Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of...

39

Transcript of Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of...

Page 1: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours
Page 2: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Disclosures

None

Page 3: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Objectives

Mechanisms of bleeding in CVT surgery Predictors of bleeding Approach to the severely bleeding patient Use of transfusion protocols to improve patient outcomes

Page 4: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Background

Transfusion in CVT surgery is common • 30 to 40% receive RBC units

• 1/3 of elective CAGB procedures require allogeneic blood

product support

• Consumes ~20% U.S. blood supply

Page 5: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Massive Transfusion: Winnipeg, Canada

Cardiothoracic

Surgery

GI hemorrhage Trauma

Vascular

Surgery

Other surgery

Obstetrical

34%

3%

22%

12%

15% 20%

Page 6: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

• Turns out…bleeding is bad

• Worse when transfused

• Highly associated with:

– Death

– Thrombosis

Page 7: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

CVT Surgery: Mechanisms of bleeding

Dilutional • Pump Prime • Cell Salvage • Crystalloid / Colloid

Consumption Hypothermia

Acidosis

Thrombocytonia & Platelet Dysfunction • ‘Pump platelet’

Medications

Hyperfibrinolytic state

(inherited coagulation defects)

Page 8: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

CVT Surgery: Mechanisms of bleeding

Dilutional • Pump Prime • Cell Salvage • Crystalloid / Colloid

Page 9: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

CVT Surgery: Mechanisms of bleeding

Dilutional • Pump Prime • Cell Salvage • Crystalloid / Colloid

Consumption Hypothermia

Acidosis

Thrombocytonia & Platelet Dysfunction • ‘Pump platelet’

Medications

Hyperfibrinolytic state

(inherited coagulation defects)

Page 10: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

CVT Surgery: Mechanisms of bleeding

Dilutional • Pump Prime • Cell Salvage • Crystalloid / Colloid

Consumption Hypothermia

Platelet activation / degranulation

Reduced Coagulation enzyme activity

Increased fibrinolysis

NO change in INR/aPTT

Page 11: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

CVT Surgery: Mechanisms of bleeding

Dilutional • Pump Prime • Cell Salvage • Crystalloid / Colloid

Consumption Hypothermia

Acidosis pH: 7.4 to 7.0 70% reduction in the activation of the prothrombinase complex

Page 12: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

CVT Surgery: Mechanisms of bleeding

Dilutional • Pump Prime • Cell Salvage • Crystalloid / Colloid

Consumption Hypothermia

Acidosis

Thrombocytonia & Platelet Dysfunction • ‘Pump platelet’

Medications

Hyperfibrinolytic state

(inherited coagulation defects)

Page 13: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

CVT Surgery: Mechanisms of bleeding

Ischemic Reperfusion injury Release of TPA from endothelial surface Presence of in situ thrombus formation (aka mediastinal clot)

Hyperfibrinolytic state

Page 14: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Predictors of bleeding

Patient factors • Age > 65 years • Female gender • Weight < 77 kg • Multiple comorbidities

Medications • Antiplatelet agents • Anticoagulants • Thrombolytics

Preoperative laboratory values • Pre-op anemia (<135 g/L)

• Pre-op thrombocytopenia (<150x109)

• Increased creatinine

Surgical factors • Surgeon • Non-elective surgery • Previous cardiac surgery • Combined procedures • Prolonged CBP time (>2 hours) • Hypothermic circulatory arrest

Page 15: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

‘Surgical’ Bleeding / need for re-operation

1. 500 mL of fresh bleeding in first hour

400 mL per hour for 2 hours

300 mL per hour for 3 hours

2. > 1,000 mL of bleeding in the first 4 hours

2. Sudden massive bleeding

3. Signs of cardiac tamponade

Page 16: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

The Papworth postoperative

blood loss chart

Patient with Surgical Bleeding

95th Percentile

Median blood loss

for unit

Time in critical care (hr)

Blo

od

loss (

ml)

Page 17: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Objectives

Mechanisms of bleeding in CVT surgery Predictors of bleeding Approach to the severely bleeding patient Use of transfusion protocols to improve patient outcomes

