935–1944
Bosch J, Thabut D, Albillos A et al (2008) Recombinant factor VIIa for variceal bleeding in patients with advanced cirrhosis: a randomized, controlled trial. Hepatology 47:1604–1614
Mayer SA, Brun NC, Begtrup K et al (2008) Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med 358:2127–2137
O’Connell KA, Wood JJ, Wise RP et al (2006) Thromboembolic adverse events after use of recombinant human coagulation factor VIIa. JAMA 295:293–298
Vincent JL, Rossaint R, Riou B et al (2006) Recommendations on the use of recombinant activated factor VII as an adjunctive treatment for massive bleeding – a European perspective. Crit Care 10:R120
Warren BL, Eid A, Singer P et al (2001) Caring for the critically ill patient. High-dose antithrombin III in severe sepsis: a randomized controlled trial. JAMA 286:1869–1878
Kienast J, Juers M, Wiedermann CJ et al (2006) Treatment effects of high-dose antithrombin without concomitant heparin in patients with severe sepsis with or without disseminated intravascular coagulation. J Thromb Haemost 4:90–97
Finfer S, Bellomo R, Boyce N et al (2004) A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 350:2247–2256
Dellinger RP, Levy MM, Rhodes A et al (2013) Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 39:165–228
Caironi P, Tognoni G, Masson S et al (2014) Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med 370:1412–1421
Ginès P, Angeli P, Lenz K et al (2010) EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol 53:397–417
Sort P, Navasa M, Arroyo V et al (1999) Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 341:403–409
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Interessenkonflikt
S. Petros gibt an, dass kein Interessenkonflikt besteht.
Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
Additional information
Redaktion
U. Janssens, Eschweiler
M. Joannidis, Innsbruck
K. Mayer, Gießen
Rights and permissions
About this article
Cite this article
Petros, S. Therapie mit Blutprodukten. Med Klin Intensivmed Notfmed 111, 241–252 (2016). https://doi.org/10.1007/s00063-015-0138-4
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00063-015-0138-4