Bleeding in paediatric surgery - case presentations
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A talk by Birgitta Romlin at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Delivered in collaboration between scanFOAM, SSAI & SFAI.
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Bleeding in paediatric surgery - case presentations
- 1. Birgitta Romlin MD,PhD Anaesthesia and Intensive Care Queen Silvia Childrenâs Hospital, Gothenburg, Sweden Bleeding and coagulation, pediatric case reports SSAI 2017
- 3. Case 1 Boy 12 years hit by a car, femur fracture and suspected pelvis fracture. Arrives at the emergency department after a long transport time of 3 hours. Haemoglobin in the ambulance 73 g/L. The boy is awake but tired, systolic blood pressure 78 Saturation 92 with oxygen Transported in vacuum mattress 3
- 4. Case 1 Who wants to start with 4:4:1? Who wants to give O-neg blood? Who wants to wait for blood samples? What kind of blood samples/measurements do you want? Is there anything else you want to do/give? 4
- 5. Case 1 The boy left for a trauma CT What kind of monitoring do you want during transport and CT? 5 Temperature: Arterial line:(blood pressure, active bleeding) Blood gas: pH, Ca, Hb, BE, Lactate
- 6. Case 1 CT showed femur fracture with severe bleeding Lung contusion on the right side with pleura excudate Stable pelvis fracture Some bleeding around the liver 6 Treatment at arrival 0 neg blood 1 unit Tranexamic acid (Cyklokapron) 1 g After TEM Fibrinogen 2 g Platelets 300 ml
- 7. Haemostasis â optimal conditions Temperature pH Ca2+ Coagulation disturbances (1/3) at arrival Hb >90 g/l TPK >100 * 109 /l APTT Standard value PK <1.5 INR Fibrinogen >2 - 2.5 g/l
- 8. Early/directly use of blood products/procoagulation drugs E-konc: plasma: Trbc: 4:4:1 (SWE) (1:1:1 US) Tight collaboration with blood department Massive Transfusion Protocol Surgery (Damage control) Hb, TPK, ROTEM/TEG, Fibrinogen, Blood gas (APTT, INR) Fibrinogen Cyklokapron Temperature-Ca-pH REEVALUATION Bleeding treatment
- 9. The european guideline on management of major bleeding and coagulopathy following trauma. Crit Care (2016) 20:100 Monitoring of haemostasis We recommend that the routine practice includes the early and repeated monitoring of coagulation, using either a traditional laboratory determination [prothrombine time (PT), activated partial thromboplastin time (APTT), platelet counts and fibrinogen (Grade 1A) and/or a viscoelastic method (Grade 1C). Recommendations: 1 â Strong 2 - Minor Evidence: A â High quality B â Intermediary C â Low quality
- 10. Key points Trauma care very similar to adult care, need for calculation of fluid/transfusions and medication Standard monitoring with thromboelastometry, blood samples Donât forget the basics (pH, Ca, Temp, Hb)
- 11. Case 2 16.20 in the afternoon In theatre since 8 oÂŽclock this morning Transposition of the great arteries Weight 3.1 kg
- 12. What makes children different Coagulation factor VII, IX, X, XI, XII and prothrombin are 50% less than adult levels Factor VIII, XIII, V, fibrinogen and vWF are somewhat higher than adult levels. Coagulation inhibitors: antithrombin, protein C and S are also 50% less than adult levels. Neonates have hyporeactive platelets (granula release, aggregation) Under physiological conditions neonatal platelets are at least as efficient as adult platelets in achieving primary haemostasis.
- 13. Impact of cardio pulmonary bypass Hypothermia Bleeding/ increased blood loss Loss/dilution of clotting factors Inflammation PMN activation Interaction of blood with artificial surfaces (ECC system, oxygenator, cardiotomy suction) Intrinsic/Extrinsic Coagulation thrombin/TF Heparin Fibrinolysis tPA, PAI-1 platelet dysfunction
- 14. Why monitor coagulation? Can we effect the outcome by monitoring coagulation?
