Optimising bleeding management: One hospital s experience DR DANIEL FAULKE

Transcription

1 Optimising bleeding management: One hospital s experience DR DANIEL FAULKE

2 Conflict of interest I have received part sponsorship from Haemoview/Tem International to travel to an industry sponsored conference in 2012 My hospital has received grants in the form of free product, not tied to any conditions, from Haemoview

3 Summary Highly successful bleeding management project Point of care testing focal point for multidisciplinary involvement Sustainable and improving savings Well planned change management approach with rigorous QA & Audit One size doesn t fit all tailor choices to institutional need

4 Changing Practice: The Prince Charles Hospital Experience Bronwyn Pearse, CNC (Patient Blood Managment) Critical Care Services Prince Charles Hospital, Brisbane, Australia

5 No. Of Units 3000 Number of Blood Product Units: Year Prior to POCT The problem Transfusion rate increasing?more acuity ?more antiplatelet drugs 0 RBC FFP Platelets Cryoprecipitate Primary CABG especially showed alarming increase Federal cost shifting to institution looming Reopen rate and literature evidence of harm 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 47% 26% Blood Products % Patients Receiving Blood Products Year Prior to POCT (July 2011-June2012) 34% 10% RBC FFP Platelets Cryoprecipitate

6 Why minimise bleeding? Acute issues: instability, acute end organ ischaemia, tamponade, allergic/infective risks transfusion Cost of transfusion 2011 $1.8mil at TPCH Decreased survival e.g. cardiac surgery HR 1.67 over 6/12 (Surgenor et al A+A 2009 Jun108(6) ) Any transfusion: adjusted 30 day mort 1.9% vs 1.1 (Kuduvalli et al Eur J Cardiothoracic Surgery 2005 Apr 27(4) 592-8) Twice 5yr mortality (15 vs 7%); Adj RR 1.7 (Engoren et al Ann Thorac Surg 2002 Oct 74(4) )

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8 Increased primary CABG transfusion CCRG research interest 2009 TEG trialled POCT Multidisciplinary symposium Project stalled Appointment CNC 2011 Further sponsorship Medical exec SEED funding patients Multidisciplinary meetings 2012 Compelling data After 6-9 months Federal cost shifting 2012

9 Multidisciplinary Approach Engage Clinicians / Establish Ownership Sustainable / Cost Effective Validity / Quality Control Monitor & Evaluate Outcomes

10 Engage Clinicians - Working Group Stakeholders Surgeons Anaesthetists Intensivists Haematologists Haematology Scientists Blood Bank Transfusion CNC Anaesthetic Technicians Perfusionists Nurses (ICU & OT)

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12 Programme details. Preoperative Anaemia screening programme Pharmacy support/surgeon antiplatelet/anticoagulant Intraoperative Tranexamic acid, Prothrombinex, Antithrombin Haemodilution minimisation reduce fluid, pump prime, blood cardioplegia, cell saver as appropriate Use of POCT Surgical haemostasis glues and a tincture of time RBC targets Postoperative Red cell targets Ignore coags/no tests if not bleeding

13 ROTEM Rotational Thromboelastometry Similar to TEG in theory Rotating axis (+/ ) Light source Results in minutes, can temperature correct Spring Detector Ball bearing Plastic pin Cuvette with blood Fibrin strands and platelet aggregates between surfaces Heated cuvette holder

14 Temogram Parameters - α angle ( ) Lysis (%) CT = Clotting Time (sec) MCF = Maximum Clot Firmness (mm) Clot Quality CFT = Clot Formation Time (Sec)

15 Multiplate Allows analysis of platelet contribution to clot strength Overcomes limitation of viscoelastic tests overwhelming activation of platelets by thrombin burst Selective reagents examine activation of platelets via different pathways ASPI test for cyclooxygenase inhibition ADP test for purine receptor antagonism TRAP test for GpIIbIIIa receptor antagonism

16 Multiplate twin impedance sensor platelets aggregate on metal sensors and increase electrical resistance

17 aggregation [AU] Parameters test 1 test aggregation velocity test time [min] Area under the curve = AUC most important parameter expressed in AU*min or U (10 AU*min = 1 U)

18 Implementation Plan Governance Accountability Reporting structure Instrument Operators Interpreters Monitoring and Reporting of Outcomes Quality Control Reproducibility Maintenance

