Der Anaesthesist

, Volume 60, Issue 6, pp 546–554 | Cite as

Behandlung von polytraumatisierten Patienten

Zusammenfassung der aktualisierten europäischen Leitlinien
Leitlinien und Empfehlungen

Zusammenfassung

Die Akutbehandlung polytraumatisierter Patienten mit Massenblutungen stellt trotz verbesserter chirurgischer und konventioneller Therapien eine besondere interdisziplinäre Herausforderung dar. Die epidemiologische Bedeutung dieses komplexen Krankheitsbilds ergibt sich aus der hohen Zahl von 5 Mio. Menschen, die weltweit jährlich an den Folgen eines Traumas sterben. Da traumaassoziierte Massenblutungen auf dem Boden einer Koagulopathie potenziell vermeidbar und behandelbar sind, gilt die Exsanguination als die häufigste vermeidbare Komplikation, die zum frühen Versterben nach Trauma führt. Mit dem Ziel, Behandlungsalgorithmen nach dem aktuellen Stand der Wissenschaft für die Versorgung schwer verletzter Patienten mit Gerinnungsstörungen zu entwickeln, wurde die „Task Force for Advanced Bleeding Care in Trauma“ 2005 gegründet. Die Erstveröffentlichung aus dem Jahr 2007 wurde entsprechend den Grundsätzen der „evidence-based medicine“ unter Berücksichtigung neuer klinischer Studien in überarbeiteter Form publiziert. Der vorliegende Beitrag gibt einen Überblick über die einzelnen Empfehlungen unter besonderer Berücksichtigung wesentlicher Neuerungen.

Schlüsselwörter

Trauma Blutungen Bluttransfusion Gerinnung Blutstillende Techniken 

Treatment of massive bleeding

Summary of the updated European guidelines

Abstract

Despite improved strategies in the treatment of polytraumatized patients the mortality rate of severely injured patients remains high. Thus, worldwide 5 million patients die due to trauma or trauma-related complications each year. As the majority of early trauma-related deaths are attributed to or caused by exsanguination the prevention and treatment of coagulopathy is of paramount significance. With the aim of developing guidelines and improve strategies to treat polytraumatized patients the multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2005. Under consideration of new clinical studies, an updated version of the original publication from 2007 has recently been published. Based on a systematic review of published literature the recommendations were formed according to “Grading of Recommendations Assessment, Development and Evaluation” (GRADE). This publication summarizes the main recommendations with a special emphasis on revisions and new aspects.

Keywords

Trauma Hemorrhages Blood transfusion Coagulation Hemostatic techniques 

Notes

Interessenkonflikt

O.G.: Im Rahmen experimenteller Studien wurden dem korrespondierenden Autor rFVIIa (NovoSeven®; Novo Nordisk), Fibrinogen (Haemocomplettan®, CSL Behring) und PPSB (Cofact®, Biotest) zur Verfügung gestellt. Außerdem erhielt O.G. Forschungsförderung von der Fa. Biotest.

R.R.: Der Koautor erhielt von den Firmen CSL Behring, Novo Nordisk, Bayer, Air Liquide Honorare für Vorlesungen und Beratertätigkeiten. Außerdem erhielt R.R. Forschungsförderung von den Firmen AGA-Linde, Air Liquide, Novo Nordisk, Eli Lilly and Glaxo Wellcome.

D.R.S.: Die Abteilung für Anästhesiologie erhält Förderung von den folgenden Institutionen bzw. Firmen: Universität Zürich, Zürich, Schweiz; the Research Award Center for Zurich Integrative Human Physiology, Zürich, Schweiz; the Swiss National Science Foundation, Bern, Schweiz (Fördernummer: SPUM 33CM30_124117); the European Society of Anaesthesiology (ESA), Brüssel, Belgien; the Swiss Society of Anesthesiology and Reanimation (SGAR), Bern, Schweiz; the Swiss Foundation for Anesthesia Research, Zürich, Schweiz; the Swiss Life Foundation Switzerland, Zürich, Schweiz; Bundesprogramm Chancengleichheit, Bern, Schweiz; Stiftung für Staublungen-Forschung, Zürich, Schweiz; B. Braun, Sempach, Schweiz; CSL Behring, Bern, Schweiz; Vifor SA, Villars-sur-Glâne, Schweiz, und UBS, Zürich, Schweiz.

