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Rahmenbedingungen für eine intakte Hämostase

Was muss am Unfallort, im Schockraum und intraoperativ beachtet werden?

Prerequisites of a functional haemostasis

What must be considered at the scene of an accident, in the emergency room and during an operation?

  • Notfallmedizin
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Zusammenfassung

Eine Koagulopathie hat sich als unabhängiger Prädiktor für die perioperative Mortalität erwiesen. Deshalb wird die Erhaltung einer stabilen Gerinnungssituation als eine wichtige Voraussetzung angesehen, um die perioperative Morbidität und Mortalität zu reduzieren. Eine intakte Gerinnung ist an enge Rahmenbedingungen bezüglich Körpertemperatur, Säure-Basen-Haushalt, Plasma-Kalzium-Spiegel und Hämatokrit geknüpft. Notfallsituationen, wie schwer traumatisierte Patienten und ausgeprägte operationsbedingte Blutungen, können einen erheblichen Einfluss auf die Rahmenbedingungen einer intakten Hämostase ausüben und eine klinisch relevante Blutung fördern. Dabei sind die herkömmlichen Globaltests der Gerinnung bei der Diagnostik von Störungen der Rahmenbedingungen wenig hilfreich, da diese Untersuchungen ausschließlich mit Plasma bei einer genormten Temperatur von 37°C mit einem Kalziumüberschuss und bei ausgeglichenem Säure-Basen-Status durchgeführt werden. Damit sind die Laborergebnisse im Kontext der instabilen Rahmenbedingungen der Gerinnung wenig aussagekräftig. Deshalb ist die Kenntnis der Auswirkungen von veränderten, die Gerinnung beeinflussenden Rahmenbedingungen eine Voraussetzung zur Vermeidung schwerer Koagulopathien mit möglicherweise letalem Ausgang. Es konnte gezeigt werden, dass ein deutliches Risiko für das Auftreten klinisch bedeutsamer Koagulopathien besteht, wenn eine Körpertemperatur ≤34°C, ein pH-Wert ≤7,15, eine Konzentration des ionisierten Kalziums unter 0,9 mmol/l und/oder ein Hämatokrit unter 30–35% vorliegen. Das kombinierte Auftreten der angeführten Faktoren verschlechtert die Blutgerinnungsfähigkeit zusätzlich. Besonders nachteilig wirkt sich das gleichzeitige Auftreten von Hypothermie und Acidose aus. Die Optimierung der Rahmenbedingungen sollte möglichst früh, also bereits an der Unfallstelle beginnen und im Schockraum und OP-Saal fortgeführt werden. Der folgende Artikel soll anhand der Literaturdaten eine Übersicht zu den die Gerinnung beeinflussenden Rahmenbedingungen geben und Möglichkeiten zum Erhalt einer intakten Hämostase aufzeigen.

Abstract

A coagulopathy is an independent predictor of perioperative mortality. Therefore, maintenance of a functional coagulation system is an essential precondition to reduce morbidity and mortality in the perioperative setting. Sound coagulability also depends on prerequisites such as body temperature, acid-base balance, plasma calcium concentration and haematocrit. Severe trauma or perioperative bleeding can gravely influence these factors and boost the blood loss. Common global tests of coagulation are not helpful in this setting because they are conducted on plasma with a normalised temperature of 37°C, an excess of calcium and a stabile acid-base balance. Hence, knowledge of the effects of altered prerequisites is a premise to avoid a possibly lethal coagulopathy. According to the current literature, an increased risk for clinically significant coagulopathy exists with a body temperature ≤34°C, an acidosis ≤7.15, ionised calcium under 0.9 mmol/l or a haematocrit under 30–35%. A combination of these factors deteriorates the coagulopathy and hypothermia in addition to acidosis is especially harmful. Prevention of derangement of these factors should start as early as possible, i.e. in trauma patients at the scene of the accident and should be continued in the operating room.

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Abbreviations

AISS:

„abdominal injury severity score“

ATIII:

Antithrombin III

BT:

Blutungszeit

Ca++:

Kalzium

Cai++:

ionisiertes Ca++

CI:

„confidence interval“

EK:

Erythrozytenkonzentrat

F:

Gerinnungsfaktor

FFP:

„fresh frozen plasma“

HAES:

Hydroxyäthylstärke

Hb:

Hämoglobin

HKT:

Hämatokrit

ISS:

„injury severity score“

OR:

Odd-Ratio

PFA-100:

Plättchenfunktionsanalysator

PTT:

partielle Thromboplastinzeit

Q:

Quick-Wert

SHT:

Schädel-Hirn-Trauma

TAT:

Thrombin-Antithrombin-Komplexe

TEG:

Thrombelastographie

TF:

„tissue factor“

TK:

Thrombozytenkonzentrat

TS:

„trauma score“

TZ:

Thrombinzeit

vWF:

Von-Willebrand-Faktor

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Danksagung

Die Autoren bedanken sich bei Frau Melanie Stroman, Apotheke KKH Rendsburg, für die Berechnungen der Tab. 4 und bei Prof. Dr. B. Poetzsch, Institut für Experimentelle Hämatologie und Transfusionsmedizin der Universität Bonn, für die kritische Durchsicht des Manuskriptes.

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  1. Klinik für Anästhesie und Intensivmedizin, Westküstenklinikum, Heide, Deutschland

    S. Schröder

  2. Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universität, Kerpener Str. 62, 50937, Köln, Deutschland

    H. Lier & S. Kampe

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Lier, H., Kampe, S. & Schröder, S. Rahmenbedingungen für eine intakte Hämostase. Anaesthesist 56, 239–251 (2007). https://doi.org/10.1007/s00101-006-1109-1

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