Skip to main content
SpringerLink
Log in

Koagulopathie

Bedeutung beim polytraumatisierten Patienten und aktuelle Aspekte der Gerinnungstherapie

Coagulopathy in multiple trauma: new aspects of therapy

  • CME Weiterbildung • Zertifizierte Fortbildung
  • Published:
Der Anaesthesist Aims and scope Submit manuscript

Zusammenfassung

Gerinnungsstörungen zählen zu den häufigsten Ursachen posttraumatischer Exsanguinationen, die mit einer Letalität von bis zu 40% assoziiert sind. Da die Massenblutung auf dem Boden einer Koagulopathie potenziell vermeidbar ist, gilt das Verbluten als die häufigste vermeidbare Komplikation, die zum Versterben nach Trauma führt. Die Koagulopathie ist oft multifaktoriell und wird u. a. durch den blutungsbedingten Verlust bzw. die Dilution der Gerinnungsfaktoren und Thrombozyten verursacht. Das gleichzeitige Vorliegen einer Azidose, Hypothermie und Koagulopathie wird aufgrund der damit assoziierten hohen Letalität oft auch als „lethal triad“ bezeichnet. Zur Behandlung einer manifesten Koagulopathie wird zumeist eine empirische Therapie mit hämostatisch wirksamen Blutprodukten eingeleitet. Allerdings ist die Transfusion von Erythrozytenkonzentraten komplikationsbehaftet, da sie mit postoperativen Infektionen und Multiorganversagen assoziiert ist. Beim Management der Massenblutung ist daher eine klare Strategie zur Verhinderung einer Koagulopathie bzw. zur Wiederherstellung des hämostatischen Gleichgewichts erforderlich, um ein Ausbluten des Patienten zu verhindern und die Notwendigkeit zur Transfusion mit Erythrozyten zu minimieren.

Abstract

Coagulopathy after trauma is a major cause for uncontrolled hemorrhage in trauma vicitims. Approximately 40% of trauma related deaths are attributed to or caused by exsanguination. Therefore the prevention of coagulopathy is regarded as the leading cause of avoidable death in these patients. Massive hemorrhage after trauma is usually caused by a combination of surgical and coagulopathic bleeding. Coagulopathic bleeding is multifactorial, including dilution and consumption of both platelets and coagulation factors, as well as dysfunction of the coagulation system. Because of the high mortality associated with hypothermia, acidosis and progressive coagulopathy, this vicious circle is often referred to as the lethal triad, potentially leading to exsanguination. To overcome this coagulopahty-related bleeding an empiric therapy is often instituted by replacing blood components. However, the use of transfusion of red blood cells has been shown to be associated with post-injury infection and multiple organ failure. In the management of mass bleeding it is therefore crucial to have a clear strategy to prevent coagulopathy and to minimize the need for blood transfusion.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4

Literatur

  1. Ahonen J, Jokela R (2005) Recombinant factor VIIa for life-threatening post-partum haemorrhage. Br J Anaesth 94: 592–595

    Article  PubMed  Google Scholar 

  2. Armand R, Hess JR (2003) Treating coagulopathy in trauma patients. Transfus Med Rev 17: 223–231

    Article  PubMed  Google Scholar 

  3. Barrowcliffe TW, Cattaneo M, Podda GM et al. (2006) New approaches for measuring coagulation. Haemophilia 12: 76–81

    Article  PubMed  Google Scholar 

  4. Boffard KD, Riou B, Warren B et al.; NovoSeven Trauma Study Group (2005) 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: 8–15

    Google Scholar 

  5. Carless PA, Henry DA, Moxey AJ et al. (2004) Desmopressin for minimising perioperative allogeneic blood transfusion. Cochrane Database 1: CD001884

    Google Scholar 

  6. Ciavarella D, Reed RL, Counts RB et al. (1987) Clotting factor levels and the risk of diffuse microvascular bleeding in the massively transfused patient. Br J Haematol 67: 365–368

