Point-of-Care-Testing – Einführung in die Methodik: Indikationen und Limitationen

Zusammenfassung

Der Einsatz moderner Point-of-Care-Geräte zur perioperativen Gerinnungsdiagnostik hat in den letzten Jahren u.a. durch die Weiterentwicklung bekannter Techniken (z.B. Thrombelastografie/-metrie) eine zunehmende Verbreitung erfahren. Durch eine verbesserte Benutzerfreundlichkeit erweitern diese Techniken das Spektrum der Gerinnungsdiagnostik im klinischen Einsatz. Doch sind sie wirklich das "Nonplusultra" in der Diagnostik der nicht chirurgischen Blutungsursache? Der Beitrag möchte Anwendungsmöglichkeiten und Grenzen der Point-of-Care-Gerinnungsdiagnostik aufzeigen.

Abstract

The advancement of well known techniques in Point-of-Care coagulation diagnostics (e.g. thromboelastography/-metry) has lead to further distribution in perioperative coagulation management. By increasing user friendliness these devices have helped to expand the spectrum of coagulation diagnostics in daily clinical routine. But can they really be considered as the ne plus ultra in diagnosis of coagulopathy? In this article the authors would like to mark up indications as wells as limitations in Point-of-Care coagulation diagnostics.

Kernaussagen

• Die Rotationsthrombelastometrie als Weiterentwicklung der Thrombelastografie nach Hartert eignet sich zur bettseitigen Gerinnungsdiagnostik.

• Die Thrombelastometrie weist diagnostische Lücken hinsichtlich der Erfassung primärer Hämostasestörungen (idiopathisch, medikamentös bedingt) auf. Diese können teilweise durch den zusätzlichen Einsatz der Impedanzaggregometrie geschlossen werden.

• Die Impedanzaggregometrie ist zum Monitoring einer thrombozytenaggregationshemmenden Therapie geeignet und kann ein vermindertes Ansprechen auf diese Medikamente erfassen.

• Der Vollblutansatz bei der POC-Diagnostik gibt das Zusammenspiel von plasmatischen Faktoren, Thrombozyten, Erythrozyten und Leukozyten bei der Hämostase wieder. Rahmenbedingungen wie Temperatur oder Kalziumkonzentration werden nicht erfasst.

• Durch den Wegfall von Transportweg und Präanalytik der Proben ermöglicht die POC-Gerinnungsdiagnostik eine schnellere und spezifischere hämostatische Therapie.

• Rotationsthrombelastometrie und Impedanzaggregometrie sind aufgrund ihrer einfachen Handhabung nicht nur Tools für “Gerinnungsexperten”, ihre Anwendung kann schnell erlernt werden.

• Der Einsatz von Thrombelastometrie und Impedanzaggregometrie außerhalb zentraler Laboreinrichtungen erhöht den Aufwand zur geregelten Durchführung qualitätssichernder Maßnahmen.

• Die zunächst erforderlichen Investitionen bei der Etablierung der POC-Gerinnungsdiagnostik können neben der Verminderung der Transfusionsraten allogener Blutprodukte längerfristig wahrscheinlich auch zu einer Kosteneinsparung beitragen.

Schlüsselwörter:

Point-of-Care - POC - Thrombelastometrie - Impedanzaggregometrie

Key words:

