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Thrombozytenfunktionsstörung bei Traumapatienten, ein unterschätztes Problem? Ergebnisse einer monozentrischen Untersuchung

Platelet function disorder in trauma patients, an underestimated problem? Results of a single center study

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Zusammenfassung

Hintergrund

Plasmatische Gerinnungsstörungen bei Schwerverletzten sind häufig; zu thrombozytären Funktionsstörungen existiert nur wenig Evidenz. Ein Monitoring der Thrombozytenfunktion ist nicht etabliert.

Methodik

Retrospektive monozentrische Studie an einem überregionalen Traumazentrum von 2010–2016. Bei Patienten, die nach den Kriterien des DGU-Traumaregisters über den Schockraum als Direktzuweisung vom Unfallort aufgenommen wurden, war eine Bestimmung der Thrombozytenfunktion mittels Platelet Function Analyzer (PFA 100®) erfolgt. Nach Ausschluss aller Patienten mit gerinnungswirksamer Dauermedikation wurden mögliche Einflussfaktoren einer Thrombozytenfunktionsstörung ermittelt.

Ergebnisse

Von 310 Patienten (44,0 ± 14,7 Jahre, 76 % männlich, Verletzungsschwere im „Injury Severity Score“ [ISS] 28,4 ± 14,2 Punkte) zeigten sich eine verzögerte Thrombozytenaktivierung im Ansatz mit ADP bei 25,5 %, mit Epinephrin bei 31 %. In Laborparametern ergaben sich Hinweise auf einen höheren Blutverlust. Verlängerte Verschlusszeiten gingen einher mit einer erhöhten Transfusionsrate und einer erhöhten Mortalität. Logistische Regression identifizierte den Hb(Hämoglobin)- und Fibrinogenwert bei Aufnahme als unabhängige Prädiktoren einer Thrombozytenfunktionsstörung, sowohl im Ansatz mit Adenosindiphosphat (ADP) (p < 0,001, Cohens f = 0,61) als auch mit Epinephrin (p < 0,001, f = 0,42).

Interpretation

Bei einem Viertel bis einem Drittel der primär zugewiesenen Traumapatienten ohne gerinnungsaktive Dauermedikation zeigte sich eine verzögerte Thrombozytenaktivierung im PFA-100-Test. Bei Berücksichtigung aller Traumapatienten ist von einer noch höheren Rate auszugehen. Über den Hb- und den Fibrinogenwert im Schockraum ist eine orientierende Einschätzung möglich. Die Entwicklung differenzierungsfähiger Testverfahren der Thrombozytenfunktion für die Schockraumversorgung des individuellen Patienten erscheint dringend notwendig.

Abstract

Background

Plasmatic coagulation disorders in trauma patients are common and their management is subject to current guidelines. Less evidence exists for platelet function. Although it is known that several trauma-associated factors have a negative influence on platelet function, routine monitoring has not yet become established.

Methods

A retrospective single center study was carried out at a German level 1 trauma center from 2010 to 2016. In all patients fulfilling the requirements for the German Trauma Society (DGU) Traumaregister® who were admitted directly from the scene of the incident, platelet function was analyzed using the Platelet Function Analyzer (PFA 100®) with adenosine diphosphate (ADP) and epinephrine as activation factors. After exclusion of patients with intake of long-term anticoagulant and antiaggregant medication, possible influencing factors of a reduced platelet function were identified.

Results

The results from 310 patients (44.0 ± 14.7 years, 76% male, Injury Severity Score, ISS 28.4 ± 14.2 points) were available. A delayed platelet activation was found in 25.5% using ADP and 31% using epinephrine. Laboratory parameters indicated a greater blood loss. Prolonged closure times were associated with an increased transfusion rate of packed red blood cell concentrates and a higher mortality rate. Logistic regression revealed hemoglobin (Hb) and fibrinogen levels at admission to be independent predictors for a decreased platelet activation in the assay with ADP (p < 0.001, Cohen’s f = 0.61) and with epinephrine (p < 0.001, f = 0.42).

Conclusion

Approximately one quarter to one third of primarily admitted trauma patients without long-term anticoagulation medication showed a delayed platelet activation in the PFA-100 test. By considering all trauma patients an even higher rate can be expected. The Hb and fibrinogen levels at admission can be helpful to estimate platelet disorders. The development of platelet assays to guide the resuscitation of individual patients seems to be absolutely necessary. The contribution of platelet disorders to trauma-induced coagulopathy is not sufficiently understood. Regarding the importance assigned to platelet transfusion or administration of desmopressin, these aspects should be the subject of further research.

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Authors and Affiliations

  1. Klinik für Anästhesiologie, Intensiv‑, Notfallmedizin und Schmerztherapie, Bergmannstrost BG-Klinikum Halle (Saale), Merseburgerstr. 165, 06112, Halle (Saale), Deutschland

    V. Hofer, H. Wrigge &  P. Hilbert-Carius DEAA

  2. Klinik für Anästhesiologie, Universitätsklinik Regensburg, Regensburg, Deutschland

    V. Hofer

  3. Institut für Medizinische Epidemiologie, Biometrie und Informatik, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland

    A. Wienke

  4. Klinik für Unfall- und Wiederherstellungschirurgie, Bergmannstrost BG-Klinikum Halle (Saale), Halle (Saale), Deutschland

    G. Hofmann

  5. Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie Universitätsklinikum, Friedrich Schiller Universität Jena, Jena, Deutschland

    G. Hofmann

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  1. V. Hofer
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  4. G. Hofmann
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Correspondence to P. Hilbert-Carius DEAA.

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Interessenkonflikt

V. Hofer, H. Wrigge, A. Wienke und G. Hofmann geben an, dass kein Interessenkonflikt besteht. P. Hilbert-Carius hat Vortragshonorare von CSL Behring erhalten.

Diese retrospektive Studie erfolgte nach Konsultation der zuständigen Ethikkommission und im Einklang mit nationalem Recht.

Caption Electronic Supplementary Material

ESM-Tab. S1_

Berechnung der Verschlusszeiten mittels Korrekturformel nach Kuiper et al.

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Hofer, V., Wrigge, H., Wienke, A. et al. Thrombozytenfunktionsstörung bei Traumapatienten, ein unterschätztes Problem? Ergebnisse einer monozentrischen Untersuchung. Anaesthesist 68, 368–376 (2019). https://doi.org/10.1007/s00101-019-0597-8

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