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Jakob StensballeOverlæge, Ph.D., Lægefaglig ansvarlig for Reg H’s BlødningsvagtAnæstesi og operationsklinikken & TraumeCenter, HOC
&Transfusionsmedicinsk Enhed, Blodbanken i Region HovedstadenRigshospitalet
[email protected] COI: None
PATOFYSIOLOGIEN BAGTRAUME-INDUCERET KOAGULOPATI
Brohi et al. J Trauma 2003
TRAUME-INDUCERET KOAGULOPATI
Dutton et al. J Trauma 2010; Hess et al. J Trauma 2008; Gando et al. Annals of Surg 2011; Johansson et al. J Trauma 2012
TRAUME-INDUCERET KOAGULOPATI
Dutton et al. J Trauma 2010; Hess et al. J Trauma 2008; Gando et al. Annals of Surg 2011; Johansson et al. J Trauma 2012
TRAUME-INDUCERET KOAGULOPATI
Johansson, Stensballe et al. J Trauma 2012
TRAUME-INDUCERET KOAGULOPATI
Trauma-InducedCoagulopathy
Acute TraumaticCoagulopathyResuscitation
AssociatedCoagulopathy
ResuscitationAssociated
Coagulopathy
Stensballe et al.Curr Opinion of CritCare. 2017.
Systemic Endotheliopathy
Trauma HemorrhageShock
EndogenousHeparinazation
ActivatedProtein C
Hyper-fibrinolysis
Trauma-InducedCoagulopathy
Acute TraumaticCoagulopathyResuscitation
AssociatedCoagulopathy
PlateletDysfunction
Shock
Systemic Endotheliopathy
Stensballe et al.Curr Opinion of CritCare. 2017.
Dutton et al. J Trauma 2010; Hess et al. J Trauma 2008; Gando et al. Annals of Surg 2011; Kashuk et al. Annals of Surg 2011; Johansson et al. J Trauma 2012Johansson, Stensballe et al. SJTREM 2009; Johansson & Ostrowski. Medical Hypotheses 2010
TRAUME-INDUCERET KOAGULOPATI
Endothelial activation and damage
Johansson, Stensballe et al. SJTREM 2009; Johansson & Ostrowski. Medical Hypotheses 2010
Vicious circle
Oxygen versus hæmostase
TRAUME-INDUCERET KOAGULOPATI
Skade på karbarriere
Wataha et al. Transfusioin 2013
Kapillærlækage Syndrom
J Trauma. 2011
Ann Surg. 2018
Systemic Endotheliopathy
Trauma HemorrhageShock
EndogenousHeparinazation
ActivatedProtein C
Hyper-fibrinolysis
Trauma-InducedCoagulopathy
Acute TraumaticCoagulopathyResuscitation
AssociatedCoagulopathy
PlateletDysfunction
Systemic Endotheliopathy
Stensballe et al.Curr Opinion of CritCare. 2017.
J Trauma Acute Care Surg 2014
Ann Surg 2018
Severe infection including sepsisN ≈ 1800 patients
Acute myocardial infarctionN ≈ 700 patients
Resuscitated cardiac arrestN ≈ 160 patients
Akut Kritisk Syge patienter udviser samme unike type endotheliopati som øger dødeligheden
TraumaN ≈ 2700 patients
SHock-INduced Endotheliopathy
SHINE
Johansson, Stensballe & Ostrowski. Crit Care. 2017
5-min fra U
14/11 JST
15/11 PIA
16/11 MFT
18/11 SBA
Systemic Endotheliopathy
Trauma HemorrhageShock
EndogenousHeparinazation
ActivatedProtein C
Hyper-fibrinolysis
Trauma-InducedCoagulopathy
Acute TraumaticCoagulopathyResuscitation
AssociatedCoagulopathy
PlateletDysfunction
Shock
Systemic Endotheliopathy
Acute TraumaticCoagulopathy
Trauma-InducedCoagulopathy
Stensballe et al.Curr Opinion of Crit
Care. 2017
1:1:13:3:1-4:4:2
Livstruendeblødning
8 minHolcomb et al. JAMA 2015
• Whole blood analysis
• Measures the viscoelsatical properties of the clot
• Multiple endpoints reflecting clot formation, strength & degradation
• Real-time (15 min.)
Viscoelastic Haemostatic Assays (VHA)TEG®/ROTEM®
Stensballe et al. Curr Opinion of Crit Care. 2017
TRAUME-INDUCERET KOAGULOPATI
1. Øger dødeligheden, ses hos 30-40%!
2. Aggressiv monitorering & behandling!!
3. Udløses af systemisk endotheliopati (SHINE), og fremtidens resuscitation vil fokuserer på genskabelse af normal endothelfunktion
