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Anästhesiol Intensivmed Notfallmed Schmerzther 2018; 53(06): 440-457
DOI: 10.1055/s-0043-107753
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CME-Fortbildung
Georg Thieme Verlag KG Stuttgart · New York

Point-of-Care-Diagnostik in der Traumatologie – Methoden und Evidenz

Point-of-Care Testing in Trauma Patients – Methods and Evidence
Daniel Dirkmann
,
Martin W. Britten
,
Ulrich H. Frey
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Publikationsverlauf

Publikationsdatum:
26. Juni 2018 (online)

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Zusammenfassung

Jeder 4. Schwerverletzte weist bereits bei Krankenhausaufnahme eine traumainduzierte Koagulopathie (TIK) auf, die mit einer 4-fach erhöhten Mortalität einhergeht. Rasche und zielgenaue Behandlung kann die TIK-assoziierte Sterblichkeit senken. Point-of-Care-Tests ermöglichen im Vergleich mit herkömmlichen Labormethoden eine zeitnahe und umfassende Bestimmung des Gerinnungsstatus sowie eine zielgerichtete Therapie.

Abstract

In severely injured patients, trauma-induced coagulopathy (TIC) present at hospital admission is associated with increased transfusion requirements, morbidity and mortality. Early and effective treatment contributes to improved survival rates. Laboratory coagulation assays have long turn-around times and evidence for their usefulness, especially in the context of TIC, is weak. Due to the lack of appropriate guidance, transfusion of allogeneic blood products frequently follows a ratio-based concept (e.g., transfusion of erythrocytes and plasma in a 1 : 1 ratio). Point-of-care (PoC) tests enable the assessment of prothrombin time (PT) and activated partial thromboplastin time in few minutes. However, although normal PT in these tests allows to rule out relevant effects of several anticoagulants, they are not able to detect patients with TIC and/or requiring subsequent massive transfusion. Viscoelastic tests (VETs) make it possible to assess defects in thrombin generation, hypofibrinogenaemia, thrombocytopenia, and hyperfibrinolysis, and thus enable targeted therapy. Impairment of platelet function is the common blind spot not detectable using both standard laboratory-based tests and VETs. However, PoC platelet function tests enable to detect platelet defects and patients taking anti-platelet. Furthermore, impaired platelet function has been identified as a strong predictor for coagulopathy and massive transfusion in trauma patients. In other clinical settings, coagulation management based on VETs is associated with decreased transfusion requirements, incidence of acute kidney failure, and mortality, respectively. Data of the first small prospective randomised trial indicate superiority of VET guided coagulation management solely using coagulation factor concentrates, when compared to plasma transfusions in severe trauma.

Kernaussagen

  • Eine traumainduzierte Koagulopathie (TIK) ist bei 25 – 33% der Schwer- und Schwerstverletzten nachweisbar und mit vermehrten Fremdbluttransfusionen sowie erhöhter Morbidität und Mortalität vergesellschaftet.

  • Eine frühe und effektive Behandlung kann dazu beitragen, die traumaassoziierte Sterblichkeit zu senken.

  • Laborbasierte konventionelle Gerinnungstests weisen häufig Umlaufzeiten von mehr als 60 min auf, die Evidenz für ihren Nutzen zur Therapiesteuerung ist insgesamt äußerst gering.

  • Aufgrund fehlender Messwerte ist eine zeitnahe zielgerichtete Therapie nicht möglich, weshalb oftmals die Transfusion von Blutprodukten z. B. in einem prädefinierten Erythrozyten-Blutplasma-Verhältnis (1 : 1) erfolgt.

  • Mit Point-of-Care-Methoden können konventionelle Gerinnungstests wie die Prothrombinzeit und die aktivierte partielle Thromboplastinzeit innerhalb weniger Minuten gemessen werden.

  • Eine normale Point-of-Care-PT lässt sicher die Einnahme von Vitamin-K-Antagonisten ausschließen und kann möglicherweise auch relevante Plasmakonzentrationen von Dabigatran und Rivaroxaban detektieren, sie ist aber nicht geeignet, Patienten mit einer TIK bzw. einem Massivtransfusionsrisiko zu identifizieren.

  • Viskoelastische Tests (VET) der Blutgerinnung lassen innerhalb weniger Minuten Störungen der Thrombinbildung und Fibrinpolymerisation sowie eine Hypofibrinogenämie und Thrombopenie und eine Hyperfibrinolyse erkennen und ermöglichen eine zielgerichtete Therapie.

  • Thrombozytenfunktionsstörungen und die Einnahme von Thrombozytenaggregationshemmern (TAH) bleiben sowohl bei konventionellen als auch viskoelastischen Tests unentdeckt.

  • Mittels Point-of-Care-Thrombozytenfunktionstests können die Einnahme von TAH und eine traumainduzierte Thrombopathie nachgewiesen werden. Letztere ist ein hervorragender Prädiktor für eine Massivtransfusion.

  • Eine anhand von VET gesteuerte Gerinnungstherapie ist im Vergleich mit konventionellen Tests oder keiner Gerinnungsdiagnostik mit einer geringeren Transfusionswahrscheinlichkeit, einer geringeren Inzidenz eines dialysepflichtigen Nierenversagens und einer geringeren Sterblichkeit vergesellschaftet.

  • Erste Daten einer prospektiven randomisierten Studie geben Hinweise darauf, dass eine auf VET basierende zielgerichtete Therapie mit Gerinnungsfaktorkonzentraten der Therapie mit Blutplasma bei schwerem Trauma überlegen sein könnte.

Schlüsselwörter

Traumatologie - Gerinnungsstörung - Diagnostik - Koagulopathie - Thrombozytenfunktion

Key words

trauma - coagulation disorder - diagnostics - coagulopathy - platelet function
 

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