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Stand der Gerinnungs- und Transfusionstherapie beim Schwerverletzten

Eine deutschlandweite Online-Umfrage

Current practice in coagulation and transfusion therapy in multiple trauma patients

A German nation-wide online survey

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Zusammenfassung

Hintergrund

Kaum ein anderer Bereich der Polytraumaversorgung hat in den letzten Jahren klinisch und wissenschaftlich derart viele Fortschritte erlebt wie die Pathophysiologie und Therapie der Koagulopathie/Hämorrhagie. In einer deutschlandweiten Umfrage sollte untersucht werden, inwieweit eine Sensibilisierung besteht und welche Managementstrategien angewendet werden.

Patienten und Methoden

Im Zeitraum Oktober 2011 bis Januar 2012 erfolgte eine Umfrage via Online-Fragebogen über den E-Mail-Verteiler der Deutschen Gesellschaft für Unfallchirurgie, welche 12 Fragen zu aktuellen Konzepten der Gerinnungs- und Transfusionstherapie beim Schwerverletzten beinhaltete.

Ergebnisse

Die Rücklaufquote vollständiger Fragebögen betrug 145/3006 (5 %). Die Teilnehmer der Online-Umfrage teilten sich folgendermaßen auf: 77,2 % Unfallchirurgie/Orthopädie, 15,9 % Anästhesiologie, 6,9 % andere Fachrichtungen. 64 % der Antwortenden waren in einem überregionalen und nur ca. 17 % in einem lokalen Traumazentrum tätig. Der Großteil (94 %) gab an, regelhaft Maßnahmen zur Vermeidung der Hypothermie einzusetzen. Nur ca. die Hälfte der Teilnehmer gaben an, an ihrer Klinik ein Massentransfusionsprotokoll zu verwenden. Die möglichen Inhalte dieser Protokolle wurden in unterschiedlichen Häufigkeiten angegeben und zwar einerseits gängige Komponenten (u. a. FFP 78 %; Fibrinogen 75 %), als auch Therapien für die beim Polytrauma eher schlechte Evidenz besteht (Desmopressin 39 %, rFVIIa 47 %). Das in Leitlinien durchgehend empfohlene Calcium war bei 48 % der Teilnehmer im Protokoll vorgesehen.

Schlussfolgerung

Die Umfrageergebnisse deuten darauf hin, dass in Deutschland kaum standardisierte Strukturen zu Diagnostik/Therapie der traumaassoziierten Koagulopathie bestehen, bei zumindest relativ differenziertem Blutungs- und Gerinnungsmanagement in den überregionalen Traumazentren („Level 1“), auch wenn große Variationen bezüglich der einzelnen Komponenten bestehen. Auch angesichts der Rücklaufquote stellen Gerinnung und Hämorrhagie für die meisten Unfallchirurgen weiterhin eher „Expertenthemen“ dar.

Abstract

Background

In recent years, the treatment of trauma-associated coagulopathy and bleeding has advanced enormously. The aim of this study was to assess the current practice of coagulation and transfusion management in Germany.

Patients and methods

From October 2011 until January 2012 we conducted a survey via online-questionnaire that was sent per E-Mail to all members of the German Society for Trauma Surgery. It comprised 12 questions with respect to current treatment of coagulopathy and haemorrhage in trauma patients.

Results

The response rate was 145/3006 (5 %). The respondents had following specialties: 77.2 % trauma surgery 15.9 % anesthesiology, 6.9 % others. 64 % of respondents were employed by a Level 1 trauma centre, wheras 17 % worked in a local level 3 centre. The majority (94 %) claimed to treat hypothermia regularly. Only about half of the participants reported to follow a massive transfusion protocol in their institution. The potential components of these protocols were reported in varying rates, being it well-established components (e.g. FFP 78 %; Fibrinogen 75 %) or therapies with poor evidence in multiple trauma (Desmopressin 39 %, rFVIIa 47 %). Calcium was provided by only 48 % of respondents although generally recommended in all guidelines.

Conclusion

The current study suggests that in Germany strategies and principles regarding management of trauma-associated coagulopathy are standardized only poorly. Level 1 centres appear to apply a more advanced approach, however to much variability exists with respect to the components of the transfusion protocols. The low response rate indicates that most German trauma surgeons consider coagulation and hemorrhage as “expert-topics” beyond their field of duty.

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Abbreviations

BE:

„Base excess“

BGA:

Blutgasanalyse

EK:

Erythrozytenkonzentrat

FFP:

Gefrorenes Frischplasma

Hb:

Hämoglobin

INR:

„International normalized ratio“

ISS:

„Injury Severity Score“

PPSB:

Prothrombinkomplexkonzentrat

PTT:

Partielle Thromboplastinzeit

rFVIIa:

Aktivierter rekombinanter Faktor VII

ROTEG®:

Rotationsthrombelastometrie

ROTEM®:

Rotationsthrombelastographie

SOP:

„Standard operating procedure“

TK:

Thrombozytenkonzentrat

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Einhaltung ethischer Richtlinien

Interessenkonflikt. A. Wafaisade, H. Wyen, M. Mutschler, S. Lendemans, B. Bouillon, S. Flohe, T. Paffrath, M. Maegele, T. Tjardes und C. Probst geben an, dass kein Interessenkonflikt besteht. Der Beitrag enthält keine Studien an Menschen oder Tieren.

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Authors and Affiliations

  1. Lehrstuhl für Unfallchirurgie, Orthopädie und Sporttraumatologie, Universität Witten/Herdecke am Klinikum Köln-Merheim, Ostmerheimer Straße 200, 51109, Köln, Deutschland

    A. Wafaisade, M. Mutschler, B. Bouillon, T. Paffrath, M. Maegele, T. Tjardes & C. Probst

  2. Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Klinikum der J.W. Goethe-Universität, Frankfurt am Main, Deutschland

    H. Wyen

  3. Klinik für Unfallchirurgie, Universitätsklinikum Essen, Essen, Deutschland

    S. Lendemans

  4. Klinik für Unfall- und Handchirurgie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland

    S. Flohe

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  1. A. Wafaisade
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Correspondence to A. Wafaisade.

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Wafaisade, A., Wyen, H., Mutschler, M. et al. Stand der Gerinnungs- und Transfusionstherapie beim Schwerverletzten. Unfallchirurg 118, 1033–1040 (2015). https://doi.org/10.1007/s00113-014-2596-1

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