- 15. If we are able to Reduce bleeding Reduce transfusion rate There is level I evidence that TEG monitoring reduces blood loss and transfusion requirements after adult cardiac surgery (Level A Recommendation) Avoid reoperation We might influence morbidity and mortality after paediatric cardiac surgery!
- 16. Case 2 FIBTEM HEPTEM A 10 3 mm CT 402 s MCF 3 mm CFT 406 s A 10 22 mm MCF 25 mm
- 17. Case 2 What are we monitoring with this method? Do we need further monitoring, can we assess the platelet function? Should this patient be transfused? Is this child bleeding?
- 20. Case 2 Is this child bleeding? Should this patient be transfused? What are we monitoring with this method? Do we need further monitoring, can we assess platelet function?
- 21. TEM results 29 of 50 (58%) HEP-tem CT > 240 s 43 of 50 (86%) HEP-tem CFT > 110 s 37 of 50 (74%) HEP-tem MCF < 50 mm 45 of 50 (90%) FIB-tem MCF < 9 mm
- 22. Teamwork with surgeons Clinical evaluation of bleeding, presence of oozing without visible clots. Hemodynamic derangements Hb and Hct Fibrinogen 1g Platelets 20 ml/kg
- 23. Bleeding and thrombosis Amount of transfusions Antithrombin Increased aggregation of platelets postoperatively Use of PCC and Activated FVIIa Systemic to pulmonary artery shunts Modified BT shunt
- 24. Key points Small children less than 1 year have a different setup in the coagulation system What is my method really measuring Minimize the risk for postoperative thrombosis You are able to influence the outcome
- 25. Case 3 Liver transplantation Esophagus varicer Portal hypertension Platelets 30, INR 1.6, AT 0.65, ASAT 0.7, ALAT 0.8 Weight 48 kg Fibrinogen? 26
- 26. Preoperativ TEM 27 Key point Measure coagulation capacity preoperatively in selected cases
- 27. The effects on coagulation in liver diseases The liver plays a central role in the haemostasis as it synthesizes coagulation factors, coagulation inhibitors and fibrinolytic proteins. In liver diseases the most common interference in coagulation are low platelets and effected plasma coagulation. Note that the goal is not to correct the lab values but to acheive haemostasis. Plasma mainly to correct INR prior to procedures or surgery. Take caution with prothrombin-complex as there is a high risk of thrombotic complications. 28
- 28. In summary What kind of patient? Which main bleeding/coagulation problems may I expect? Combine clinical evaluation, an algorithm and monitoring Make a decision regarding treatment Reevaluate
- 29. Thank you!
- 33. Anemi Trombocytfunktion âAdhesion/aggregation âą Minskar ââMarginaliseringâ âą Minskar Valeri CR et al: Transfusion 2001:41:977-983
- 34. Marginalisering
- 35. Hypotermi Fibrinbildning â<35° C âą PT ökar â<33° C âą APTT ökar âą Trombinbildning minskar Trombocyter âą Antalet minskar âą TxA2 minskar Wohlberg AS et al: J Trauma 2004:56:1221-1228
- 36. Hypotermi The Effects of Temperature on Clot Microstructure and Strength in Healthy Volunteers. Lawrence MJ1, Marsden N, Mothukuri R, Morris RH, Davies G, Hawkins K, Curtis DJ, Brown MR, Williams PR, Evans PA Anaest Analg 2016;122:21-6 Slower forming clots with less structural complexity as temperature is decreased. We also found that significant changes in clot microstructure occurred when the temperature was <32°C 37
- 37. Acidos pH 7.4 ï 7.0 â TF/FVIIa minskar 55 % â FXa/FVa minskar 70 % Meng ZH: J Trauma 2003:55:886-891
- 38. Hypotermi och acidos Martini WZ etal.: J Traum: 2005:58:1002-10010
