Debate: Goal directed vs Ratio-based Transfusion.
•Download as PPTX, PDF•
0 likes•270 views
Dr. Nicola Curry & Dr. James Winearls CICM Annual Scientific Meeting PROGRAM 2019
Recommended
More Related Content
What's hot
What's hot (20)
Similar to Debate: Goal directed vs Ratio-based Transfusion.
Similar to Debate: Goal directed vs Ratio-based Transfusion. (20)
More from CICM 2019 Annual Scientific Meeting
More from CICM 2019 Annual Scientific Meeting (20)
Recently uploaded
Recently uploaded (20)
Debate: Goal directed vs Ratio-based Transfusion.
- 1. FOR: GOAL DIRECTED TRANSFUSION Nikki Curry CICM, Cairns June 2019
- 2. WHICH GOAL? 77 minutes 5 minutes
- 3. COAGULOPATHY IS IMPORTANT Predictor of massive transfusion need Risk of death is x3-4 higher
- 4. DAMAGE CONTROL RESUSCITATION Aims: Stop the bleeding Treat the coagulopathy Prevent further coagulopathy Minimise tissue damage DCR Haemosta tic resuscitat ion Permissive Hypotensi on Damage control surgery
- 5. DAMAGE CONTROL RESUSCITATION Aims: Stop the bleeding Treat the coagulopathy Prevent further coagulopathy Minimise tissue damage DCR Haemosta tic resuscitat ion Permissive Hypotensi on Damage control surgery = 1:1 empiric transfusion
- 6. PREDICTION OF BLEEDING Low EXTEM CA5 predicts bleeding1 NPV for massive transfusion = 0.99 Standard care: Uses clinical acumen or MHP tools to detect bleeding: specificity = 70- 80% EXTEM CA5 values 1. Davenport et al, 2011, JTH 2. Cantle PM, Cotton BA. Prediction of massive transfusion in trauma. Crit Care Clin 2017;33:71-84. 3. Schroll R, Swift D, Tatum D, et al. Accuracy of shock index versus ABC score to predict EXTEM CA5 values
- 7. PREDICTION OF BLEEDING Low EXTEM CA5 predicts bleeding1 NPV for massive transfusion = 0.99 Standard care: Uses clinical acumen or MHP tools to detect bleeding: specificity = 70- 80% EXTEM CA5 values 1. Davenport et al, 2011, JTH 2. Cantle PM, Cotton BA. Prediction of massive transfusion in trauma. Crit Care Clin 2017;33:71-84. 3. Schroll R, Swift D, Tatum D, et al. Accuracy of shock index versus ABC score to predict EXTEM CA5 values
- 8. DOES DCR DO WHAT IT SAYS ON THE TIN? Coagulopathy progresses with transfusion
- 9. DOES DCR DO WHAT IT SAYS ON THE TIN? Coagulopathy progresses with transfusion
- 10. COAGULOPATHY IN TRAUMA HYPOCOAGULABLE Curry et al. 2012;26:223- 32.
- 13. VHA GUIDED TRANSFUSION TREATMENTReference Study Type No TEG or ROTEM Treatment Algorithm Outcomes Johansson 2009 Retrospective cohort, historical control 442 390 TEG ↑R - FFP α<52 – FFP or Fg MA<46 – plts Ly30>8% - TA DCR + TEG improved survival by 11% Kashuk 2011 Prospective Historical control 34 34 r-TEG G < 5.0 and: ↑R > 110sec - FFP α <66 – cryo MA <54 - plts Mortality fell from 65 % to 29% Schochl 2010 Retrospective 131 ROTEM FgC: if FIBTEM MCF <10mm PCC: if EXTEM CT >1.5x ULN Signif. reduction in mortality compared to expected mortality (p=0.03) Schochl 2011 Retrospective 2 databases 80 601 ROTEM As above Nil Reduction of blood exposure No difference in death
- 14. REVERSAL OF TRAUMA-INDUCED COAGULOPATHY USING FIRST-LINE COAGULATION FACTOR CONCENTRATES OR FRESH FROZEN PLASMA (RETIC): A SINGLE-CENTRE, PARALLEL-GROUP, OPEN-LABEL, RANDOMISED TRIAL. 100 patients Randomised to factor concentrate therapy vs FFP Inclusion: trauma haemorrhage, coagulopathic on ROTEM Intervention: guided by ROTEM Secondary endpoint: ROTEM guided therapy = clinical reduction in bleeding Innerhofer et al, Lancet Haematology, 2017
- 15. Overall mortality rate 27.9% Deaths: 20 in CCA group 11 in VHA group (p = 0.049) Median time to death: 11.5 vs 3.5 hrs (VHA vs CCA) Significant difference in death in first 6 hours Gonzalez et al. 2016 Annals of Surgery N = 111 Rapid TEG vs CCA Primary endpoint = 28 day mortality
- 16. ITACTIC TRIAL Large European RCT in 6 major trauma centres 392 patients Primary endpoint: proportion of subjects alive and free from MT at 24h Powered to see a 13% reduction in primary outcome in VHA group Closed Dec 2018
- 17. I-TACTIC TRIAL
- 18. VOTE: GOAL DIRECTED THERAPY
Editor's Notes
- Coagulopathy = poor outcomes So treat coagulopathy
- Clinical judgement alone = 65%
- Start with: Injury and hypoperfusion – more coagulopathy Increase in thrombin generation – coagulation cascade activated by ? TF, and talk about effects on prot c and effects on factor assays Effects on glycocalyx Platelet recruitment – talk about platelet changes in trauma haem Fibrinogen levels fibrinolysis