Rationaler Einsatz von Blutprodukten – Reduzierung des Blutprodukteverbrauchs durch ein modernes Gerinnungsmanagement

Zusammenfassung

Die präoperative Erhebung einer standardisierten Gerinnungsanamnese, die Verfügbarkeit von „Point-of-Care“-Gerinnungsdiagnostik sowie der perioperative Einsatz fremdblutsparender Maßnahmen sind Voraussetzungen eines modernen Gerinnungsmanagements. Die Therapie koagulopathischer Patienten sollte auf der Grundlage von stufenweise aufgebauten Behandlungsalgorithmen erfolgen. Zur Basistherapie gehört die chirurgische Blutstillung sowie das Einhalten bzw. die aggressive Korrektur der hämostaseologischen Rahmenbedingungen. Bei diffuser Blutung sollte frühzeitig eine antifibrinolytische Therapie in Betracht gezogen werden. Gerinnungsfaktoren-Defizite sollten zielgerichtet therapiert werden. Die Transfusion von GFP ist lediglich bei Massivtransfusionen indiziert. Die Gabe von DDAVP und die Transfusion von Thrombozytenkonzentraten sind Optionen zur Optimierung der primären Hämostase. Bei Persistenz der diffusen Blutung stellt die Gabe von rekombinantem aktiviertem Faktor VII eine Ultima-Ratio Therapieoption dar.

Abstract

Evaluating the patient's individual bleeding history with a standardized questionnaire, using “point-of-care” – methods for coagulation analyses and providing autologous transfusion techniques are preconditions of a modern coagulation management. Therapy of coagulopathic patients should be based on structured hemotherapy algorithms. Surgical haemostasis and the maintenance of the basic conditions for haemostasis are elementary requirements for an effective therapy. In cases of diffuse bleeding, early antifibrinolytic therapy should be considered. Coagulation factor deficiencies should be corrected “goal-directed” using coagulation factor concentrates. Transfusion of fresh frozen plasma is only indicated in the clinical setting of massive transfusions. DDAVP and transfusion of platelet concentrates are options to optimize primary haemostasis. In cases of on-going bleeding, recombinant activated coagulation factor VII represents an option for “ultima-ratio” therapy.

Kernaussagen

• Modernes Gerinnungsmanagement sollte algorithmusbasiert sein. Es beginnt bereits präoperativ mit der Erhebung einer standardisierten und ausführlichen Gerinnungsanamnese.

• Die vielfältigen Methoden und Maßnahmen, um den Fremdblutbedarf zu reduzieren, sollten in die reguläre perioperative Patientenversorgung integriert werden.

• Chirurgische Blutstillung ist elementare Voraussetzung für ein effizientes Gerinnungsmanagement.

• Regelmäßige Kontrolle und aggressive Korrektur der hämostaseologischen Rahmenbedingungen (pH, Temperatur, Kalzium, Hämatokrit) sind wesentliche Grundlagen einer Hämotherapie.

• Bei klinischem Verdacht auf das Vorliegen einer Hyperfibrinolyse ist die frühzeitige Gabe von Tranexamsäure vor der Therapie mit Gerinnungsfaktorenkonzentraten bzw. Plasma angezeigt.

• Zur Korrektur von Gerinnungsfaktorendefiziten stehen grundsätzlich Gerinnungsfaktorenkonzentrate und / oder Frischplasma zur Verfügung. Außerhalb des klinischen Settings von Massivtransfusionen sollte mit Gerinnungsfaktorenkonzentraten zielgerichtet therapiert werden.

• Auch bei normwertiger Routine-Gerinnungsdiagnostik kann eine relevante Störung der primären Hämostase vorliegen. Abhängig von deren Ätiologie und der Blutungsdynamik kann mit der Gabe von DDAVP ein pharmakologischer Versuch unternommen werden, die primäre Hämostase zu optimieren.

• In Anbetracht des Nebenwirkungsprofils und der Ergebnisse von Metaanalysen sollte der Einsatz von aktiviertem Faktor VII überaus restriktiv erfolgen.

Schlüsselwörter

Blutgerinnung - Gerinnungsmanagement - allogene Blutprodukte - Frischplasma - Point-of-Care-Gerinnungsdiagnostik

Keywords

Haemostasis - Coagulation management - Allogenic blood products - Fresh Frozen Plasma - Point-of-care coagulation analyses

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