hemostatic resuscitation - resuscitation congres 2017
TRANSCRIPT
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Hemostatic Resuscitation in the bleeding patient
anesthesiologie-amc.nl | Twitter: @victor_viersen| Twitter: @AnesAMC
Victor Viersen, Anesthesioloog2 februari 2017
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Conflict of interest• none
This presentation is available online viawww.slideshare.net/VictorViersen
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Lethal TriadCoagulopathy
Hypothermia Acidosis
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Damage Control Surgery• Hemorrhage control• Contamination control• Packing• Temporary closure• Maximum 60 minutes
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Damage Control Resuscitation
• Damage Control Surgery• Permissive Hypotension• Hemostatic Resuscitation
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Basics Coagulation
• Initiation/activation• Amplification• Clot strength• Fibrinoysis
Fibrinolysis
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Early Coagulopathy of trauma and shock
• 34% of all trauma patients
• Early mortality13% versus 1,5%
• Total mortality 28,4% versus 8,4%
• 30% multi organ failure
Frequency, risk stratification and therapeutic management of acute post-traumatic coagulopathy. Maegele M et al. Vox Sanguinis 2009; 97:39–49
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Early Coagulopathy of trauma and shock
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Early coagulopathy
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
ISS = Injury severity Score Prothrombin ratio = INR
Injury and hypoperfusion
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Hemodilution
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Hemodilution
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Fibrinogen (factor I)
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Fibrinogen (factor I)• Forms the actual clot• Normal value:
2,0-4,0 g/L • Critical value:
1,5 g/L (guidelines)
• Low fibrinogen associated with increased blood loss
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Fibrinogen (factor I)Vulnerable to: • Hypothermi
a • Acidosis • Dilution • Loss • Consumptio
n• Colloids
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Hyperfibrinolysis
• Endogenous thrombolysis• Severe trauma (ISS 45 +/-17)• Shock fenomena• High mortality (50-88%)• Only detected by TEM/TEG
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
X: Clot strength
Y: Time
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Hyperfibrinolysis
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Coagulopathy in the bleeding patient
1.Early traumatic coagulopathy: systemische anticoagulation & increased fibrinolysis
2.Fluid resusciation: dilution, hypothermia, acidosis
3.Consumption and loss: loss of factors, especially fibrinogen
4.Complete exhaustion:uncontroled bleeding, shock, hyperfibrinolysis
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Hemostatic Resuscitation• POC testing (ROTEM, TEG)• Tranexamic Acid• Transfusion• Factor concentrates• MTP’s
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Point of Care Testing• Viscoelastic testing: thromboelastometry
(TEM), thromboelastography (TEG)• Comparible but not exchangeable!
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Initiatie Amplificatie Clot strength Fibrinolyse
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
TEG versus ROTEM
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Amplitude
Tijd 30min 60 min
10 min
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Point of Care testing
• ROTEM is a valid predictor of coagulopathy and MT. • cutoff value for CA5 EXTEM ≤40 mm and FIBTEM ≤9 mm• detection rate for massive transfusion was 72.7% - 77.5%
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
• Standard coagulation test (SCT) designed for testing the effect of anticoagulation
• Recommendation to initate therapy at 1,5x prolongation of PT/aPTT/INR is based on historical habits rather than data
• no sound evidence that confirm that SCT’s are useful for diagnosis of coagulopathy or to guide haemostatic therapy
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Tranexamic Acid• CRASH 2: all cause mortality 16% to 14,5% in:
Adult trauma patients with significant haemorrhage (systolic blood pressure <90 mm Hg or heart rate >110 beats per min, or both), or who were considered to be at risk of significant haemorrhage
• Less vascular occlusive events (NS)• Based on work by Brohi et al. (Royal London Hospital)
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Increased fibrinolysis vs hyperfibrinolysis
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Tranexamic Acid• Do not hold back TXA until ROTEM analysis
is completed!• TXA is safe (CRASH 2, no adverse events)• Reduction of fibrinolysis/hyperfibrinolysis
is not the only positive effect of TXA
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Tranexamic Acid
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Transfusion• Ratio’s; is 1:1:1 the answer to everything?• Hemostatic effect may be maximal at 1:2
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
PROPPR trial
• First and only massive transfusion RCT• Randomized 1:1:1 versus 1:1:2• 12 level 1 centers, 680 patients• Primair outcome 24 hours and 30 day mortality
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
FFP content
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
FFP content• It is IMPOSSIBLE to correct fibrinogen to
normal levels with FFP in a 1:1:1 strategy• Average fibrinogen concentration 2,8g/L• If you transfuse 1:1:1 Fibrinogen 1,4g/L• Not enough to increase fibrinogen to 1,5g/L
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Factor Concentrates
• Fibrinogen concentrate & 4-factor concentrate to reverse coagulopathy in the bleeding patient
• Some european centers don’t use FFP• Is it effective?
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
4FC vs FFP
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Fibrinogen vs FFP
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Factor concentrates• - 20 pigs with 65% blood loss
- 65% substitution (HES) - therapy (1,2) - standardized incision in the liver
• 1. Fibrinogen 200mg/kg, 4FC 35IE/kg 2. Placebo
• groep 1: bloedverlies 240ml -> 100% survivalgroep 2: bloedverlies 1800ml -> 20% survival
• “Surgical blood loss” 7,5 timesas much when coagulopathy was NOT corrected
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Goal Directed hemostatic therapy• Combination of
POC testing and Factor concentrates
• European concept from centers without acces to FFP
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Do we still need FFP?
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
“Endotheliopathy”
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Massive Transfusion Protocol’s
• Shown to benefit outcome, reduces morbidity and mortality, reduces wastage and cost
• Not just about ratio’s• Logistics
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Recommendations• Get Viscoelastic Point of Care testing• Get a Massive Transfusion Protocol• Build an efficient system involving all relevant
specialties, departments etc.
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Take Home Message
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
www.urgentiegeneeskunde.com- Anesthesia- Critical care- Resuscitation- Trauma - Prehospital Emergency
Medicine
vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie
Fibrinogen Dose• 5L blood X 2,0 g/L = 10 gram • Fibrinogen 1,5 2,0 = 2,5 gram FC
Fibrinogen 1,0 2,0 = 5,0 gram FC• Keep in mind ongoing loss and consumption!• All of this can be lost in the time necessary to
administer this ammount