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Viskoelastizitätsbasierte „Point-of-care“-Gerinnungsdiagnostik im Kontext des Schockraummanagements von blutenden Traumapatienten

Diagnostik und Therapie der traumainduzierten Koagulopathie

Viscoelasticity-based point of care coagulation diagnostics in the context of resuscitation room management of severely injured and bleeding trauma patients

Diagnostics and treatment of trauma-induced coagulopathy

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Zusammenfassung

Nach wie vor ist die unkontrollierte Blutung mit einhergehender Störung der Blutgerinnungsfunktion, auch als traumainduzierte Koagulopathie (TIK) bezeichnet, die führende vermeidbare Todesursache beim Polytrauma. Letztere wird inzwischen als eigenständige Entität mit deutlichem Einfluss auf Morbidität und Mortalität wahrgenommen. In der klinischen Praxis werden schwerstverletzte und blutende Patienten neben den gängigen „Damage-Control-Surgery(DCS)“-Verfahren zur chirurgischen Blutungskontrolle häufig noch mit klassischen Blutprodukten in einem prädefinierten Verhältnis im Sinne des „Damage-Control-Resuscitation(DCR)“-Konzepts empirisch behandelt. Dabei stehen alternativ aber auch Algorithmen zur Verfügung, die anhand etablierter viskoelastizitätsbasierter „Point-of-Care(POC)“-Diagnostik-Verfahren und einer an Zielwerten orientierten Therapie erstellt wurden. Letztere ermöglichen zeit- und patientennah eine qualitative Untersuchung der Gerinnungsfunktion aus Vollblut und liefern unmittelbar therapeutisch nutzbare Hinweise auf Vorliegen, Entwicklung und Dynamik der Gerinnungsstörung. Der frühe Einsatz viskoelastizitätsbasierter POC-Verfahren im Kontext des Schockraummanagements schwerstverletzter und blutender Patienten wurde inzwischen mit Einsparungen potenziell auch schädlicher Blutprodukte, insbesondere bei Übertransfusion, sowie einem verbesserten Behandlungsergebnis einschließlich Überlebensvorteil vergesellschaftet. Im vorliegenden Beitrag werden die klinischen Fragestellungen zum Einsatz viskoelastizitätsbasierter Verfahren sowie Empfehlungen unter Berücksichtigung der aktuellen Literatur dargestellt.

Abstract

Uncontrolled bleeding with associated trauma-induced coagulopathy (TIC) remains the leading cause of preventable death after severe trauma. Meanwhile, TIC is recognized as a separate clinical entity with substantial impact on downstream morbidity and mortality. In clinical practice severely injured and bleeding patients are often still being treated according to established damage control surgery (DCS) procedures with surgical bleeding control and empirical transfusion of classical blood products in predefined ratios in the sense of damage control resuscitation (DCR); however, algorithms are also available, which have been constructed from established viscoelasticity-based point of care (POC) diagnostic procedures and target value-oriented treatments. The latter enables a timely qualitative assessment of coagulation function from whole blood at bedside and provides rapid and clinically useful information on the presence, development and dynamics of the coagulation disorder. The early implementation of viscoelasticity-based POC procedures in the context of resuscitation room management of severely injured and bleeding patients was uniformly associated with reductions in potentially harmful blood products, especially overtransfusions, and an overall improvement in outcome including survival. The present article reviews the clinical questions around the use of viscoelasticity-based procedures as well as recommendations for the early and acute management of bleeding trauma patients taking the current literature into account.

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Authors and Affiliations

  1. Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie, Kliniken der Stadt Köln-Merheim, Universität Witten/Herdecke (UW/H), Campus Köln-Merheim, Ostmerheimerstr. 200, 51109, Köln, Deutschland

    Marc Maegele

  2. Institut für Forschung in der Operativen Medizin (IFOM), Universität Witten/Herdecke (UW/H), Campus Köln-Merheim, Köln, Deutschland

    Marc Maegele

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Correspondence to Marc Maegele.

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M. Maegele erhielt Honorare für Vorträge, Mitarbeit in Beratungsgremien sowie Forschungsprojekte von Alexion, Astra Zeneca, Bayer, Biotest, IL-Werfen, LFB Biomedicaments, Portola Inc und TEM International.

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

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Maegele, M. Viskoelastizitätsbasierte „Point-of-care“-Gerinnungsdiagnostik im Kontext des Schockraummanagements von blutenden Traumapatienten. Unfallchirurgie 126, 542–551 (2023). https://doi.org/10.1007/s00113-023-01300-5

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