- 41. Measurements from packed red blood cells 3d 3d 4d 5d 6d 9d pH 6.8 6.9 6.9 6.9 6.9 6.7 BE -22 -24 -29 -28 -28 -32 Hb 188 184 225 193 192 182 Lac 6.2 4.9 7.7 8.2 9.1 12.0 Glu 27 27 25 27 26 24 Potassium 9.0 9.1 13.0 13.4 14.4 19.6
- 42. Transfusions, lifesaving but also dangerous Positive effects Improve tissue oxygen delivery Autoregulation of tissue blood flow Increased number of platelets and coagulation factors Negative effects Substantial changes in the immune system, immunomodulation Infections Storage time (ATP down-RBC shape and rigidity)(2,3DPG down) 1 week Morbidity, mortality Guzzetta NA.. Paediatr Anaesth. 2011
- 43. Risk factors for bleeding Weight/age are the strongest risk factors for bleeding. CPB time, type of surgery, aorta clamp time Reoperations, which have a high risk for fibrinolysis pH, Ca Protamin inhibitory effect on recept Gp I/IX/V and interaction with vWF. High ACT could delay treatment of low platelet/fibrinogen Most common changes after CPB Low platelet count and platelet dysfunction Low levels of fibrinogen Miller BE Anesth Anal 1997;85:1196-1202 Williams GD Anesth Analg 1999;89:57-64 Lang T Anesth Analg 2009;108:751-8
- 44. Platelet dysfunction (ADP-test <30 U) 0 10 20 30 40 50 60 70 Before surgery During CPB After CPB ICU Day 1 %
- 45. Interpretation Insignificant bleeding Normal TEM Insignificant bleeding Abnormal TEM Significant bleeding Normal TEM Significant bleeding Abnormal TEM Bleeding is a prerequisite for transfusion
- 46. Cut off values Proposal/discussion of cut off values for transfusion in paediatric cardiac surgery EXTEM MCF A10<30, FIBTEM<5 mm Analysis of our ROTEM parameters revealed that clotting time (CT)ââ„â111âs, MCF A10 â€â38âmm measured on the EXTEM and A10ââ€â3âmm obtained on the FIBTEM tests were the three relevant parameters to guide haemostatic therapy. MCF HEPTEM< 43 mm, CFT HEPTEM > 166 s, showed markedly increased transfusion prevalence Nakayama Br J Anaesth 2015 Faraoni Eur J Anaesth 2015 Romlin Submitted Br J Anaesth
- 47. Algorithm Preop history Sampling (HEPTEM, EXTEM,FIBTEM),Platelet test TEM and clinical evaluation Decision about transfusion Reevaluate when still in theatre Leave patient in ICU without ongoing significant bleeding Enriquez and Shore-Lesserson Br J Anaesth 2009
- 48. Could we interact with the coagulation system in any other way? Haemoglobin/Hematocrit during and after bypass Modified ultrafiltration increases Hct, fibrinogen and total plasma proteins, influence inflammatory respons and complement activation Cellsaver Optimization of the dose of protamine sulphate
- 50. Koagulation och âyttre miljönâ BT: 60/40 mmHg Puls: 158 min-1 Timdiures: 0 ml/tim Echo: Tom vĂ€-kammare Kirurgen: âGe NovoSeven, den stora dosenâ för jag ser inte var det blöder Blodcentralen ringer: âBlodet Ă€r snart slut! Behöver vi bestĂ€lla mer?â Narkossköterskan: Pat Ă€r sur och Ca2+ Ă€r lĂ„gt Assistenten: Ge Octostim
- 52. Monitorering av hemostasen LaboratorievĂ€rden â Trombocyter â APTT â PK(INR) â Fibrinogen â Blodgas PatientnĂ€ra analyser â ROTEM â TEG â Sonoclot â Multiplate Vilken information fĂ„r jag av mina mĂ€tmetoder och vilken klinisk konsekvens fĂ„r svaret
- 53. Hemostas
- 55. Sampling At the end of CPB before weaning? Thromboelastometry(HEPTEM, FIBTEM) The result will be ready in time for weaning pH,temperatur and Ca level should be normal
- 56. Vad krÀvs för bra hemostas?
