Hemostatic Resuscitation - Resuscitation Congres 2017

vooruitstrevend in perioperatieve zorgafdeling Anesthesiologie

Hemostatic Resuscitation in the bleeding patient

anesthesiologie-amc.nl | Twitter: @victor_viersen| Twitter: @AnesAMC

Victor Viersen, Anesthesioloog2 februari 2017

Conflict of interest• none

This presentation is available online viawww.slideshare.net/VictorViersen

Lethal TriadCoagulopathy

Hypothermia Acidosis

Damage Control Surgery• Hemorrhage control• Contamination control• Packing• Temporary closure• Maximum 60 minutes

Damage Control Resuscitation

• Damage Control Surgery• Permissive Hypotension• Hemostatic Resuscitation

Basics Coagulation

• Initiation/activation• Amplification• Clot strength• Fibrinoysis

Fibrinolysis

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

Early Coagulopathy of trauma and shock

Early coagulopathy

ISS = Injury severity Score Prothrombin ratio = INR

Injury and hypoperfusion

Hemodilution

Fibrinogen (factor I)

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

Fibrinogen (factor I)Vulnerable to: • Hypothermi

a • Acidosis • Dilution • Loss • Consumptio

n• Colloids

Hyperfibrinolysis

• Endogenous thrombolysis• Severe trauma (ISS 45 +/-17)• Shock fenomena• High mortality (50-88%)• Only detected by TEM/TEG

X: Clot strength

Y: Time

Hyperfibrinolysis

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

Hemostatic Resuscitation• POC testing (ROTEM, TEG)• Tranexamic Acid• Transfusion• Factor concentrates• MTP’s

Point of Care Testing• Viscoelastic testing: thromboelastometry

(TEM), thromboelastography (TEG)• Comparible but not exchangeable!

Initiatie Amplificatie Clot strength Fibrinolyse

TEG versus ROTEM

Amplitude

Tijd 30min 60 min

10 min

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%

• 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

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)

Increased fibrinolysis vs hyperfibrinolysis

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

Tranexamic Acid

Transfusion• Ratio’s; is 1:1:1 the answer to everything?• Hemostatic effect may be maximal at 1:2

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

FFP content

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

Factor Concentrates

• Fibrinogen concentrate & 4-factor concentrate to reverse coagulopathy in the bleeding patient

• Some european centers don’t use FFP• Is it effective?

4FC vs FFP

Fibrinogen vs FFP

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

Goal Directed hemostatic therapy• Combination of

POC testing and Factor concentrates

• European concept from centers without acces to FFP

Do we still need FFP?

“Endotheliopathy”

Massive Transfusion Protocol’s

• Shown to benefit outcome, reduces morbidity and mortality, reduces wastage and cost

• Not just about ratio’s• Logistics

Recommendations• Get Viscoelastic Point of Care testing• Get a Massive Transfusion Protocol• Build an efficient system involving all relevant

specialties, departments etc.

Take Home Message

www.urgentiegeneeskunde.com- Anesthesia- Critical care- Resuscitation- Trauma - Prehospital Emergency

Medicine

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

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