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Moderne Gerinnungstherapie beim blutenden Schwerverletzten

Faktorengabe nach „Point-of-care“

Modern coagulation management in bleeding trauma patients

Point-of-care guided administration of coagulation factor concentrates and hemostatic agents

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Zusammenfassung

Hintergrund

Unkontrollierte Blutungen einschließlich traumainduzierter Koagulopathie (TIK) sind nach wie vor die häufigste vermeidbare Todesursache beim Schwerverletzten und rasche Diagnostik und Behandlung sind mit verbessertem Outcome assoziiert. Eine an Zielwerten orientierte individualisierte Therapie („goal-directed therapy“) unter Einschluss von „Point-of-care“(POC)-Verfahren ist möglicherweise der empirischen und verhältnisbasierten Therapie mit Blutprodukten vorzuziehen.

Material und Methode

Selektive Literaturübersicht unter Berücksichtigung aktueller Empfehlungen/Expertenmeinungen zur Gerinnungstherapie bei blutenden Schwerverletzten via individualisierter Therapie („goal-directed therapy“) mit POC-viskoelastischer Substitution (ROTEM®) von Gerinnungsfaktoren und Hämostatika.

Ergebnisse

Die Gabe von Fibrinogenkonzentrat beim blutenden Schwerverletzten ist ab ROTEM®-FIBTEM A10 < 10 mm (FIBTEM A5 < 9 mm; FIBTEM MCF < 12 mm) und erniedrigter EXTEM A10 < 45 mm (EXTEM A5 < 35 mm; EXTEM MCF < 55 mm) zu erwägen; die Gabe von Prothrombinkomplexkonzentrat (PPSB) basierend auf einer verzögerten Gerinnselinitiierung (ROTEM®-EXTEM CT > 80 s). Aussagen zum Monitoring eines Faktor(F)-XIII-Defizits oder zur Therapiesteuerung mit FXIII-Konzentraten sind derzeit nicht möglich. Viskoelastische Testverfahren zeichnen sich durch hohe Sensitivität und Spezifität für den Nachweis einer Hyperfibrinolyse mit therapeutischer Gabe eines Antifibrinolytikums aus.

Schlussfolgerungen

Individualisierte Therapiekonzepte auf Grundlage von POC-viskoelastischen Testverfahren (ROTEM®) bieten eine sinnvolle Alternative zu den verhältnisbasierten Konzepten und sind mit reduziertem Transfusionsbedarf und reduzierter Morbidität vergesellschaftet.

Abstract

Background

Uncontrolled bleeding with trauma-induced coagulopathy (TIC) is still the leading cause of preventable death following severe multiple injury. Rapid diagnosis and treatment are associated with improved outcome. Early individualized goal-directed therapy and the use of point-of-care technology may be superior to empiric and ratio-based therapies with conventional blood products.

Materials and methods

Selective review of the literature considering current recommendations/expert opinion for coagulation management in bleeding trauma patients via individualized goal-directed therapy and the use of viscoelastic point-of-care (ROTEM®)-guided substitution of coagulation factor concentrates and hemostatic agents.

Results

The administration of fibrinogen concentrate in bleeding trauma patients may be considered if ROTEM®-FIBTEM A10 < 10 mm (FIBTEM A5 < 9 mm; FIBTEM MCF < 12 mm) and EXTEM A10 < 45 mm (EXTEM A5 < 35 mm; EXTEM MCF < 55 mm); the administration of prothrombin complex concentrate (PCC) may be considered if signs of delayed coagulation initiation (ROTEM®-EXTEM CT > 80 s). At this stage, no concluding statement can be made for monitoring or treatment guidance with factor XIII by using point-of-care technology. Viscoelastic assays display high sensitivity and specificity for the detection of hyperfibrinolysis with subsequent administration of an antifibrinolytic.

Conclusions

Individualized therapeutic concepts based upon viscoelastic point-of-care (ROTEM®) assays present an alternative to empiric and ratio-based therapies with conventional blood products in bleeding trauma patients and may be associated with reduced need for allogenic blood products and morbidity.

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Authors and Affiliations

  1. Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie, Kliniken der Stadt Köln-Merheim, Universität Witten/Herdecke (UW/H), Campus Köln-Merheim, Ostmerheimerstr. 200, 51109, Köln, Deutschland

    Marc Maegele

  2. Institut für Forschung in der Operativen Medizin (IFOM), Haus 38, Universität Witten/Herdecke (UW/H), Campus Köln-Merheim, Ostmerheimerstr. 200, 51109, Köln, Deutschland

    Marc Maegele

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M. Maegele gibt an, Honorare für Vorträge und Teilnahmen an Experten- und Beratungsgremien sowie finanzielle Unterstützungen zur Teilnahme an Kongressen von Astra Zeneca, Bayer, Biotest, CSL Behring, LFB Biomedicaments France und TEM International/IL Werfen erhalten zu haben.

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Maegele, M. Moderne Gerinnungstherapie beim blutenden Schwerverletzten. Med Klin Intensivmed Notfmed 114, 400–409 (2019). https://doi.org/10.1007/s00063-017-0337-2

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