Koagulations-monitorering

Anders Östlund MD PhD

Funktionsområde Trauma och Akut kirurgi

Perioperativ Medicin och Intensivvård (PMI) Karolinska Universitetssjukhuset, Solna

Provtagning

•  Blodgaser:pH/BE/lactat,Hb,S-Ca++,S-K+

•  TEG(tromboelastografi)/ROTEM(tromboelastometri)

•  (Koag.prover:fibrinogen,TPK,PK/INR,APTT)

Massivokontrolleradblödning

Transfusionsprotokoll(Blodprod4:4:1,Tranexamsyra,Fibrinogen)

↓

Målstyrdbehandling(Tromboelastometri:TEG/ROTEM)

Viskoelastiskkoagulationsanalys

•  Utföraanalysbedsideellerlåtablodcentralen/lab.göradetta?

•  TEGellerROTEM?

www.co-criticalcare.com Volume 19 Number 6 December 2013

Wikman 2015-09-26

Spahn et al. Critical Care 2013, 17:R76 Updated European Guideline

ROTEM-analyspåtraumapatienterKarolinska,Solna

•  Citratrörskickasmedrörposttillblodcentralen

•  Blodcentralensätterprovet/påbörjaranalysen

•  Resultatet/kurvornakansespåtraumaenhetensdatorbedside

•  Inom10-15min.kangradenochtypenavkoagulopatiuppskattas

Viskoelastiskhelblodsanalys-ROTEM

Wikman 2015-09-26

Koagulations faktorer

Fibrinogen, trombocyter Fibrinolys

Taune Wikman 2013-11-06

(Ref. CT38-79s MCF50-72mm) (Ref. CT100-240s MCF50-72mm)

(Ref. MCF9-25mm)

INTEM EXTEM

FIBTEM

Taune Wikman 2013-11-06

(Ref. CT38-79s MCF50-72mm) (Ref. CT100-240s MCF50-72mm)

(Ref. MCF9-25mm)

Taune Wikman 2013-11-06

(Ref. CT38-79s MCF50-72mm) (Ref. CT100-240s MCF50-72mm)

(Ref. MCF9-25mm) Extem-CT↑-bristpåkoag.faktorer/plasmaExtem-MCF↓-bristpåtrombocyterellerfibrinogenFibtem-MCF↓-bristpåfibrinogen

Taune Wikman 2013-11-06

(Ref. CT100-240s MCF50-72mm) (Ref. CT38-79s MCF50-72mm)

(Ref. MCF9-25mm)

Taune Wikman 2013-11-06

(Ref. CT100-240s MCF50-72mm) (Ref. CT38-79s MCF50-72mm)

(Ref. MCF9-25mm)

Taune Wikman 2013-11-06

(Ref. CT100-240s MCF50-72mm) (Ref. CT38-79s MCF50-72mm)

(Ref. MCF9-25mm)

trombocytbrist

((100-240s, 50-72mm) (38-79s, 50-72mm)

(9-25mm)

((100-240s, 50-72mm) (38-79s, 50-72mm)

(9-25mm)

Brist på fibrinogen + övriga koagul.-faktorer, ingen heparineffekt

((100-240s, 50-72mm) (38-79s, 50-72mm)

(9-25mm)

Taune Wikman 2013-11-06

Taune Wikman 2013-11-06

(9-25mm)

((100-240s, 50-72mm) (38-79s, 50-72mm)

OBSMissvisandeROTEM-kurvavid:

•  Hypokalcemi(Catillsättsföreanalysen)

•  Hypotermi(analysengörsvid37⁰C)

•  Trombocythämmandeläkemedel

•  Waran-beh

•  Hemofili,v.Willebrand

Keene et al. 2013