Frischgefrorenes Plasma und Blutgerinnungsfaktoren

Nach Traumata und perioperativ sind schwere Blutungen mit einer erhöhten Morbidität und Mortalität assoziiert. Ein möglicher Therapieansatz ist die Transfusion von Erythrozytenkonzentraten und Plasma. Noch effektiver soll eine zielgerichtete Gerinnungstherapie mit Gerinnungsfaktorkonzentraten auf Basis einer Point-of-Care-Diagnostik sein. Sie ist möglicherweise auch mit weniger transfusions- und blutungsbedingten Komplikationen assoziiert.

Abstract

After severe trauma, but also perioperatively, massive bleeding is associated with increased morbidity and mortality. In severely injured patients, hemorrhagic shock remains to be the main cause of death in addition to traumatic brain hemorrhage. In non-cardiac surgery, a surgical bleeding complication increases perioperative morbidity (intensive care length of stay, acute renal failure, infections, thromboembolic complications) by a factor of three to four and mortality by a factor of six. In cardiac surgery, postoperative bleeding requiring surgical revision is associated with a 50% increase in mortality. One possible therapeutic approach is the transfusion of erythrocytes to plasma in a fixed ratio. This practice of untargeted coagulation therapy is mainly used in the USA and some Scandinavian countries. Mortality is significantly worse in the USA than in central Europe, particularly in the case of severe injuries. There is increasing evidence that targeted coagulation therapy with coagulation factor concentrates based on the results of point-of-care coagulation diagnostics is more effective and associated with fewer transfusion- and bleeding-related complications.

Kernaussagen

• Das Gerinnungsmanagement auf Basis einer Therapie mit Gerinnungsfaktorkonzentraten ist zentraler Bestandteil einer modernen hämostatischen Therapie.

• Um die Substanzen zielgerichtet einsetzen zu können, ist die Point-of-Care- Gerinnungsdiagnostik eine entscheidende Grundvoraussetzung.

• Mit der Gabe von Plasma kann eine bestehende Gerinnungsstörung weder zeitnah noch effektiv behandelt werden, da die Konzentration von Fibrinogen und anderen Gerinnungsfaktoren hierfür zu gering ausfällt.

• Die Plasmatransfusion ist unvermeidlich mit einer Volumenexpansion verbunden, die dazu führt, dass die Konzentration kritisch reduzierter Faktoren nur begrenzt zunehmen kann. Diese Volumenbelastung kann u. a. zu dem klinischen Bild eines Transfusion-associated Cardiac Overload führen.

• Im Rahmen von Massivblutungen sind frühzeitig niedrige Fibrinogenspiegel zu beobachten. Die Therapie einer vorliegenden Hypofibrinogenämie sollte primär mit Fibrinogenkonzentrat erfolgen.

• Die Therapie mit PPSB zur Antagonisierung von Vitamin-K-Antagonisten bei Patienten mit schweren Blutungen wird von internationalen Leitlinien mit hoher Evidenz empfohlen.

• Zur Wiederherstellung der Hämostase unter antikoagulatorischer Therapie mit Faktor-Xa-Inhibitoren wird regelhaft PPSB verwendet („off-label“).

• Bei Verdacht oder laborchemisch nachgewiesenem erworbenem Mangel an Gerinnungsfaktoren des Prothrombinkomplexes im Rahmen von schweren Blutungen kann die Therapie mit PPSB erfolgen.

• Faktor XIII hat eine Schlüsselrolle bei der Stabilisierung und Stärkung des Blutgerinnsels (Thrombus). Die aktuellen Leitlinien empfehlen das Monitoring von FXIII sowie den Einsatz von FXIII-Konzentrat bei Vorliegen eines Mangels, einer anhaltenden Blutung und im Rahmen eines Gerinnungsalgorithmus bzw. bei Vorliegen eines funktionellen Defizits.

Schlüsselwörter

Frischplasma - FFP - PPSB - Gerinnungsfaktoren - Transfusion - Blutung

Keywords

fresh frozen plasma - bleeding - coagulation factor concentrates - point-of-care

Publication History

Article published online:
08 January 2025

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