Page 18: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Approach to bleeding CVT patient

Maintain tissue oxygenation

Adequate circulating volume

Achieve hemostasis

Prevent coagulopathy

Page 19: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours
Page 20: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Component Therapies and Targets

Red Blood Cells

• Tissue Oxygenation (over-rated)

• Intravascular volume

• Under appreciated hemostatic

function

• Target in bleeding: 100 g/L

Page 21: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Component Therapies and Targets

Platelets

• Necessary for 10 hemostasis

• Number irrelevant if dysfunctional

• CPB circuit • Medications • Hypothermia (reversible)

• Target in bleeding: 50-70 x109/L

Page 22: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Component Therapies and Targets

Frozen plasma

• Contains 100% concentration of all

coagulation factors

• Lots of fibrinogen • 2-4 g/L

• Target in bleeding: < 1.5

Page 23: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Component Therapies and Targets

Cryoprecipitate

• Fibrinogen

• (Factor VIII, vWF, XIII)

• Rarely indicated

• Target in bleeding: 1 g/L

* Consider in isolated hyperfibrinolysis

Page 24: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

• Double blind placebo controlled RCT n= 300 • Protamine 25 mg/hr x 6 hours vs. saline

• Protamine eliminated heparin rebound

• Modest reductions in bleeding • No difference in transfusion

Page 25: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Hemostatic monitoring during bleeding

Options • Hemoglobin • Platelet • aPTT/INR • Fibrinogen

• Thromboelastography

• Gut instinct

Page 26: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Thromboelastography (TEG/ROTEM)

• TEG Developed in 1948 • Assesses the viscoelastic properties of whole blood

Page 27: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Spring

Rotating axis (+/ - 4.75°)

Light source

Detector

Plastic pin

Cuvette with blood

Fibrin strands and platelet aggregates between surfaces

Heated cuvette holder

Ball bearing

ROTEM

Page 28: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

• 990 patient before-and-after study

• 7% reduction in proportion receiving RBCs • 4% reduction in proportion receiving FFP • 5% reduction in proportion receiving Platelets

Page 29: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Objectives

Mechanisms of bleeding in CVT surgery Predictors of bleeding Approach to the severely bleeding patient Use of transfusion protocols to improve patient outcomes

Page 30: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

• Systematic review of the literature • 11 published cohort and case-control studies

• Civilian and military trauma • 10/11 studies reported decreased mortality associated

with an increased FFP:RBC ratio

• Only 1 study attempted to control for survival bias • No RCTs identified

Page 31: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

• pro

Page 32: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours
Page 33: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Transfusion protocols NOT in trauma

• Communication

• Processes of care

• Safe ratios of blood components

• Increased waste?

• Unproven outcomes

Page 34: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Pharmacologic measures

• Tranexamic acid

• DDVAP

• VIIa

• Fibrinogen concentrates

Page 35: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

• Single centre, double blind RCT, aortic surgery. N=61

• Treatment of coagulopathic bleeding

• Dosing guided by ROTEM

• Fewer allogeneic blood components in patients receiving fibrinogen (median, 2 vs. 13 U; P < 0.001)

• Total avoidance of transfusion was achieved in 13 (45%) of 29 patients receiving fibrinogen

Page 36: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

• 6 RCTs; 248 patients

• All – unclear or high risk of bias

• 12 ongoing trials!

• Reduced incidence of allogeneic transfusion

– 5 studies; 207 patients

– (RR 0.47, 95% CI 0.31 to 0.72)

Fibrinogen concentrate in bleeding

Page 37: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Fibrinogen: Unanswered questions

• Who should receive?

• When to give?

• What dose?

• What outcomes?

• What about safety?

• Cost effectiveness?

Page 38: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Objectives

Mechanisms of bleeding in CVT surgery Predictors of bleeding Approach to the severely bleeding patient Use of transfusion protocols to improve patient outcomes

Page 39: Disclosures - Critical Care Canada Forum...Surgical Bleeding / need for re-operation 1. 500 mL of fresh bleeding in first hour 400 mL per hour for 2 hours 300 mL per hour for 3 hours

Questions…?