- 57. 2,0 2,5 3,0 3,5 4,0 Fibrinogen (g/L) 0 500 1000 1500 2000 2500 Postoperativebleeding(ml/18h) Aljassim et al. Scand Cardiovasc J 2006; 40:43-48 r = - 0.76 , p<0.001 Preop fibrinogen och blödning TF + VIIa Xa + Va Trombin Fibrin XIa Xa + Va IXa+VIIIa
- 58. FibrinogennivÄ vid kirurgi Hiippala ST et al.: Anesth Analg 1995;81:360
- 59. Catastrophic hemorrhage Airway maintenance with cervical spine protection Breathing and ventilation Circulation with hemorrhage control Disability: Neurologic status Exposure Emerg Med J 2006 23: 745-746
- 60. Management of bleeding and coagulopathy following major trauma: an updated European guideline AnvĂ€ndning av fibrinogen âWe recommend treatment with fibrinogen concentrate or cryoprecipitate if significant bleeding is accompanied by thrombelastometric signs of a functional fibrinogen deficit or a plasma fibrinogen level of less than 1.5 to 2.0 g/l (Grade 1C). We suggest an initial fibrinogen concentrate dose of 3 to 4 g or 50 mg/kg of cryoprecipitate, which is approximately equivalent to 15 to 20 units in a 70 kg adult. Repeat doses may be guided by thrombelastometric monitoring and laboratory assessment of fibrinogen levels (Grade 2C).â Management of bleeding and coagulopathy following major trauma: an updated European guideline, Crit Care. 2013; 17(2): R76.
- 61. Management of bleeding and coagulopathy following major trauma: an updated European guideline HĂ€mning av fibrinolys We recommend that tranexamic acid be administered as early as possible to the trauma patient who is bleeding or at risk of significant hemorrhage at a loading dose of 1 g infused over 10 minutes, followed by an intravenous infusion of 1 g over 8 h. (Grade 1A) We recommend that tranexamic acid be administered to the bleeding trauma patient within 3 h after injury. (Grade 1B) We suggest that protocols for the management of bleeding patients consider administration of the first dose of tranexamic acid en route to the hospital.(Grade 2C) â We suggest that antifibrinolytic agents be considered in the bleeding trauma patient (Grade 2C). We recommend monitoring of fibrinolysis in all patients and administration of antifibrinolytic agents in patients with established hyperfibrinolysis (Grade 1B). Suggested dosages are tranexamic acid 10 to 15 mg/kg followed by an infusion of 1 to 5 mg/kg per hour or Δ-aminocaproic acid 100 to 150 mg/kg followed by 15 mg/kg/h. Antifibrinolytic therapy should be guided by thrombelastometric monitoring if possible and stopped once bleeding has been adequately controlled (Grade 2C).â Management of bleeding and coagulopathy following major trauma: an updated European guideline, Crit Care. 2013; 17(2): R76.
- 62. Tillbaka till vÄrat fall Vad avgör vidare transfusioner 64
- 63. Vad avgör vidare transfusioner Blödning eller ej Vital parametrar Provsvar/ROTEM 65
- 65. Management of bleeding and coagulopathy following major trauma: an updated European guideline AnvĂ€ndning av OctostimÂź We suggest that desmopressin (0.3 ÎŒg/kg) be administered in patients treated with platelet-inhibiting drugs or with von Willebrand disease. (Grade 2C) We do not suggest that desmopressin be used routinely in the bleeding
- 66. Management of bleeding and coagulopathy following major trauma: an updated European guideline NovoSeven We suggest that the use of recombinant activated coagulation factor VII (rFVIIa) be considered if major bleeding and traumatic coagulopathy persist despite standard attempts to control bleeding and best- practice use of conventional haemostatic measures. (Grade 2C) We do not suggest the use of rFVIIa in patients with intracerebral hemorrhage caused by isolated head trauma. (Grade 2C) PCC We suggest the measurement of substrate-specific anti-factor Xa activity in patients treated or suspected of being treated with oral antifactor Xa agents such as rivaroxaban, apixaban or endoxaban. (Grade 2C) If bleeding is life-threatening, we suggest reversal of rivaroxaban, apixaban and endoxaban with highdose (25 to 50 U/kg) PCC. (Grade 2C) We do not suggest the administration of PCC in patients treated or suspected of being treated with oral direct thrombin inhibitors, such as dabigatran.
