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Pathophysiologie der Blutung

Pathophysiology of bleeding

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Zusammenfassung

Blutung ist mit einer erhöhten Morbidität und Mortalität assoziiert. In der Pathophysiologie einer Blutung spielen anatomische und hämostatische Ursachen eine zentrale Rolle, wobei anatomische Ursachen die weit häufigere Blutungsursache darstellen. Während Trauma und operative Eingriffe die führenden Ursachen einer Blutung in der operativen Medizin darstellen, stehen in der inneren Medizin die gastrointestinalen Blutungen im Vordergrund. Große Blutungen führen sekundär zu homöostatischen Störungen, die nicht nur die weitere Blutung verstärken, sondern auch in der Pathogenese der Organdysfunktion eine wichtige Rolle spielen. Erworbene Koagulopathien infolge einer antithrombotischen Therapie oder einer Grunderkrankung tragen zum Ausmaß und zur Dynamik einer Blutung bei, während hereditäre Blutungsdiathesen selten vorkommen. Das Gleichgewicht zwischen der physiologischen Pro- und Antikoagulation spielt in der Pathophysiologie der Blutung und Gerinnung eine große Rolle. Daher lässt sich die Pathophysiologie der Blutung allein durch einfach verfügbaren Gerinnungsparameter nicht abbilden. Das Ziel der Gerinnungskorrektur im Rahmen der Behandlung einer lebensbedrohlichen Blutung ist nicht die Normalisierung der Gerinnung, sondern die Blutstillung. Neben der genauen klinischen Einschätzung unter Berücksichtigung der Physiologie der Gerinnung kann die zielgerichtete Gerinnungsdiagnostik zur sinnvollen Steuerung der Gerinnungstherapie beitragen.

Abstract

Bleeding is associated with an increased morbidity and mortality. Anatomic and hemostatic causes play a central role in the pathophysiology of bleeding, with anatomic causes being by far more common. While trauma and invasive procedures are the leading causes of bleeding in surgical disciplines, gastrointestinal bleeding is the major cause of bleeding in internal medicine. Major bleedings lead to secondary homeostatic changes, which in turn not only contribute to further bleeding, but also to the pathogenesis of organ dysfunction. Acquired coagulopathies due to antithrombotic treatment or an underlying disease also contribute to the extent and the dynamics of bleeding, while hereditary bleeding disorders are seldom. The balance between the physiological pro- and anticoagulant pathway plays a significant role in the pathophysiology of bleeding and coagulation. Therefore, the pathophysiology of bleeding cannot be described by means of easily available laboratory coagulation workup. The aim of coagulation correction during the management of life-threatening bleeding is not to normalize coagulation, but rather to stop bleeding. Besides a careful clinical evaluation of the course of bleeding coupled with basic understanding of the physiology of coagulation, targeted laboratory coagulation workup can contribute to a rational coagulation treatment concept.

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  1. Interdisziplinäre Internistische Intensivmedizin, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland

    Sirak Petros

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S. Petros erhielt Vortragshonorar von CSL Behring und Sanofi. Er hat außerdem eine Forschungskooperation mit folgenden Firmen: CSL Behring, Leo, Stago, Werfen.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Valentin Fuhrmann, Duisburg

Sirak Petros, Leipzig

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Petros, S. Pathophysiologie der Blutung. Med Klin Intensivmed Notfmed 116, 475–481 (2021). https://doi.org/10.1007/s00063-021-00844-x

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