    PubMed  Google Scholar 

  7. Claridge JA, Sawyer RG, Schulman AM et al. (2002) Blood transfusions correlate with infections in trauma patients in a dose-dependent manner. Am Surg 68: 566–572

    PubMed  Google Scholar 

  8. Cosgriff N, Moore EE, Sauaia A et al. (1997) Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidoses revisited. J Trauma 42: 857–861

    PubMed  Google Scholar 

  9. Dietrich W, Spath P, Ebell A, Richter JA (1997) Prevalence of anaphylactic reactions to aprotinin: analysis of two hundred forty-eight reexposures to aprotinin in heart operations. J Thorac Cardiovasc Surg 113: 194–201

    Article  PubMed  Google Scholar 

  10. Dzik WH (2004) Predicting hemorrhage using preoperative coagulation screening assays. Curr Hematol Rep 3: 324–330

    PubMed  Google Scholar 

  11. Engelman DT, Gabram SG, Allen L et al. (1996) Hypercoagulability following multiple trauma. World J Surg 20: 5–10

    Article  PubMed  Google Scholar 

  12. Enomoto TM, Thorborg P (2005) Emerging off-label uses for recombinant activated factor VII: grading the evidence. Crit Care Clin 21: 611–632

    Article  PubMed  Google Scholar 

  13. Erber WN (2002) Massive blood transfusion in the elective surgical setting. Transfus Apher Sci 27: 83–92

    Article  PubMed  Google Scholar 

  14. Fries D, Krismer A, Klingler A et al. (2005) Effect of fibrinogen on reversal of dilutional coagulopathy: a porcine model. Br J Anaesth 95: 172–177

    Article  PubMed  Google Scholar 

  15. Gubler KD, Gentilello LM, Hassantash SA, Maier RV (1994) The impact of hypothermia on dilutional coagulopathy. J Trauma 36: 847–851

    PubMed  Google Scholar 

  16. Heddle NM (1999) Pathophysiology of febrile nonhemolytic transfusion reactions. Curr Opin Hematol 6: 420–426

    Article  PubMed  Google Scholar 

  17. Henry DA, Moxey AJ, Carless PA et al. (2001) Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database 1: CD001886

    PubMed  Google Scholar 

  18. Hiippala S (1998) Replacement of massive blood. Vox Sang 74: 399–407

    PubMed  Google Scholar 

  19. Hoffman M, Monroe DM (2001) A cell-based model of hemostasis. Thromb Haemost 85: 958–966

    PubMed  Google Scholar 

  20. Hoyt DB (2004) A clinical review of bleeding dilemmas in trauma. Semin Hematol 41: 40–43

    Article  PubMed  Google Scholar 

  21. Lynn M, Jeroukhimov I, Klein Y, Martinowitz U (2002) Updates in the management of severe coagulopathy in trauma patients. Intensive Care Med 28: 241–247

    Article  Google Scholar 

  22. Mahdy AM, Webster NR (2004) Perioperative systemic haemostatic agents. Br J Anaesth 93: 842–858

    Article  PubMed  Google Scholar 

  23. Mangano DT, Tudor IC, Dietzel C; Multicenter Study of Perioperative Ischemia Research Group Ischemia Research and Education Foundation (2006) The risk associated with aprotinin in cardiac surgery. N Engl J Med 354: 353–365

    Article  PubMed  Google Scholar 

  24. Mannucci PM (2004) Treatment of von Willebrand’s disease. N Engl J Med 351: 683–694

    Article  PubMed  Google Scholar 

  25. Martinowitz U, Michaelson M; The Israeli Multidisciplinary rFVIIa Task Force (2005) Guidelines for the use of recombinant activated factor VII (rFVIIa) in uncontrolled bleeding: a report by the Israeli Multidisciplinary rFVIIa Task Force. J Thromb Haemost 3: 640–648

    Article  PubMed  Google Scholar 

  26. Meng ZH, Wolberg AS, Monroe DM, Hoffman M (2003) The effect of temperature and pH on the activity of factor VIIa: implications for the efficacy of high-dose factor VIIa in hypothermic and acidotic patients. J Trauma 55: 886–891