Controlling Bleeding By: Thalita Ribeiro. Bleeding Major bleeding can be life-threatening. Bleeding can be external or internal. You can bleed form your.

Controlling Bleeding By: Thalita Ribeiro. Bleeding Major bleeding can be life-threatening. Bleeding can be external or internal. You can bleed form your.

WBCs & Differential Count Clotting & Bleeding Time...Bleeding Time Test (Duke Method) –Cont. Interpretation:Normal bleeding time is between 2-5 minutes. Prolonged bleeding time could

WBCs & Differential Count Clotting & Bleeding Time...Bleeding Time Test (Duke Method) –Cont. Interpretation:Normal bleeding time is between 2-5 minutes. Prolonged bleeding time could

MANAGEMENT OF ACUTE VARICEAL BLEEDING - … · The clinical practice guidelines on the management of acute variceal bleeding ... acute upper gastrointestinal bleeding due ... BLEEDING

MANAGEMENT OF ACUTE VARICEAL BLEEDING - … · The clinical practice guidelines on the management of acute variceal bleeding ... acute upper gastrointestinal bleeding due ... BLEEDING

ProCalc Nsg 132 Calculating ml per hour Example 1 An IV will be administered using an infusion pump that delivers ml/hr. D2.5W (2.5% Dextrose in Water)

ProCalc Nsg 132 Calculating ml per hour Example 1 An IV will be administered using an infusion pump that delivers ml/hr. D2.5W (2.5% Dextrose in Water)

La Casa Gallega · 2020. 10. 14. · ml ml ml ml ml ml ml ml ml ml ml ml ml $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ s $ $ $ s $ $ 190. 348. 190. 340. 205. 385. 170. 195. 280. 190. 58.

La Casa Gallega · 2020. 10. 14. · ml ml ml ml ml ml ml ml ml ml ml ml ml $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ s $ $ $ s $ $ 190. 348. 190. 340. 205. 385. 170. 195. 280. 190. 58.

Obstetric Hemorrhage Geetha P Rajendran MD Dept. of Ob … · Anesthesia . Interventional ... Activate MTP – call (add ... Continued bleeding with EBL >1500 mL OR >2 units PRBCs

Obstetric Hemorrhage Geetha P Rajendran MD Dept. of Ob … · Anesthesia . Interventional ... Activate MTP – call (add ... Continued bleeding with EBL >1500 mL OR >2 units PRBCs

AlphaLISA Assay to Detect Weak Interactions Between ...€¦ · AlphaLISA Acceptor beads (20 µg/mL final) for one hour. Finally, 25 µL of Streptavidin Donor beads (20 µg/mL final)

AlphaLISA Assay to Detect Weak Interactions Between ...€¦ · AlphaLISA Acceptor beads (20 µg/mL final) for one hour. Finally, 25 µL of Streptavidin Donor beads (20 µg/mL final)

24-Hour Urine Comprehensive Hormone Profile Handbook · • Breakthrough Bleeding Symptoms of Too Low Dosing • Hot flashes • Night sweats • Breakthrough bleeding If it is necessary

24-Hour Urine Comprehensive Hormone Profile Handbook · • Breakthrough Bleeding Symptoms of Too Low Dosing • Hot flashes • Night sweats • Breakthrough bleeding If it is necessary

Menorrhagia Definition: Heavy (>80 ml) or prolonged (>7 days) uterine bleeding excessive volume and durations of flow regular, normal intervals.

Menorrhagia Definition: Heavy (>80 ml) or prolonged (>7 days) uterine bleeding excessive volume and durations of flow regular, normal intervals.

Acute Lower Gastrointestinal Bleeding Lower GI Bleeding€¦ ·  · 2011-11-18Acute Lower Gastrointestinal Bleeding ... University of California, San Francisco! Lower GI Bleeding!

