3. Internationales Symposium: „Autologe Transfusion - Von der Euphorie zur Ratio: Praktisches Handeln aus wissenschaftlicher Sicht” (Teil III)
Die Dilutionskoagulopathie, ein unterschätztes Problem?

Zusammenfassung

Große Blutverluste werden akut, solange keine Frischplasmen zur Verfügung stehen, in erster Linie durch Kristalloide, Kolloide und Erythrozytenkonzentrate ersetzt, so dass eine Verdünnung aller plasmatischer Gerinnungsfaktoren resultiert. Eine blutungsbedingte Verlustkoagulopathie geht daher nahezu immer mit einer Verdünnungskoagulopathie einher. Formeln zur Berechnung kritischer Blutverluste sowie Standardgerinnungstests sind im Falle einer Massivtransfusion oft nicht hilfreich. Demgegenüber haben point-of-care-taugliche Systeme wie die Thrombelastographie bedeutende Vorteile. Im Rahmen der Verlust- und Dilutionskoagulopathie ist zunächst die plasmatische Gerinnung gestört, wobei Fibrinogen als erstes kritische Werte zu erreichen scheint. Dabei wird die Fibrinpolymerisation nicht nur durch den blutungsbedingten Fibrinogenverlust und Verdünnung beeinträchtigt, sondern auch durch die Interaktion mit künstlichen Kolloiden, insbesondere durch Hydroxyethylstärkepräparate. Die Therapie der Verlust- und Verdünnungskoagulopathie erfolgt mit Frischplasmen. Sind diese nicht in ausreichender Zahl oder in einem akzeptablen Zeitraum verfügbar, muss auf Faktorenkonzentrate zurückgegriffen werden. Weder die Therapie mit Frischplasmen noch die Behandlung mit Gerinnungsfaktorenkonzentraten wurde in ausreichendem Maße klinisch untersucht. Es werden weitere Studien notwendig sein, um Richtlinien erarbeiten zu können, wie Gerinnungsmanagement im Rahmen großer Blutverluste zu erfolgen hat.

Abstract

When no fresh frozen plasma is available, acute major blood loss is compensated above all with crystalloids, colloids and erythrocyte concentrates, meaning that all plasma clotting factors are diluted. Consumption coagulopathy is almost always accompanied by dilutional coagulopathy. Formulas for calculating critical blood loss and standard coagulation tests are often not helpful in the case of massive transfusion. On the other hand, systems suitable for point of care, such as thrombelastography, have important advantages. In the case of consumption and dilutional coagulopathy plasma coagulation is disturbed and critical values are first seen for fibrinogen. Not only is fibrin polymerization impaired by the bleeding-induced loss and dilution of fibrinogen, but also by interaction with artificial colloids, particularly hydroxyethyl starch preparations. Therapy of consumption and dilutional coagulopathy calls for fresh frozen plasma. If this is not available in sufficient quantity or within a reasonable time, coagulation factor concentrates must be used. Neither fresh frozen plasma therapy nor treatment with coagulation factor concentrates has been the subject of detailed clinical study. Further studies are needed to work out guidelines for coagulation management in the case of massive blood loss.

Schlüsselwörter

Kristalloide - Kolloide - Dilutionskoagulopathie - Thrombelastographie

Key words

Crystalloids - colloids - dilutional coagulopathy - thrombelastography

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