D.R.S. ist Vorsitzender der „ABC Faculty“ und Mitglied der „ABC Trauma Faculty“, die von der Thomson Physicians World GmbH, Mannheim, Deutschland, und durch Novo Nordisk A/S, Bagsvärd, Dänemark, gefördert werden.

In den vergangenen 5 Jahren erhielt D.R.S. Honorare für Vorlesungen und Beratertätigkeiten von den folgenden Firmen: Abbott AG, Baar, Schweiz; AstraZeneca AG, Zug, Schweiz; Bayer (Schweiz) AG, Zürich, Schweiz; B. Braun Melsungen AG, Melsungen, Deutschland; Boehringer Ingelheim (Schweiz) GmbH, Basel, Schweiz; Bristol-Myers-Squibb, Rueil-Malmaison Cedex, Frankreich; CSL Behring GmbH, Hattersheim a. M., Deutschland, und Bern, Schweiz; Curacyte AG, München, Deutschland; Ethicon Biosurgery, Sommerville, New Jersey, USA; Fresenius SE, Bad Homburg v.d.H., Deutschland; Galenica AG, Bern, Schweiz (inbegriffen Vifor SA, Villars-sur-Glâne, Schweiz); GlaxoSmithKline GmbH & Co. KG, Hamburg, Deutschland; Janssen-Cilag AG, Baar, Schweiz; Novo Nordisk A/S, Bagsvärd, Dänemark; Octapharma AG, Lachen, Schweiz; Organon AG, Pfäffikon/SZ, Schweiz; Oxygen Biotherapeutics, Costa Mesa, Kalifornien; Pentapharm GmbH (tem International), München, Deutschland; Roche Pharma (Schweiz) AG, Reinach, Schweiz, und Schering-Plough International, Inc., Kenilworth, New Jersey, USA.

Die Autoren versichern, dass die Präsentation des Themas unabhängig und die Darstellung der Inhalte produktneutral ist.

