Pathophysiologie und Therapie bei Massenblutung
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1 Swisstransfusion Bern, 7. September 2012 Pathophysiologie und Therapie bei Massenblutung Lorenzo ALBERIO Universitätsklinik für Hämatologie und Hämatologisches Zentrallabor
2 Coagulopathy of Trauma Haemorrhage Volume loss Tissue hypoperfusion Coagulation factors Volume depletion Hypothermia ph APC Fibrinolysis Volume replacement: dilution dysfunction hypothermia Coagulation factors dysfunction
3 Coagulopathy of Trauma Haemorrhage Volume loss Tissue hypoperfusion Coagulation factors Volume depletion Hypothermia ph APC Fibrinolysis Volume replacement: dilution dysfunction hypothermia Coagulation factors dysfunction
4 Coagulopathy and Mortality PT > 14.0 sec aptt > 34.0 sec J Trauma 2003;55:39
5 J Trauma 2003;54:1127 Coagulopathy and Mortality
6 What is causing the coagulopathy? Injury severity is not the only cause of coagulopathy
7 Increased in vivo thrombin generation? DIC? Ann Surg 2007;245:812 Increased thrombin generation has an impact on aptt/pt only in the presence of tissue hypoperfusion
8 Coagulopathy of trauma : mechanisms Injury (thrombin generation) + shock (?) coagulopathy
9 Coagulopathy of trauma : mechanisms Ann Surg 2007;245:812
10 Coagulopathy of trauma : mechanisms Shock endothelial lesion Soluble TM: systemic APC Bound TM: focal APC Curr Opin Crit Care 2007;13:680
11 Coagulopathy of trauma : mechanisms New hypothesis: - systemic anticoagulation by APC Ann Surg 2012;255:379
12 Coagulopathy of trauma : mechanisms PAI-1 Curr Opin Crit Care 2007;13:680
13 Coagulopathy of trauma : mechanisms Ann Surg 2012;255:379
14 Coagulopathy of trauma : mechanisms Injury Shock + (thrombin) (soluble TM) Coagulopathy (systemic APC : - anticoagulation - hyperfibrinolysis) Curr Opin Crit Care 2007;13:680
15 Trauma and Coagulopathy: Time J Trauma 2003;55:39 J Trauma 2003;54:1127 Ann Surg 2007;245:812
16 Coagulopathy of Trauma Haemorrhage Volume loss Tissue hypoperfusion APC Fibrinolysis Early
17 Synthese In combination, direct tissue trauma and shock with systemic hypoperfusion appear to be the primary factors responsible for the development of coagulopathy in the immediate postinjury phase. J Trauma 2008;65:748 [ ] when tissue anoxia is avoided and surgical trauma is controlled, the occurrence of coagulopathy may remain low despite massive transfusion. Can J Anesth 2006;53:S40
18 Coagulopathy of Trauma Haemorrhage Volume loss Tissue hypoperfusion Coagulation factors Volume depletion Hypothermia ph APC Fibrinolysis Later Volume replacement: dilution dysfunction Coagulation factors dysfunction hypothermia Early
19 Volume replacement: Dysfunction Major orthopedic surgery Gelatin (Gelofusin) HES (Voluven) Ringer Lactate Anesth Analg 2007;105:905 bl cut every 90 min
20 Volume replacement: Dysfunction Major orthopedic surgery Gelatin (Gelofusin) HES (Voluven) Ringer Lactate Anesth Analg 2007;105:905 bl cut every 90 min
21 Volume replacement: Dysfunction Major orthopedic surgery Gelatin (Gelofusin) HES (Voluven) Ringer Lactate Anesth Analg 2007;105:905 bl cut every 90 min
22 Volume replacement Major orthopedic surgery Anesth Analg 2007;105:905
23 Volume replacement: Dysfunction Major orthopedic surgery Gelatin (Gelofusin) HES (Voluven) Ringer Lactate Anesth Analg 2007;105:905 bl cut every 90 min
24 Volume replacement Major orthopedic surgery Anesth Analg 2007;105:905
25 Synthese Gelatins and HES induce more dilution and a greater degree of dysfunction of coagulation factors and von Willebrand factor than crystalloids
26 Volume replacement Cochrane Database of Systematic Reviews, Issue 2, 2009
27 Treatment approach Tranexamic acid (1g /10 + 1g /8h i.v.) CRASH-2 study Injury 2012;43:1021
28 CRASH-2 study Lancet 2010;376:23
29 Treatment approach Tranexamic acid, early (1g /10 + 1g /8h i.v.) Crystalloids Avoid colloids Prevent shock CRASH-2 study Cochrane Review prevent syst. APC Massive haemorrhagic protocols Injury 2012;43:1021
30 Massive Haemorrhage Protocols even though the data are not of high quality they do not demonstrate harm, and intuitively it would seem sensible that a well organised, locally applied protocol will facilitate rapid transfusion delivery and, assuming treatment delays are harmful, improve outcome. Injury 2012;43:1021
31 Treatment approach Tranexamic acid, early (1g /10 + 1g /8h i.v.) Crystalloids Avoid colloids Prevent shock CRASH-2 study Cochrane Review prevent syst. APC Massive haemorrhagic protocols Early adminstration of RBC and FFP Injury 2012;43:1021
32 Early administration of RBC and FFP increased FFP administration per se may be beneficial in patients requiring massive transfusion In contrast, FFP has been reported of little benefit in patients receiving fewer than 10 units of RBC Provocative thinking: RBC and FFP (1:1) as volume replacement, in order to prevent an excessive loss of coag. factors Injury 2012;43:1021
33 Early administration of RBC and FFP The RCT literature did not demonstrate a correlation between reduction of transfusion requirement and improvement in survival Crit Care 2011,15:R92
34 Treatment approach Tranexamic acid, early (1g /10 + 1g /8h i.v.) Crystalloids Avoid colloids Prevent shock CRASH-2 study Cochrane Review prevent syst. APC Massive haemorrhagic protocols Early adminstration of RBC and FFP Interventional Radiology pelvic trauma! Haemostatic adjunts (Fibrinogen, PCC, rfviia, FXIII) Injury 2012;43:1021
35 Haemostatic adjunts 60 μg/kg c c Swiss Med Wkly. 2011;141:w13213
36 Haemostatic adjunts There is increasing interest in prothrombin complex concentrates and fibrinogen concentrates for massive blood loss. Advantages of these agents are standardisation of dose, lower viral transmission risk, low volume, and lack of transfusion associated adverse events. So far the literature offers only case report and observational evidence in favour of their use. Not only will efficacy need to be demonstrated in controlled trials, but safety issues (i.e. effects on thrombosis and disseminated intravascular coagulation) will need to be fully assessed prior to formulation of recommendations for use. Injury 2012;43:1021
37 Surviving acute trauma coagulopathy... Deep Vein Thrombosis N Engl J Med 1994;331:1601
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