- 68. Koagulationsprofil APTT 63 s PK 3.3 INR Fibrinogen 1.6 g/l AT ~ 0.1 kIE/l Trombocyter 143*109 /l NATEM VÀrde Range CT (s) 980 300-1000 CFT (s) 441 150-700 α (°) 32 30-70 A20 (mm) 34 35-60 MCF (mm) 36 40-65 Klassisk bild vid leversvikt
- 69. Tillbaka till fallet Kraftigt sivande blödning frÄn början dÄ man dissekerar ut levern, kontinuerliga transfusioner av blod, plasma och trombocyter Inotropt stöd för att upprÀtthÄlla blodtryck Buffer och kalk upprepas Följs med ROTEM och Multiplate Operationen fÄr avbrytas för att stabilisera vitala parametrar71
- 70. TEM : 01.30 72
- 71. TEM : 04.30 73 pH 7.30 BE -6.9 Sat 98 Hb 111 EVF 34 Na 130 K 6.4 Ca 1.15 Glu 8.0 Lakt 3.0
- 72. Sammanfattning Struktur-Organisation-Eftertanke Vad Àr mitt huvudproblem ur blödningssynpunkt Basala kunskaper om koagulation LÀkemedel och doseringar74
- 73. Kostnad och dosering Ocplex,=protrombinkomplex, F II, VII, IX, X, prot C, prot S OBS TÀnk pÄ att detta lÀkemedel kan doseras I bÄde Enheter och ml, kontrollera noga. 500E spÀds i 20 ml = 25 E/ml EngÄngsdosen fÄr ej överstiga 3000 E=120 ml för vuxna. INR 2-2.5 ge 0.9-1.3 ml ocplex/kg kroppsvikt, INR 2.5-3.0 ge 1.3-1.6 ml ocplex/kg kroppsvikt, INR 3.0-3.5 ge 1.6-1.9 ml ocplex/kg kroppsvikt, INR>3.5 ge >1.9 ml ocplex/kg kroppsvikt. Dosering till barn INR över 3.0 ge 25E/kg INR 2.0-3.0 ge 15E/kg INR 1.5-1.9 ge 10E/kg 500E kostar 3500 kr Hemate= F VIII, vWF, vid allvarli/livshotande blödning 0.6-1 E/kg, profylax eller liten blödning 0.3-0.6 E/kg 1000E kostar 6937 kr Novo Seven= aktiverat FVIIa, doseras 90-100 ug/kg (1mg=1000 ug) 1 mg kostar 6200 kr, en vuxen behandling pÄ 70 kg patient blir 43 400 kr Fibrinogen 1g kostar 4100 kr Mer info pÄ www.SBU.se
- 75. : TRAP ADP Arachidonic Acid Collagen ArA1 COX TXA2 TXA2 COLtest ASPItest TRAPtest ADPtest PGE1 ADPtest HS (ADP + PGE1) aktivering HÀmning GpIIb/IIIa hÀmmare: Reopro Ÿ (Abciximab) Aggrastat Ÿ (Tirofiban) Integrillin Ÿ (Eptifibatid) Aspirin Ÿ Clopidogrel Prasugrel Ticagrelor 1 FrislÀppande av arachidonsyra ASPItest (Arachidonsyra): AspirinŸ & övriga cyklooxygenas blockerare (79-141U) ADPtest (ADP)(P2Y12) Plavix Ÿ, & övriga ADP receptor blockerare (55-117U) TRAPtest (trombin receptor aktiverat protein), bl.a. kontroll av GP IIb/IIIa-blockerare (87-147U)
- 76. Paediatric cardiac surgery Lake Carol L, Booker Peter D. Pediatric cardiac anesthesia. 2005 1% of all children are born with a congenital heart disease Annually, 600 children are operated in Sweden There are about 35 different diagnoses 200 different operation methods Cardio-pulmonary bypass is necessary in most cases
- 77. Case 1 FIBTEM EXTEM A 10 3 mm CT 57 s MCF 3 mm CFT 444 s A 10 23 mm MCF 35 mm Just before leaving you got this answer from the TEM (thromboelastogram)