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The Role Of Point of Care Coagulation Testing (POCCT) in Patient Blood Management
Elham Khalaf Adeli
Overview
PBM , bleeding management, Coagulation POC TestingReview of laboratory conventional coagulation TestsestsReview of coagulation Point of care( POCCT) testingtesting Clinical efficacy of Coagulation POCC Testing and PBMPBMConclusion
What is Patient What is Patient Blood Blood ManagementManagement
Preventative medical or surgeries strategies to conserve the Pateint s own blood to reduce orconserve the Pateint,s own blood to reduce or avoid the need for a blood transfusion and improve patient outcomeimprove patient outcome.
Optimize Optimize MinimizeMinimizeoptimize optimize
Optimize Optimize erythroerythro--poieispoieis
MinimizeMinimizebleeding bleeding & & blood lossblood loss
physiologic physiologic tolerance tolerance of anemiaof anemia
© Axel Hofmann/Shannon Farmer –SHEF Meeting Perth August 2010
pp blood lossblood loss of anemiaof anemia
Multifactorial Causes for Coagulopathy/ Bleeding t i S imanagement in Surgeries
C l th Bl di N d t T f i
● Disturbances of primary hemostasis
Coagulopathy Bleeding Need to Transfusion
● Abnormalities of blood plasma, e.g., clotting-factor deficiency , anticoagulants
● Complex coagulopathies, e.g., hyperfibrinolysis.
Blood clotting is conventionally tested with two global tests, the PT,International Normalized Ratio (INR) and the activated partial thromboplastin time (aPTT) along with the platelet count and inthromboplastin time (aPTT), along with the platelet count and, in some cases, the fibrinogen concentration.
Intrinsic pathway
XIIaCascade Model
TF
Extrinsic PathwayXIa
ProthrombinVIIa
TF
IXa
XaVa
VIIIa
Fibrinogen Fibrin( and Platelet)Thrombin Soft clot
g ( )XIIIa
FibrinHard clot
I i i hThis model explains the laboratory
XIIa
Intrinsic pathway coagulation tests
PT
TFExtrinsic PathwayXIa
VIIa
TF
IXa
XaVa
VIIIa
Fibrinogen Fibrin(Soft clot)Thrombing
XIIIa
Fibrin (hard Clot)
I i i hThis model explains the laboratory
PTT
XIIa
Intrinsic pathway coagulation tests
TFExtrinsic PathwayXIa
VIIa
TF
IXa
XaVa
VIIIa
Fibrinogen Fibrin(Soft clot)Thrombing
XIIIa
Fibrin (hard Clot)
I i i hThis model explains the laboratory
XIIa
Intrinsic pathway coagulation tests (In Vitro)
TFExtrinsic PathwayXIa
VIIa
TF
IXa
XaVa
VIIIa
TT
Fibrinogen Fibrin(Soft clot)Thrombing
XIIIa
Fibrin (hard Clot)
Intrinsic pathway Laboratory TestsXIIa
Laboratory Tests
TFExtrinsic PathwayXIa
Clot Firmness & Stability
VIIa
TF
IXaVIII
XaVa
VIIIa
Anionic phospholipid ( platelet)
??
??Fibrinogen Fibrin monomer Thrombin
XIIIa
Anionic phospholipid ( platelet)
Polymer
??
??XIIIa
Fibrin (hard Clot)
??
Really , how Really , how does hemostasis does hemostasis
work In vivowork In vivo
Coagulation Coagulation ……….
system is system is dynamicdynamic
Disadvantages of Conventional Coagulation Tests
Reflect only the initial formation of thrombin in plasmaConvey clot in static condition not dynamicNor do the conventional coagulation tests conveyNor do the conventional coagulation tests convey any information about clot stability over timeNot a true reflection of what happens in theNot a true reflection of what happens in the body
Disadvantages of Conventional Coagulation Tests
Golden time in management of bleeding will be lost Turnaround Time????be lost . Turnaround Time????