Literatur

  1. 1.
    Hoyt DB (2004) A clinical review of bleeding dilemmas in trauma. Semin Hematol 41:40–43PubMedCrossRefGoogle Scholar
  2. 2.
    Spahn DR, Cerny V, Coats TJ et al (2007) Task Force for Advanced Bleeding Care in Trauma. Management of bleeding following major trauma: a European guideline. Crit Care 11:R17PubMedCrossRefGoogle Scholar
  3. 3.
    Rossaint R, Bouillon B, Cerny V et al (2010) Management of bleeding following major trauma: an updated European guideline. Crit Care 14:R52PubMedCrossRefGoogle Scholar
  4. 4.
    Guyatt G, Gutterman D, Baumann MH et al (2006) Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians task force. Chest 129:174–181PubMedCrossRefGoogle Scholar
  5. 5.
    Cothren CC, Moore EE, Hedegaard HB, Meng K (2007) Epidemiology of urban trauma deaths: a comprehensive reassessment 10 years later. World J Surg 31:1507–1511PubMedCrossRefGoogle Scholar
  6. 6.
    Beekley AC, Sebesta JA, Blackbourne LH et al (2008) 31st Combat Support Hospital Research Group. Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes. J Trauma 64:28–37CrossRefGoogle Scholar
  7. 7.
    Vincent JL, Dufaye P, Berre J et al (1983) Serial lactate determinations during circulatory shock. Crit Care Med 11:449–451PubMedCrossRefGoogle Scholar
  8. 8.
    Davis JW, Parks SN, Kaups KL et al (1996) Admission base deficit predicts transfusion requirements and risk of complications. J Trauma 41:769–774PubMedCrossRefGoogle Scholar
  9. 9.
    Lynn M, Jeroukhimov I, Klein Y, Martinowitz U (2002) Updates in the management of severe coagulopathy in trauma patients. Intensive Care Med 28:241–247CrossRefGoogle Scholar
  10. 10.
    Stone HH, Strom PR, Mullins RJ (1983) Management of the major coagulopathy with onset during laparotomy. Ann Surg 197:532–535PubMedCrossRefGoogle Scholar
  11. 11.
    Rotondo MF, Schwab CW, McGonigal MD et al (1993) „Damage control“: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 35:375–382PubMedCrossRefGoogle Scholar
  12. 12.
    Ertel W, Keel M, Eid K et al (2001) Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma 15:468–474PubMedCrossRefGoogle Scholar
  13. 13.
    Aufderheide TP, Sigurdsson G, Pirrallo RG et al (2004) Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation 109:1960–1965PubMedCrossRefGoogle Scholar
  14. 14.
    Davis DP, Hoyt DB, Ochs M et al (2003) The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. J Trauma 54:444–453PubMedCrossRefGoogle Scholar
  15. 15.
    Maegele M, Lefering R, Yucel N et al (2007) Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients. Injury 38:298–304PubMedCrossRefGoogle Scholar
  16. 16.
    Mann KG, Butenas S, Brummel K (2003) The dynamics of thrombin formation. Arterioscler Thromb Vasc Biol 23:17–25PubMedCrossRefGoogle Scholar
  17. 17.
    Ganter MT, Hofer CK (2008) Coagulation monitoring: current techniques and clinical use of viscoelastic point-of-care coagulation devices. Anesth Analg 106:1366–1375PubMedCrossRefGoogle Scholar
  18. 18.
    Schierhout G, Roberts I (1998) Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomised trials. BMJ 316:961–964PubMedGoogle Scholar
  19. 19.
    Cochrane Injuries Group (1998) Human albumin administration in critically ill patients: systematic review of randomised controlled trials. Cochrane Injuries Group Albumin Reviewers. BMJ 317:235–240Google Scholar
  20. 20.
    Roberts I, Alderson P, Bunn F et al (2004) Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev:CD000567Google Scholar
  21. 21.
    Bernabei AF, Levison MA, Bender JS (1992) The effects of hypothermia and injury severity on blood loss during trauma laparotomy. J Trauma 33:835–839PubMedCrossRefGoogle Scholar
  22. 22.
    Shafi S, Elliott AC, Gentilello L (2005) Is hypothermia simply a marker of shock and injury severity or an independent risk factor for mortality in trauma patients? Analysis of a large national trauma registry. J Trauma 59:1081–1085PubMedCrossRefGoogle Scholar
  23. 23.
    Smith MJ, Stiefel MF, Magge S et al (2005) Packed red blood cell transfusion increases local cerebral oxygenation. Crit Care Med 33:1104–1108PubMedCrossRefGoogle Scholar
  24. 24.
    Leal-Noval SR, Rincon-Ferrari MD, Marin-Niebla A et al (2006) Transfusion of erythrocyte concentrates produces a variable increment on cerebral oxygenation in patients with severe traumatic brain injury: a preliminary study. Intensive Care Med 32:1733–1740PubMedCrossRefGoogle Scholar
  25. 25.
    Leal-Noval SR, Munoz-Gomez M, Arellano-Orden V et al (2008) Impact of age of transfused blood on cerebral oxygenation in male patients with severe traumatic brain injury. Crit Care Med 36:1290–1296PubMedCrossRefGoogle Scholar
