The Role Of Point of Care Coagulation Testing (POCCT) in Patient Blood Management. Elham Khalaf Adeli

Transcription

1 The Role Of Point of Care Coagulation Testing (POCCT) in Patient Blood Management Elham Khalaf Adeli

2 Overview PBM, bleeding management, Coagulation POC Testing Review of laboratory conventional coagulation Tests Review of coagulation Point of care( POCCT) testing Clinical efficacy of Coagulation POCC Testing and PBM Conclusion

3 What is Patient Blood Management Preventative medical or surgeries strategies to conserve the Pateint,s Pateint s own blood to reduce or avoid the need for a blood transfusion and improve patient outcome outcome. Optimize erythro-erythro poieis p Minimize bleeding & blood loss Axel Hofmann/Shannon Farmer SHEF Meeting Perth August 2010 optimize physiologic tolerance of anemia

4 Multifactorial Causes for Coagulopathy/ Bleeding management in Surgeries Coagulopathy Bleeding Need to Transfusion Disturbances of primary hemostasis 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, in some cases, the fibrinogen concentration.

5 Intrinsic pathway XIIa Cascade Model XIa Prothrombin IXa VIIIa Xa Va VIIa Extrinsic Pathway TF Soft clot Thrombin Fibrinogen Fibrin( and Platelet) XIIIa Fibrin Hard clot

6 Intrinsic i pathway XIIa XIa This model explains the laboratory coagulation tests PT Extrinsic Pathway TF IXa VIIIa Xa Va VIIa Fibrinogen Thrombin Fibrin(Soft clot) XIIIa Fibrin (hard Clot)

7 PTT Intrinsic i pathway XIIa This model explains the laboratory coagulation tests XIa Extrinsic Pathway TF IXa VIIIa Xa Va VIIa Fibrinogen Thrombin Fibrin(Soft clot) XIIIa Fibrin (hard Clot)

8 Intrinsic i pathway XIIa This model explains the laboratory coagulation tests (In Vitro) XIa Extrinsic Pathway TF IXa VIIIa Xa Va VIIa TT Fibrinogen Thrombin Fibrin(Soft clot) XIIIa Fibrin (hard Clot)

9 Intrinsic pathway XIIa XIa Clot Firmness & Stability Laboratory Tests Extrinsic Pathway TF IXa VIIIa Fibrinogen Xa Va Thrombin VIIa? Anionic phospholipid ( platelet) Fibrin monomer XIIIa?? Polymer Fibrin (hard Clot)

10 Really, how does hemostasis work In vivo. Coagulation system is dynamic

11 Disadvantages of Conventional Coagulation Tests Reflect only the initial formation of thrombin in plasma Convey clot in static condition not dynamic Nor do the conventional coagulation tests convey any information about clot stability over time Not a true reflection of what happens in the body

12 Disadvantages of Conventional Coagulation Tests Golden time in management of bleeding will 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 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

13 Viscoelastic Techniques as POCCTs Roles of Thromboelastometry and thromboelastography for patient Blood Management/ Bleeding Management/ Surgeries Bollinger et,al. Transfuse Med Rev.2013 Oct:27(4):213-20

14 -It was first developed in 1948 by Dr Hullmut Hartert Blood collected as whole blood Citrated tubes Tested at 37 C Graphic results are available in real time on screen Takes 20 min until first results are Takes 20 min until first results are available

15 Clot formation(ct/r) : -Clotting factors -Anticoagulant Kinetics of the clot Clot strength/stability(mcf/ma) -Fibrinogen -Platelets Clot Lysis(LI30/ML) - Hyperfibrinolysis Millid Thakur,et al.a Review of Thromboelastography.IJPUT.2012;1(1):25-29

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17 INTEM: coagulation is activated via the contact phase HEPTEM: coagulation is activated as in INTEM in the presence of heparins. EXTEM: coagulation is activated by tissue factor to monitor the coagulation 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.

18 POC-Based Algorithm for Bleeding FFP management Clot Formation Clotting Factors r Anticoagul VII ant FFP PCC VII Protamine sulfate Clot strength/ Stability Fibrinogen Platelet Fibrinogen concentrate DDAVP Plt Concentrate t Clot Lysis Hyperfibrin olysis Antifibrinolytic Agents XIII Concentrate

19 POC-Based Algorithm for Bleeding FFP management Clot Formation Clotting Factors r Anticoagul VII ant FFP PCC VII Protamine sulfate Fibrinogen concentrate Clot strength/ Stability Clot Lysis Fibrinogen Platelet Hyperfibrin olysis DDAVP Plt Concentrate VWF concentrate Antifibrinolytic Agents XIII Concentrate

20 First line Therapy with factor Concentrate& &Drug Intervention Blood Product Factor Drug concentrate FFP Fibrinogen Antifibrinolytic Cryoprecipitate PCC DDAVP Platelet rvii FXIII concentrate Protamine sulfate vwf concentrate Rotational Thromboelastometry (ROTEM)-Based Coagulation Management in Cardiac Surgery and Major Trauma Kenichi A. et al,journal of Cardiothoracic and Vascular Anesthesia, 2012

21 Make your Own Algorithm First line Therapy with factor Concentrate and drug Several hemostatic products are discussed in relation to ROTEM parameters, but the availability of products differs among institutions and countries. Therefore you must have your own algorithm for your institution. Consider Cost &Benefit for your algorithm in Bleeding Management Evaluate the efficacy of algorithm Rotational Thromboelastometry (ROTEM)-Based Coagulation Management in Cardiac Surgery and Major Trauma Kenichi A. et al,journal of Cardiothoracic and Vascular Anesthesia, 2012

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23 Implementation ti of POCCT Based protocol for Bleeding Management Blood Product (n=1120) 12 Months Prior POCT (n=1056) 12 Months POCT RBC 47%(524) 35%(370) Platelets 34%(380) 14.5%(153) FFP 26%(291) 9.4(99)

24 Implementation of POCCT Based protocol for Bleeding Management Blood Product (n=1120) (n=1056) Difference Pre POCCT Post POCCT RBC Platelet FFP

25 Conclusion Bleeding management as a important pillar in PBM Detect and treat coagulopathy early Monitor coagulation bed side with POC devices Use factor concentrates to avoid the adverse effects of transfusion Having a coagulation algorithm at your hospital is mandatory

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