Transfusion in major bleeding: new insights. Gert Poortmans

Transcription

1 Transfusion in major bleeding: new insights Gert Poortmans

2 Trauma Cardiac Surgery Major Surgery with ongoing blood loss Burn Surgery

3 Lethal Triad Polytransfusion: definitions Coagulation Coagulopathy of trauma Goals in transfusion Polytransfusion in trauma Coagulopathy in cardiac surgery Doses Prices Conclusions

4 Lethal Triad Acidose Hypothermie Coagulopathy

5 Lethal Triad Acidosis PH < 7,2: coagulopathy T < 34 C: coagulopathy Ca 2+ < 0,9 mmol/l: coagulopathy

6 Polytransfusion: Definitions Loss of 1X bloodvolume / 24 hrs 50% bloodvolume in 3 hrs Ongoing blood loss: 150ml/h Transfusion: > 10 PRC /24 hrs Transfusion: > 4 PRC / 4 hrs

7 Coagulation 1 Initiation (INR, APTT) 2 Amplification 3 Propagation 4 Stabilization

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10 Coagulopathy of trauma ATC, TAC, TIC (APTT >60s, INR >1,5) 0 48 hrs: 50% of mortality in polytrauma = coagulopathy Coagulopathy in 25% of trauma on admission (exclusively in shock) 25% ICU-costs in trauma are transfusion-related.

11 Coagulopathy of trauma Fibrinogen is the first deficient factor in haemorrage Fibrinogen compensates for thrombocytopenia The time to administer haemostatic therapy correlates with patient outcome.

12 Coagulopathy of trauma No impairment of coagulation cascade Systemic anticoagulation and fibrinolysis. Coagulopathy and fibrinolysis parallel base deficit.

13 Coagulopathy of trauma Hypoperfusion and tissue destruction => SIRS => increased thrombomodulin => decreased thrombin => activates Protein C APC => increases plasmin => fibrinolysis APC => inhibits FVa and FVIIIa

14 Goals in transfusion Hgb > 7-9g/dl Platelets: > 50 x 10 3 moderate bloodloss > 100 x 10 3 massive bloodloss Fibrinogen > 1 1,5 2 g/l (gravidae)

15 Polytransfusion in trauma Correction of coagulation ASAP Ratio FFP/PRC 1:1, 1:2, 1:1:1 Retrospective, military Prospective: Survivor bias

16 Polytransfusion in trauma FFP > cristalloïds in resuscitation in mortality FFP > infection, sepsis, ALI and MOF FFP = 3 X TRALI (most frequent transfusion related complication) FFP maintains but not increases fibrinogenconcentration

17 Polytransfusion in trauma FFP: ml/kg TACO: diastolic dysfunction TRIM TRALI Additional PRC, platelets, Calcium

18 Polytransfusion in trauma FFP: citrate overload: Coagulopathy Decreased ejection fraction Arrhythmias Increased neuromuscular excitability

19 Polytransfusion in trauma Fibrinogen mg/kg CF IU/kg Antifibrinolytics: TA Less PRC, platelets, volume Less MOF, ventilatory time, ICU time and LOS

20 Polytransfusion in trauma FFP fibrinogen, CF Only small prospective studies Major retrospective studies

21 Coagulopathy in cardiac surgery Multifactorial Decreased concentration of CF (coagulation factors) Decreased activity of CF Residual heparin Excess protamine Thrombocytopenia Platelet dysfunction Fibrinolysis

22 Coagulopathy in cardiac surgery Post CPB-coagulopathy: Systemic hypocoagulation Mediastinal fibrinolysis

23 Coagulopathy in cardiac surgery Contact-system intrinsic pathway Traditional view on CPB coagulation dysfunction Surface activation is not the driving force

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26 Coagulopathy in cardiac surgery Extrinsic pathway: Endothelial cells when activated produce TF (ischemia, reperfusion, cytokines) TF released from damaged/ruptured cells Driving force in cardiac surgery coagulopathy.

27 Coagulopathy in cardiac surgery Fibrinolysis: Biofeedback systems: HMWK, FXIIa Role of FXIII: hemodilution and consumption

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29 Doses: FFP: ml/kg - 50 ml/kg Fibrinogen: mg/kg CF (PPSB): IE/kg TA (Exacyl): 10mg/kg bolus 1mg/kg/u infusion rfviia (Novoseven) mcg/kg Desmopressin (Minrin) 0,3mcg/kg

30 Prices: PRC: 250 up to 1600 FFP: 200 TC: 500 PPSB: 300 Haemocomplettan:

31 Conclusions Need for major prospective investigations into the use of fibrinogen and CF. What is the value of a combination of smaller prospective studies, together with retrospective studies and pathofysiology

32 Conclusions Need for perioperative POC-testing but no golden standard. TEG, ROTEM, PFA, ACT, INR, APTT fibrinogenlevels: clot strength, quality, fibrinolysis and platelet function The administration of fibrinolytics is logical in view of fibrinolysis of ATC and coagulopathy of cardiac surgery

33 Conclusions The utility of fibrinogen or CF is not innovative but the limited successes and potential dangers associated with the use of FFP are. geft mor e zakske plasma is a mortal sin.