Strategies for transfusion therapy and monitoring

Transcription

1 Strategies for transfusion therapy and monitoring Jakob Stensballe Consultant Anaesthetist & Transfusion Medicine MD PhD Dept. of Anesthesia, Centre of Head and Orthopedics & Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet COI No

2

3

4

5 Pathophysiology Coagulopathy related to Trauma/Shock - Acute Traumatic Coagulopathy Coagulopathy secondary to dilution with crystalloids and colloids Coagulopathy secondary to haemotherapy Coagulopathy secondary to comsumption (injury, DIC etc.) Coagulopathy due to hypothermia and metabolic acidosis Coagulopathy due to ischemia-reperfusion injury Coagulopathy due to antithrombotics Micro Vascular Bleeding (MVB) Hardy J-F et al. Can J Anesth 2004 Brohi K et al. Curr Opinion of Crit Care. 2007

6 Fluid resuscitation

7

8

9

10 Bleeding None Moderate controllable Massive uncontrollable

11 Massive uncontrollable 1:1:1 4:4:2

12 Transfusion packages Thawed FFP (AB RhD negative) immediately available for transfusion. Transfusion Package 4 RBC : 4 FFP : 2 Platelet Concentrates (ratio ~ 1 : 1 : 1) Results in Haematocrit ~ 30% Coagulation factor concentration >30% Platelet count of /L Normal TEG The packages are to be used until surgical control For patients with uncontrollable haemorrhage Johansson, Stensballe et al. Transfusion 2007 The Copenhagen Concept

13 8 min Holcomb et al. JAMA 2015

14 Before and after study MT patients (including obstetric calamities) Intervention group 442 ( ) vs. historic control 390 ( ) Intervention group transfused packages and TEG Number at risk Time in days Control group transfused based on ASA 1996 guidelines Log-rank, P< Johansson et Stensballe. Vox Sang 2009

15 Fewer advanced interventional procedures OR 1.25 [ ]; P = the whole cohort OR 1.58 [ ]; P = patients > 1 FFP

16 Moderate controllable

17 The influence of RBC transfusion on long-term survival after isolated CABG after controlling for the effect of demographics, comorbidities, operative factors, and the early hazard for death Survival status for 10,289 patients who underwent isolated CABG from was examined The outcome measure was all-cause mortality during the follow-up period. Koch et al. Ann Thorac Surg 2006

18 BLOOD Cells from human-to-human Transplantation Alive cells & DNA 1 Blood = 1 New Donor Side-effects Immune system Physiology Transfusion reactions Transfusion-translated infections Secher EL, Stensballe J, Afshari A. Acta anaesth scand. 2014

19 Age 67 year Septic shock (Need for NA) 90-d mortality 45 % 7 versus 9 g/dl

20

21 5243 adults EuroSCORE I > 6 Trigger < 7.5 (4.65 mmol/l) vs < 9.5 g/dl

22

23 4.3 mmol/l 70 g/dl

24

25 Haemostasis!

26 Plasma-based tests? INR/PT APTT developed to monitor heparin and vitamin K antagonists

27 Platelet count?. nothing but a number..

28

29 Viscoelastic Haemostatic Assays (VHA) Whole blood analysis TEG /ROTEM Measures the viscoelsatical properties of the clot Multiple endpoints reflecting clot formation, strength & degradation Real-time (15 min.)

30

31 31 NEW Fully Automated VHA s (TEG 6s/ROTEM Sigma)

32 TEG Tracing and Coagulopathy Normal Hypocoagulable Hypercoagulable Trombocytopathy Trombocytopenia Hypercoagulable Primary Fibrinolysis Hypocoagulable

33 ROTEM TEG Activator ROTEM Activator CK Kaolin EXTEM TF (Standard) CK-H Kaolin HEPTEM CA Heparinase Heparinase FF Functional Fibrinogen Functional Fibrinogen-H Rapid TEG TF PLT-Antag. TF PLT-Antag. Heparinase TF-Kaolin FIBTEM APTEM INTEM TF PLT. Antag. TF Aprotinin Contact Activator Rapid TEG-H TF-Kaolin Heparinase

34 Functional Fibrinogen TEG / FIBTEM ROTEM MA FF 6.3 mm (normal values 14-24)

35 Treatment algorithm Stensballe et al. Curr Opin Anesthesiol 2014 If treament failure call Bloodbank

36

37 Stensballe et al. Curr Opinion of Crit Care. 2017

38 The Copenhagen Concept

39 The Copenhagen Concept cont. The Copenhagen Concept CT/LAB ICU Blood bank specialist on call 24/7 Blood bankanalyze Trauma centre OR

40 My practical points Go for a little crystalloids (1:1) Be restrictive with bloods in most patients Monitor Hb. (trigger < 70 g/dl ~ < 4.3 mmol/l) Goal-direct therapy with TEG/ROTEM (normal clot) Massive bleeding is treated with 1:1:1 (4:4:2) and further goal-direct