Point-of-Care - POC - thromboelastometry - whole blood impedance aggregometry

• Literatur

• 1 Junker R, Schlebusch H, Luppa PB. Point-of-care testing in hospitals and primary care. Dtsch Arztebl Int 2010; 107: 561-567
• 2 Luppa PB, Schlebusch H Hrsg. POCT – Patientennahe Labordiagnostik. Aufl. Berlin, Heidelberg: Springer; 2012. 2.
• 3 Hartert H. Blutgerinnungsstudien mit der Thrombelastographie, einem neuen Untersuchungsverfahren. Klinische Wochenschrift 1948; 26: 577-583
• 4 Kang YG, Martin DJ, Marquez J et al. Intraoperative changes in blood coagulation and thrombelastographic monitoring in liver transplantation. Anesth Analg 1985; 64: 888-896
• 5 Calatzis A, Fritzsche P, Calatzis A et al. roTEG Coagulation Analyzer – Ein neues System zur intraoperativen Bedside-Gerinnungsdiagnostik. Anaesthesist 1995; 44: 491-491
• 6 Lang T, von Depka M. Possibilities and limitations of thrombelastometry/-graphy. Hamostaseologie 2006; 26: 20-29
• 7 Gorlinger K. Coagulation management during liver transplantation. Hamostaseologie 2006; 26: 64-76
• 8 Gorlinger K, Dirkmann D, Hanke AA et al. First-line therapy with coagulation factor concentrates combined with point-of-care coagulation testing is associated with decreased allogeneic blood transfusion in cardiovascular surgery: a retrospective, single-center cohort study. Anesthesiology 2011; 115: 1179-1191
• 9 Lier H, Vorweg M, Hanke A et al. Thromboelastometry guided therapy of severe bleeding. Essener Runde algorithm. Hamostaseologie 2013; 33: 51-61
• 10 Weber CF, Gorlinger K, Meininger D et al. Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology 2012; 117: 531-547
• 11 Hoffman M, Monroe 3rd. DM. A cell-based model of hemostasis. Thromb Haemost 2001; 85: 958-965
• 12 Nielsen VG, Geary BT, Baird MS. Evaluation of the contribution of platelets to clot strength by thromboelastography in rabbits: the role of tissue factor and cytochalasin D. Anesth Analg 2000; 91: 35-39
• 13 Weber CF, Jambor C, Marquardt M et al. Thrombelastometric detection of factor XIII deficiency. Anaesthesist 2008; 57: 487-490
• 14 Kaiser AF, Neubauer H, Franken CC et al. Which is the best anticoagulant for whole blood aggregometry platelet function testing? Comparison of six anticoagulants and diverse storage conditions. Platelets 2012; 23: 359-367
• 15 Koscielny J, Ziemer S, Radtke H et al. A practical concept for preoperative identification of patients with impaired primary hemostasis. Clin Appl Thromb Hemost 2004; 10: 195-204
• 16 Haas T, Spielmann N, Mauch J et al. Comparison of thromboelastometry (ROTEM(R)) with standard plasmatic coagulation testing in paediatric surgery. BrJAnaest 2012; 108: 36-41
• 17 Toulon P, Ozier Y, Ankri A et al. Point-of-care versus central laboratory coagulation testing during haemorrhagic surgery. A multicenter study. Thromb Haemost 2009; 101: 394-401
• 18 Adam S, Karger R, Kretschmer V. Photo-optical methods can lead to clinically relevant overestimation of fibrinogen concentration in plasma diluted with hydroxyethyl starch. Clin Appl Thromb Hemost 2010; 16: 461-471
• 19 Fenger-Eriksen C, Moore GW, Rangarajan S et al. Fibrinogen estimates are influenced by methods of measurement and hemodilution with colloid plasma expanders. Transfusion 2010; 50: 2571-2576
• 20 Hiippala ST. Dextran and hydroxyethyl starch interfere with fibrinogen assays. Blood Coagul Fibrinolysis 1995; 6: 743-746
• 21 Ives C, Inaba K, Branco BC et al. Hyperfibrinolysis elicited via thromboelastography predicts mortality in trauma. J Am Coll Surg 2012; 215: 496-502
• 22 Dirkmann D, Gorlinger K, Dusse F et al. Early thromboelastometric variables reliably predict maximum clot firmness in patients undergoing cardiac surgery: a step towards earlier decision making. Acta Anaesthesiol Scand 2012; [Epup ahead of print]
• 23 Jambor C, Weber CF, Gerhardt K et al. Whole blood multiple electrode aggregometry is a reliable point-of-care test of aspirin-induced platelet dysfunction. Anesth Analg 2009; 109: 25-31
• 24 Neubauer H, Kaiser AF, Endres HG et al. Tailored antiplatelet therapy can overcome clopidogrel and aspirin resistance – the BOchum CLopidogrel and Aspirin Plan (BOCLA-Plan) to improve antiplatelet therapy. BMC Med 2011; 9: 3-3
• 25 Ben-Dor I, Kleiman NS, Lev E. Assessment, mechanisms, and clinical implication of variability in platelet response to aspirin and clopidogrel therapy. Am J Cardiol 2009; 104: 227-233
• 26 Mueller T, Dieplinger B, Poelz W et al. Utility of the PFA-100 instrument and the novel multiplate analyzer for the assessment of aspirin and clopidogrel effects on platelet function in patients with cardiovascular disease. Clin Appl Thromb Hemost 2009; 15: 652-659
• 27 Rahe-Meyer N, Winterhalter M, Hartmann J et al. An evaluation of cyclooxygenase-1 inhibition before coronary artery surgery: aggregometry versus patient self-reporting. Anesth Analg 2008; 107: 1791-1797
• 28 Velik-Salchner C, Wenzel V, Maybauer DM et al. Recombinant human activated protein C in experimental models of acute lung injury: the timing is critical!. Intensive Care Med 2007; 33: 2048-2050