Acute Lower Gastrointestinal Bleeding Lower GI Bleeding€¦ ·  · 2011-11-18Acute Lower Gastrointestinal Bleeding ... University of California, San Francisco! Lower GI Bleeding!

Web pres GI bleed and ischemia 2014 · 3 Bleeding rate for detection RBC scintigraphy 010.1- 02ml/min0.2 ml/min Convent mesent angio 0.5 ml/min CTA 0.2-0.3 ml/min » iv – high dose,

Web pres GI bleed and ischemia 2014 · 3 Bleeding rate for detection RBC scintigraphy 010.1- 02ml/min0.2 ml/min Convent mesent angio 0.5 ml/min CTA 0.2-0.3 ml/min » iv – high dose,

CHAPTER 23 BLEEDING. Introduction Bleeding can be external or internal. Bleeding can cause weakness, shock, and death.

CHAPTER 23 BLEEDING. Introduction Bleeding can be external or internal. Bleeding can cause weakness, shock, and death.

First Aid Of Bleeding By Dr. Hanan Said Ali. Learning Objectives: *- Define the bleeding. *-Identify types of bleeding. *-List types of external bleeding.

First Aid Of Bleeding By Dr. Hanan Said Ali. Learning Objectives: *- Define the bleeding. *-Identify types of bleeding. *-List types of external bleeding.

Evaluation of Abnormal Uterine Bleeding · Evaluation of Abnormal Bleeding ! Ovulatory Bleeding - Occurs at predictable ... bleeding from os? - Uterus- Assess uterine size, mobility,

Evaluation of Abnormal Uterine Bleeding · Evaluation of Abnormal Bleeding ! Ovulatory Bleeding - Occurs at predictable ... bleeding from os? - Uterus- Assess uterine size, mobility,

Specimen Collection and Preparation Guide · T313 Urine Container, 60 mL Standard aliquot container for 24-hour collection. T596 Urine Container, Amber, 60 mL Aliquot tube for 24-hour

Specimen Collection and Preparation Guide · T313 Urine Container, 60 mL Standard aliquot container for 24-hour collection. T596 Urine Container, Amber, 60 mL Aliquot tube for 24-hour

Calculating IV prescribed Drug Dose in ml/hour

Calculating IV prescribed Drug Dose in ml/hour

ASIN AQUA Oxygen CZ, EN, DE - bassengutstyr.no · ASIN AQUA Oxygen 10 OK Temperature Water level ml/m3 day Algicid ml/ma day ON Flocc 10 ml/hour 28,5 155 cm 00 FILTRATION TIMER OXY

ASIN AQUA Oxygen CZ, EN, DE - bassengutstyr.no · ASIN AQUA Oxygen 10 OK Temperature Water level ml/m3 day Algicid ml/ma day ON Flocc 10 ml/hour 28,5 155 cm 00 FILTRATION TIMER OXY

ProCalc Nsg 232 Calculating IV Drug Dose per Hour & Minute Example 1 Dextrose 5% in water with Amicar is infusing at a rate of 55 ml per hour. The.

ProCalc Nsg 232 Calculating IV Drug Dose per Hour & Minute Example 1 Dextrose 5% in water with Amicar is infusing at a rate of 55 ml per hour. The.

Management: bleeding examined€¦ · MENORRHAGIA or dysfunctional uterine bleeding (DUB) were terms historically used to describe heavy menstrual bleeding. Heavy bleeding refers

Management: bleeding examined€¦ · MENORRHAGIA or dysfunctional uterine bleeding (DUB) were terms historically used to describe heavy menstrual bleeding. Heavy bleeding refers

Brake & Clutch Bleeding Equipment - Lincoln Industrial · Brake & Clutch Bleeding Equipment ... • 4.5 oz (135 ml) ... This compact yet powerful unit bleeds up to 2 quarts (1.9 liters)

Brake & Clutch Bleeding Equipment - Lincoln Industrial · Brake & Clutch Bleeding Equipment ... • 4.5 oz (135 ml) ... This compact yet powerful unit bleeds up to 2 quarts (1.9 liters)