19 Development of Quality Control Infrastructure

20 Stat Lab

21 Results Streamed Live

22 TPCH Cardiac Surgery ROTEM / Multiplate Transfusion Algorithm Do not treat patient unless there is clinically significant bleeding Optimise conditions - T > 36 degrees, ph > 7.2, Ca > 1 mmol / l, Hb = / > 7 g/dl INTEM - CT > 240 secs & HEPTEM - CT / INTEM - CT < 0.8 Yes Heparin Effect Yes Redosage of Protamine EXTEM A10 =/<40mm & FIBTEM A10 =/< 10mm EXTEM - CT > 90 secs OR HEPTEM - CT > 280 secs Yes Yes Low Fibrinogen Low Coagulation Factors Yes Yes Cyroprecipitate PCC / FFP Re-examination of ROTEM Plus or Minus Multiplate Analysis 10 mins after treatment EXTEM A10 =/< 40mm & FIBTEM A10 > 10mm Yes Poor Platelet Contribution Yes Platelets ADP - AUC < 30 ASPI - AUC < 30 TRAP - AUC < 50 Yes Platelet Dysfunction Yes Aim for : Lysis Index A30 > 15 % Yes Hyperfibrinolysis Yes Tranexamic Acid Temp > 36 ph > 7.2 Ca > 1 mmol/l Hb > 7g/dl Do not treat patient unless there is clinically significant bleeding

23 But it s not all POCT folks The key is comprehensive.. PATIENT BLOOD MANAGEMENT DRIVEN BY MULTIDISCIPLINARY TEAM!!

24 TPCH RBC transfusion triggers Usual absolute acceptable nadir Hb 60g/L on CPB end organ ischemia/injury risk then Hb >70g/L most happy here Typical aim for Hb > 70 in otherwise well post CPB Aim for Hb >80 in critical ischaemia and/or use monitors Based on STS guidelines 2007/2011

25 Other strategies Tranexamic acid use almost ubiquitous Introduction of Antithrombin Prothrombinex 1 st line agent of choice for warfarin reversal Greater attention to haemostasis Standard lab coags stopped post op measured if bleeding only

26 Cost of blood products halved Reduced reopen rate Reduced infection rate Collaborative model excellent for cross-department relations Second ROTEM bought, TPCH case example for NBA and throughout Queensland Health

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30 41% 35% 27% All p<0.001

31 Great Initial success!! Can we sustain it? Where to from here?

32 Anaemia management nurse Preop Hb monitoring Iron infusions Referral for endoscopy CNC Patient blood management Intraop/postop strategies eg POCT CNC Transfusion Safety and quality of transfusion Audit usage Audit wastage

33 Programme details. Preoperative Anaemia screening programme Pharmacy support/surgeon antiplatelet/anticoagulant Intraoperative Tranexamic acid, Prothrombinex, Antithrombin Haemodilution minimisation reduce fluid, pump prime, blood cardioplegia, cell saver as appropriate Use of POCT Surgical haemostasis glues and a tincture of time RBC targets Postoperative Red cell targets Ignore coags/no tests if not bleeding

34 Programme details. Preoperative Anaemia screening programme Pharmacy support/surgeon antiplatelet/anticoagulant Intraoperative Tranexamic acid, Prothrombinex, Antithrombin Haemodilution minimisation reduce fluid, pump prime, blood cardioplegia, cell saver as appropriate Use of POCT Surgical haemostasis glues and a tincture of time RBC targets Postoperative Red cell targets Ignore coags/no tests if not bleeding

35 Programme details. Preoperative Anaemia screening programme Pharmacy support/surgeon antiplatelet/anticoagulant Intraoperative Tranexamic acid, Prothrombinex, Antithrombin Haemodilution minimisation reduce fluid, pump prime, blood cardioplegia, cell saver as appropriate Use of POCT Surgical haemostasis glues and a tincture of time RBC targets Postoperative Red cell targets Ignore coags/no tests if not bleeding

36 Programme details. Preoperative Anaemia screening programme Pharmacy support/surgeon antiplatelet/anticoagulant Intraoperative Tranexamic acid, Prothrombinex, Antithrombin Haemodilution minimisation reduce fluid, pump prime, blood cardioplegia, cell saver as appropriate Use of POCT Surgical haemostasis glues and a tincture of time RBC targets Postoperative Red cell targets Ignore coags/no tests if not bleeding

37 Where to from here?