  26. 26.
    Zygun DA, Nortje J, Hutchinson PJ et al (2009) The effect of red blood cell transfusion on cerebral oxygenation and metabolism after severe traumatic brain injury. Crit Care Med 37:1074–1078PubMedCrossRefGoogle Scholar
  27. 27.
    Salim A, Hadjizacharia P, DuBose J et al (2008) Role of anemia in traumatic brain injury. J Am Coll Surg 207:398–406PubMedCrossRefGoogle Scholar
  28. 28.
    Hunt BJ (1998) Indications for therapeutic platelet transfusions. Blood Rev 12:227-1233PubMedCrossRefGoogle Scholar
  29. 29.
    Consensus conference (1987) Platelet transfusion therapy. JAMA 257:1777–1780CrossRefGoogle Scholar
  30. 30.
    Stanworth SJ, Brunskill SJ, Hyde CJ et al (2004) Is fresh frozen plasma clinically effective? A systematic review of randomized controlled trials. Br J Haematol 126:139–152PubMedCrossRefGoogle Scholar
  31. 31.
    Holcomb JB, Wade CE, Michalek JE et al (2008) Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg 248:447–458PubMedGoogle Scholar
  32. 32.
    Spinella PC, Perkins JG, Grathwohl KW et al (2008) Effect of plasma and red blood cell transfusions on survival in patients with combat related traumatic injuries. J Trauma 64:69–77CrossRefGoogle Scholar
  33. 33.
    Borgman MA, Spinella PC, Perkins JG et al (2007) The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 63:805–813PubMedCrossRefGoogle Scholar
  34. 34.
    Duchesne JC, Hunt JP, Wahl G et al (2008) Review of current blood transfusions strategies in a mature level I trauma center: were we wrong for the last 60 years? J Trauma 65:272–276PubMedCrossRefGoogle Scholar
  35. 35.
    Fenger-Eriksen C, Lindberg-Larsen M, Christensen AQ et al (2008) Fibrinogen concentrate substitution therapy in patients with massive haemorrhage and low plasma fibrinogen concentrations. Br J Anaesth 101:769–773PubMedCrossRefGoogle Scholar
  36. 36.
    Fenger-Eriksen C, Jensen TM, Kristensen BS et al (2009) Fibrinogen substitution improves whole blood clot firmness after dilution with hydroxyethyl starch in bleeding patients undergoing radical cystectomy: a randomized, placebo-controlled clinical trial. J Thromb Haemost 7:795–802PubMedCrossRefGoogle Scholar
  37. 37.
    Solomon C, Pichlmaier U, Schoechl H et al (2010) Recovery of fibrinogen after administration of fibrinogen concentrate to patients with severe bleeding after cardiopulmonary bypass surgery. Br J Anaesth 104:555–562PubMedCrossRefGoogle Scholar
  38. 38.
    Stinger HK, Spinella PC, Perkins JG et al (2008) The ratio of fibrinogen to red cells transfused affects survival in casualties receiving massive transfusions at an army combat support hospital. J Trauma 64:79–85CrossRefGoogle Scholar
  39. 39.
    Charbit B, Mandelbrot L, Samain E et al (2007) The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost 266–273Google Scholar
  40. 40.
    Kalina U, Bickhard H, Schulte S (2008) Biochemical comparison of seven commercially available prothrombin complex concentrates. Int J Clin Pract 62:1614–1622PubMedCrossRefGoogle Scholar
  41. 41.
    Bruce D, Nokes TJ (2008) Prothrombin complex concentrate (Beriplex P/N) in severe bleeding: experience in a large tertiary hospital. Crit Care 12:R105PubMedCrossRefGoogle Scholar
  42. 42.
    Grottke O, Henzler D, Rossaint R (2010) Activated recombinant factor VII (rFVIIa). Best Pract Res Clin Anaesthesiol 24:95–106PubMedCrossRefGoogle Scholar
  43. 43.
    Boffard KD, Riou B, Warren B et al (2005) NovoSeven Trauma Study Group. 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 5:8–15CrossRefGoogle Scholar
  44. 44.
    O’Connell KA, Wood JJ, Wise RP et al (2006) Thromboembolic adverse events after use of recombinant human coagulation factor VIIa. JAMA 295:293–298CrossRefGoogle Scholar
  45. 45.
    Mangano DT, Tudor IC, Dietzel C (2006) The risk associated with aprotinin in cardiac surgery. N Engl J Med 354:353–365PubMedCrossRefGoogle Scholar
  46. 46.
    CRASH-2 trial collaborators, Shakur H, Roberts I, Bautista R et al (2010) Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 376:23–32Google Scholar
  47. 47.
    Carless PA, Henry DA, Moxey AJ et al (2004) Desmopressin for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev:CD001884Google Scholar
  48. 48.
    Crescenzi G, Landoni G, Biondi-Zoccai G et al (2008) Desmopressin reduces transfusion needs after surgery: a meta-analysis of randomized clinical trials. Anesthesiology 109:1063–1076PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  1. 1.Klinik für AnästhesiologieUniversitätsklinikum AachenAachenDeutschland
  2. 2.Institut für AnästhesiologieUniversitätsspital ZürichZürichSchweiz

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