Test Order
Test Processing
Test Result application
Patient Management
40 to 60 minutes!!!! after blood drawing.This turnaround time is so long that the resultsThis turnaround time is so long that the results
may not reflect the current state of the coagulation system and lead to inappropriate treatment
Toulon P, et al:Point-of-care versus central laboratory coagulation testing during haemorrhagic surgery. A multicenter study. Thromb Haemost 2009
Viscoelastic Techniques as POCCTsRoles of Thromboelastometry and thromboelastography for patient Blood Management/ Bleeding Management/ Surgeries
Bollinger et,al. Transfuse Med Rev .2013 Oct:27(4):213-20
-It was first developed in 1948 by Dr Hullmut Hartert Blood collected as whole bloodBlood collected as whole blood Citrated tubes Tested at 37°C Graphic results are availableGraphic results are available in real time on screen
Takes ≤20 min until first results areTakes ≤20 min until first results are available
Clot formation(CT/R) :
KineticsKinetics of the clotof the clot-Clotting factors-Anticoagulant Kinetics Kinetics of the clotof the clotg
Clot strength/Stability(MCF/MA)-Fibrinogen-Fibrinogen-Platelets
Cl t L i (LI30/ML)Clot Lysis(LI30/ML)- Hyperfibrinolysis
Millid Thakur,et al.A Review of Thromboelastography.IJPUT.2012;1(1):25-29
INTEM: coagulation is activated via the contact phase
HEPTEM: coagulation is activated as in INTEM in the presence of heparins. p
EXTEM: coagulation is activated by tissue factor to monitor the coagulation process via thecoagulation process via the extrinsic pathway.
FIBTEM: coagulation is activated as in EXTEM to monitor the clot firmness after blocking platelet contribution to the clot firmness.
APTEM: coagulation is also activated as in EXTEM. Intend to monitor the clot firmness after blocking hyperfibrinolysis by aprotinin.
FFPPOC-Based Algorithm for Bleeding management
Clotting Factors
management FFP PCC VII
Clot Formation
r VIIAnticoagulant
Protamine sulfateant
Fibrinogen
Fibrinogen concentrate
Clot strength/ Stability
Fibrinogen
Plt C t t
DDAVP
Platelet Plt Concentrate
Antifibrinolytic
Clot LysisHyperfibrin
olysis
Agents
XIII Concentrate
FFPPOC-Based Algorithm for Bleeding management
Clotting Factors
management FFP PCC VII
Clot Formation
r VIIAnticoagulant
Protamine sulfate
ant
Fibrinogen
Fibrinogen concentrate
Clot strength/ Stability
Fibrinogen
Plt Concentrate
DDAVP
Platelet
Antifibrinolytic
VWF concentrate
Clot LysisHyperfibrin
olysis
AntifibrinolyticAgents
XIII Concentrate
First‐line Therapy with factor Drug&Concentrate Drug&Concentrate
InterventionDrugFactorBlood Product DrugFactor
concentrateBlood Product
AntifibrinolyticFibrinogen FFP
DDAVPPCCCryoprecipitate
Protamine sulfate
rVIIPlatelet
FXIII concentrate
vWF concentrate
Rotational Thromboelastometry (ROTEM)-Based Coagulation Management in Cardiac Surgery and Major TraumaKenichi A. et al,Journal of Cardiothoracic and Vascular Anesthesia, 2012
Make your Own Algorithm• First‐line Therapy with factor Concentrate and drug
• Several hemostatic products are discussed inSeveral hemostatic products are discussed in relation to ROTEM parameters, but the availability of products differs amongavailability of products differs among institutions and countries. Therefore you must have your own algorithm for your institution.have your own algorithm for your institution.
• Consider Cost &Benefit for your algorithm in Bleeding ManagementBleeding Management
• Evaluate the efficacy of algorithmRotational Thromboelastometry (ROTEM)-Based Coagulation Management in Cardiac Surgery and Major TraumaKenichi A. et al,Journal of Cardiothoracic and Vascular Anesthesia, 2012
I l t ti f POCCT B dImplementation of POCCT Based protocol for Bleeding Management
(n=1056)(n=1120)Blood Product 12 Months POCT12 Months Prior
POCT
35%(370)47%(524)RBC 35%(370)47%(524)RBC
14.5%(153)34%(380)Platelets
9.4(99) 26%(291)FFP
Implementation of POCCT BasedImplementation of POCCT Based protocol for Bleeding Management
Diff( 1056)( 1120)Bl d P d Difference(n=1056)Post POCCT
(n=1120)Pre POCCT
Blood Product
981-18592840 RBC
‐607359966Platelet
‐11314001531FFP
Conclusion
• Bleeding management as a important pillar in PBMBleeding management as a important pillar in PBM• Detect and treat coagulopathy early • Monitor coagulation bed side with POC devices• Monitor coagulation bed side with POC devices • Use factor concentrates to avoid the adverse effects of transfusionof transfusion
• Having a coagulation algorithm at your hospital is mandatorymandatory