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Frischplasma und Faktorenkonzentrate zur Therapie der perioperativen Koagulopathie

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Fresh plasma and concentrates of clotting factors for therapy of perioperative coagulopathy

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Zusammenfassung

Die erworbene, perioperative Koagulopathie entwickelt sich meist aus einer akuten Blutung. Beim primär gesunden Patienten mit normaler Knochenmark- und Leberfunktion tritt erst ein Mangel an Gerinnungsfaktoren ein, bevor sekundär eine Thrombopenie hinzukommt. Der Ersatz von Gerinnungsfaktoren kann grundsätzlich durch Frischplasma (Einzelspender oder Poolplasma) oder Faktorenkonzentrate erfolgen. Frischplasma und Faktorenkonzentrate, die in den deutschsprachigen Ländern vertrieben werden, erfüllen alle hohe Qualitäts- und Sicherheitsstandards. Unerwünschte Wirkungen durch Infektionsübertragungen und immunologische Reaktionen sind bei virusinaktiviertem Poolplasma und Faktorenkonzentraten höchstwahrscheinlich seltener als bei Einzelspenderplasma. Dagegen sind bei Letzterem thromboembolische Komplikationen wegen des ausgeglichenen Verhältnisses von pro- und antikoagulatorisch wirkenden Faktoren nicht zu erwarten, wurden aber vereinzelt für virusinaktiviertes Poolplasma und Faktorenkonzentrate beschrieben. Faktorenkonzentrate sind einfacher zu lagern und stehen sofort zum Einsatz zur Verfügung, während gefrorenes Frischplasma für die klinische Anwendung erst aufgetaut werden muss. Bei aktivierter Hämostase sind die unter physiologischen Bedingungen beschriebenen Halbwertszeiten der plasmatischen und zellulären Gerinnungskomponenten oft erheblich reduziert. Deshalb müssen bei der perioperativen Koagulopathie mit akutem Blutverlust meist höhere Dosierungen von Frischplasma und Faktorenkonzentraten für die effektive Therapie verabreicht werden, als in vielen aktuellen Leit- und Richtlinien zur Gerinnungstherapie beschrieben sind. Bei der Gabe von Frischplasma ist im Gegensatz zu den Faktorenkonzentraten zudem der resultierende Volumeneffekt zu berücksichtigen. Zusammenfassend lässt sich sagen, dass im Rahmen eines zeitgemäßen perioperativen Gerinnungsmanagements sowohl Frischplasma als auch Faktorenkonzentrate verfügbar und dem Anästhesisten vertraut sein sollten, um an die Situation des blutenden Patienten angepasst und zielgerichtet, an Laborwerten orientiert, eingesetzt werden zu können.

Abstract

Acquired, perioperative coagulopathy often develops due to acute bleeding. In the case of primarily healthy patients with normal bone marrow and liver functions, a lack of coagulation factors initiates coagulopathy before secondary thrombopenia arises. Replacement of coagulation factors can be performed by infusion of fresh plasma (single donor or pooled plasma) or concentrates of clotting factors. Fresh plasma as well as concentrates of clotting factors available in German-speaking countries are of high quality and fulfil all safety standards. Undesirable side-effects due to transmission of infections and immunological reactions are – in all probability – more uncommon for virus-inactivated plasma and clotting factors than for single donor plasma. In contrast, thromboembolic complications are unlikely when using fresh frozen plasma, because it contains a balanced ratio of pro-coagulatory and anti-coagulatory factors. For virus-inactivated pooled plasma and concentrates of clotting factors, sporadic reports of thromboembolic events have been published. Concentrates of clotting factors can be stored easily and are rapidly prepared for use. In contrast, fresh frozen plasma has to be thawed before application leading to a significant delay in the schedule. During activated hemostasis, the half-life of clotting factors is significantly reduced in comparison to a stable physiological situation. In the case of perioperative coagulopathy higher dosages of fresh plasma and clotting factors than those recommended in published guidelines are often necessary for successful treatment. When using fresh plasma for coagulation therapy the resulting volume load must be considered. In conclusion, a modern concept of perioperative coagulation management should include fresh plasma as well as concentrates of clotting factors. The anesthetist should be familiar with the available components and be able to consider and adapt them to the individual situation.

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Interessenkonflikt

Der korrespondierende Autor weist auf eine Verbindung mit folgender Firma/Firmen hin: Herr Dr. B. Heindl hat von der Firma ZLB Behring und Herr Dr. M. Spannagl von den Firmen ZLB Behring und Baxter Honorare für wissenschaftliche Vorträge erhalten.

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Heindl, B., Spannagl, M. Frischplasma und Faktorenkonzentrate zur Therapie der perioperativen Koagulopathie. Anaesthesist 55, 926–936 (2006). https://doi.org/10.1007/s00101-006-1038-z

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  • DOI: https://doi.org/10.1007/s00101-006-1038-z

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