• 29 von Pape KW, Dzijan-Horn M, Bohner J et al. Control of aspirin effect in chronic cardiovascular patients using two whole blood platelet function assays. PFA-100 and Multiplate. Hamostaseologie 2007; 27: 155-160
• 30 Woo KS, Kim BR, Kim JE et al. Determination of the prevalence of aspirin and clopidogrel resistances in patients with coronary artery disease by using various platelet-function tests. Korean J Lab Med 2010; 30: 460-468
• 31 Gorlinger K, Fries D, Dirkmann D et al. Reduction of fresh frozen plasma requirements by perioperative point-of-care coagulation management with early calculated goal-directed therapy. Transfus Med Hemother 2012; 39: 104-113
• 32 Hanke AA, Dellweg C, Kienbaum P et al. Effects of desmopressin on platelet function under conditions of hypothermia and acidosis: an in vitro study using multiple electrode aggregometry*. Anaesthesia 2010; 65: 688-691
• 33 Weber CF, Dietrich W, Spannagl M et al. A point-of-care assessment of the effects of desmopressin on impaired platelet function using multiple electrode whole-blood aggregometry in patients after cardiac surgery. Anesth Analg 2010; 110: 702-707
• 34 Devereaux PJ, Goldman L, Cook DJ et al. Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ 2005; 173: 627-634
• 35 Gutt CN, Oniu T, Wolkener F et al. Prophylaxis and treatment of deep vein thrombosis in general surgery. Am JSurg 2005; 189: 14-22
• 36 Lison S, Weiss G, Spannagl M et al. Postoperative changes in procoagulant factors after major surgery. Blood Coagul Fibrinolysis 2011; 22: 190-196
• 37 Daudel F, Kessler U, Folly H et al. Thromboelastometry for the assessment of coagulation abnormalities in early and established adult sepsis: a prospective cohort study. CritCare 2009; 13
• 38 Sivula M, Pettila V, Niemi TT et al. Thromboelastometry in patients with severe sepsis and disseminated intravascular coagulation. Blood Coagul Fibrinolysis 2009; 20: 419-426
• 39 Adamzik M, Gorlinger K, Peters J et al. Whole blood impedance aggregometry as a biomarker for the diagnosis and prognosis of severe sepsis. Crit Care 2012; 16
• 40 Adamzik M, Langemeier T, Frey UH et al. Comparison of thrombelastometry with simplified acute physiology score II and sequential organ failure assessment scores for the prediction of 30-day survival: a cohort study. Shock 2011; 35: 339-342
• 41 Adamzik M, Eggmann M, Frey UH et al. Comparison of thromboelastometry with procalcitonin, interleukin 6, and C-reactive protein as diagnostic tests for severe sepsis in critically ill adults. Crit Care 2010; 14
• 42 Brenner T, Schmidt K, Delang M et al. Viscoelastic and aggregometric point-of-care testing in patients with septic shock – cross-links between inflammation and haemostasis. Acta Anaesthesiol Scand 2012; 56: 1277-1290
• 43 Gorlinger K, Bergmann L, Dirkmann D. Coagulation management in patients undergoing mechanical circulatory support. Best Pract Res Clin Anaesthesiol 2012; 26: 179-198
• 44 Niemi TT, Kukkonen SI, Hammainen PT et al. Whole blood hypercoagulability despite anticoagulation during mechanical cardiac assist. Perfusion-Uk 2008; 23: 107-110
• 45 Fries D, Innerhofer P, Streif W et al. Coagulation monitoring and management of anticoagulation during cardiac assist device support. Ann Thorac Surg 2003; 76: 1593-1597
• 46 Valarche V, Desconclois C, Boutekedjiret T et al. Multiplate whole blood impedance aggregometry: a new tool for von Willebrand disease. JTH 2011; 9: 1645-1647
• 47 Hanke AA, Roberg K, Monaca E et al. Impact of platelet count on results obtained from multiple electrode platelet aggregometry (Multiplate). Eur JMed Res 2010; 15: 214-219
• 48 Gorlinger K, Jambor C, Dirkmann D et al. Platelet function analysis with point-of-care methods. Herz 2008; 33: 297-305
• 49 Seyfert UT, Haubelt H, Vogt A et al. Variables influencing Multiplate(TM) whole blood impedance platelet aggregometry and turbidimetric platelet aggregation in healthy individuals. Platelets 2007; 18: 199-206
• 50 Glas M, Mauer D, Kassas H et al. Sample transport by pneumatic tube system alters results of multiple electrode aggregometry but not rotational thromboelastometry. Platelets [Epup ahead of print] 2012;
• 51 Dick A, Schwaiger M, Jambor C. Thromboelastography/-metry and external quality control. Results of a pilot study. Hamostaseologie 2010; 30: 91-95
• 52 Spannagl M, Dick A, Junker R. POCT in coagulation. Quality assurance. Hamostaseologie 2010; 30: 82-90
• 53 Schwermann T, Grotz M, Blanke M et al. Evaluation der Kosten von polytraumatisierten Patienten insbesondere aus der Perspektive des Krankenhauses. Der Unfallchirurg 2004; 107: 563-574
• 54 Schaden E, Kimberger O, Kraincuk P et al. Perioperative treatment algorithm for bleeding burn patients reduces allogeneic blood product requirements. Br J Anaesth 2012; 109: 376-381
• 55 Spalding GJ, Hartrumpf M, Sierig T et al. Bedside thrombelastography. Cost reduction in cardiac surgery. Anaesthesist 2007; 56: 765-771
• 56 Spalding GJ, Hartrumpf M, Sierig T et al. Cost reduction of perioperative coagulation management in cardiac surgery: value of "bedside" thrombelastography (ROTEM). Eur JCardiothorac Surg 2007; 31: 1052-1057