Gerinnungsprobleme in der Intensivmedizin – Update 2019

Störungen des Gerinnungssystems und konsekutive hämorrhagische oder thromboembolische Komplikationen sind in der Intensivmedizin ebenso häufige wie ernsthafte Probleme. Ihre frühzeitige Erkennung, korrekte diagnostische Einordnung und gezielte Behandlung sind entscheidende Faktoren für das Outcome.

Kernaussagen

• Häufige Ursachen einer Gerinnungsstörung im klinischen Alltag sind die Antikoagulation und die Thrombozytenhemmung. Ebenfalls nicht selten ist sie Folge einer Erkrankung, u. a. Leber- und Nierenerkrankungen, hämatologische Erkrankungen oder ein Schock.

• Die „Lethal Triade“ (Hypothermie, Azidose, Koagulopathie) führt zu einer Gerinnungsstörung, die chirurgische Maßnahmen, eine hämostaseologische Substitution und eine kardiozirkulatorische Stabilisierung erfordert.

• Das Auftreten diffuser Blutungen ist das wichtigste Leitsymptom einer akuten Koagulopathie.

• Quick und PTT sind schnell und überall verfügbare Globaltests der Gerinnung. Wegen der unterschiedlichen Empfindlichkeit für direkte orale Antikoagulanzien (DOAK) büßen diese Globaltests eine breite diagnostische Aussagekraft aber zusehends ein.

• Therapie der Wahl bei akuter, massiver Blutung ist neben Massivtransfusionen eine frühzeitige Substitution von Fibrinogen und Thrombozyten.

• Klinisch eindeutige Zeichen einer schweren DIC als Versagen des Protein-C-Systems sind Hautnekrosen und digitale Nekrosen an Händen und Füßen, seltener auch von Ohren, Nase und Mamillen. Der Kern der Therapie einer septischen DIC ist die Antikoagulation mit Heparin (UFH oder NMH).

• Vor allem Autoantikörper gegen die Faktoren des intrinsischen Systems – am häufigsten Faktor VIII (Hemmkörperhämophilie), seltener auch gegen andere Gerinnungsfaktoren – können zu schweren Blutungskomplikationen führen. Diagnostik und Therapie dieser erworbenen Blutungsneigung sind jedoch außerordentlich aufwendig.

• Die Ursachen des erworbenen Von-Willebrand-Syndroms sind vielfältig, im Blutungsnotfall stehen Von-Willebrand-Faktor-Konzentrate zur Verfügung. Dabei erfolgt die Anwendung – wie so oft in der intensivmedizinischen Hämotherapie – nicht innerhalb des Zulassungsbereichs.

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