    PubMed  Google Scholar 

  27. Moore FA, Moore EE, Sauaia A (1997) An independent risk factor for postinjury multiple organ failure. Arch Surg 132: 620–624

    PubMed  Google Scholar 

  28. Murray CJ, Lopez AD (1997) Mortality by cause for eight regions of the world: Global Burden of Disease Study. Lancet 349: 1269–1276

    Article  PubMed  Google Scholar 

  29. Murray CJ, Lopez AD (1997) Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study. Lancet 349: 1498–1504

    Article  PubMed  Google Scholar 

  30. Peden M, McGee K, Sharma G (2002) The injury chart book; a graphical overview of the global burden of injuries. World Health Organisation, Geneva

  31. Peng RY, Bongard FS (1999) Hypothermia in trauma patients. J Am Coll Surg 188: 685–696

    Article  PubMed  Google Scholar 

  32. Pomper GJ, Wu Y (2003) Risks of transfusion-transmitted infections: 2003. Curr Opin Hematol 10: 412–418

    Article  PubMed  Google Scholar 

  33. Rossaint R, Cerny V, Coats TJ et al. (2006) Key issues in advanced bleeding care in trauma. Shock 26: 322–331

    Article  PubMed  Google Scholar 

  34. Rouger P, Noizat-Pirenne F, Le Pennec PY (2000) Haemovigilance and transfusion safety in France. Vox Sang 78: 287–289

    PubMed  Google Scholar 

  35. Schreiber MA (2004) Damage control surgery. Crit Care Clin 20: 101–118

    Article  PubMed  Google Scholar 

  36. Schroeder ML (2002) Transfusion-associated graft-versus-host disease. Br J Haematol 117: 275–287

    Article  PubMed  Google Scholar 

  37. Spahn DR, Rossaint R (2005) Coagulopathy and blood component transfusion in trauma. Br J Anaesth 95: 130–139

    Article  PubMed  Google Scholar 

  38. Stainsby D, MacLennan S, Hamilton PJ (2000) Management of massive blood loss: a template guideline. Br J Anaesth 85: 487–491

    PubMed  Google Scholar 

  39. 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: 139–152

    Article  PubMed  Google Scholar 

  40. Vincent JL, Rossaint R, Riou B et al. (2006) Recommendations on the use of recombinant activated factor VII as an adjunctive treatment for massive bleeding – a European perspective. Crit Care 10: R120

    Article  PubMed  Google Scholar 

  41. Wolberg AS, Meng ZH, Monroe DM, Hoffman M (2004) A systematic evaluation of the effect of temperature on coagulation enzyme activity and platelet function. J Trauma 56: 1221–1228

    PubMed  Google Scholar 

  42. Yoshihara H, Yamamoto T, Mihara H (1985) Changes in coagulation and fibrinolysis occurring in dogs during hypothermia. Thromb Res 37: 503–512

    Article  PubMed  Google Scholar 

Download references

Interessenkonflikt

Es besteht kein Interessenkonflikt. Der korrespondierende Autor versichert, dass keine Verbindungen mit einer Firma, deren Produkt in dem Artikel genannt ist, oder einer Firma, die ein Konkurrenzprodukt vertreibt, bestehen. Die Präsentation des Themas ist unabhängig und die Darstellung der Inhalte produktneutral.

Author information

Authors and Affiliations

  1. Klinik für Anästhesiologie, Universitätklinikum, Pauwelsstraße 30, 52074, Aachen, Deutschland

    O. Grottke MPH, D. Henzler & R. Rossaint

  2. Institut für Anästhesiologie, Universitätsspital, Zürich, Schweiz

    D.R. Spahn

Authors
  1. O. Grottke MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. D. Henzler
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. D.R. Spahn
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. R. Rossaint
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to O. Grottke MPH.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Grottke, O., Henzler, D., Spahn, D. et al. Koagulopathie. Anaesthesist 56, 95–108 (2007). https://doi.org/10.1007/s00101-006-1120-6

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00101-006-1120-6

Schlüsselwörter

Keywords

Search

Navigation