Diagnostische Möglichkeiten und Grenzen der Thrombelastometrie/-graphie

Zusammenfassung

Die Thrombelastometrie/-graphie ermöglicht im Gegensatz zur klassischen Gerinnungsanalytik auch eine Beurteilung der Clotfestigkeit und -stabilität. Durch die Einführung von modifizierten thrombelastometrischen/-graphischen Ansätzen konnte die Standardisierung weitgehend verbessert und die diagnostische Aussagekraft erhöht werden. Durch die Verwendung eines Heparinase-Tests kann so ein Heparineffekt leicht nachgewiesen werden. Der FIBTEM ermöglicht auf dem ROTEM® auch eine weitere Differenzierung zwischen einer thrombozytär oder plasmatisch bedingten Störung der Clotfestigkeit. In diesem Zusammenhang scheint das Fibrinogen eine oft unterschätze Bedeutung für die Clotfestigkeit zu haben. Unsere klinischen Daten zeigen, dass im perioperativen Bereich ein erhöhtes D-Dimer keinen Hinweis auf einer Hyperfibrinolyse liefern kann. Durch die Thrombelastometrie/-graphie können jedoch keine Störungen der so genannten primären Hämostase erfasst werden (z. B. von-Willebrand-Syndrom). Auch die Wirkung von Azetylsalizylsäure und Clopidogrel auf die Thrombozyten kann nicht erfasst werden. Lediglich Thrombozytenaggregationshemmer, welche die Funktionalität der Glykoprotein-IIb/IIIa-Rezeptoren auf den Thrombozyten beeinflussen (z. B. ReoPro®) können in hoher Dosierung zu einer verminderten Clotfestigkeit in der Thrombelastometrie/- graphie führen. Ähnliches gilt auch für einen ausgeprägten Morbus Glanzmann. Aufgrund der Verwendung von unterschiedlichen Aktivatoren ist die Gerinnungszeit in der Thrombelastometrie/-graphie (CT/r-Wert) mit den klassischen Gerinnungsparametern nur bedingt vergleichbar. Durch die Einführung der Rotationsthrombelastometrie steht nun auch ein Bedsite-taugliches System zur Verfügung.

Summary

Thrombelastometry/-graphy provides information about clot strength and stability. Modified thrombelastometry/- graphy improved standardisation and diagnostic information using this system. Heparinase modified thrombelastometry/- graphy allows estimation of heparin. The introduction of FIBTEM on the ROTEM® first allows a clear estimation of the plasmatic and the platelet component of clot strength, which may be of interest in managing haemostasis in perioperative setting. In this context the meaning of fibrinogen should be evaluated. As our clinical data show there is no predictive value of elevated D-dimers to hyperfibrinolysis in perioperative setting. However, thrombelastometry/-graphy do not deteckt disturbances in primary haemostasis such as von Willebrand Syndrom. The effect of acetylsalicylacid and clopidogrel do not have any influence on thrombelastometry/-graphy, as well. GPIIb/IIIa-Antagonists such as ReoPro® may reduce clot strength at high dosis. A similar effect may be expected in severe M. Glanzmann. The correlation between coagulation time in thrombelastometry/-graphy (CT/r-value) to conventional coagulation may be low because of different activators used. The introduction of rotationthrombelastometry (ROTEM®) provides a stable system suitable for bedside-monitoring.

Schlüsselwörter

Thrombelastometrie - Thrombelastographie - ROTEM - TEG

Keywords

Thrombelastometry - thrombelastography - ROTEM - TEG

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