Download - MTP Octaplex rFVIIa Calgary
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MTPOctaplexrFVIIa
Calgary
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Massive Transfusion Protocol
Massive Transfusion Protocol
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“The treatment for bleeding is to stop the bleeding”
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MTP - Trigger
4 units in 4 hours ->6 units in 4 hours
AND
ongoing major bleeding
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MTP Pack (1:1:1 Ratio)
• 6 U RBCs• 6 U FFP **• 1 Dose Platelets
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MTP - FFP Facts
no typing = 4 units only
thawed product = no delay at FMC and PLC– 30 min delay at RVH
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Patient Considerations
• Acidosis (pH 7.2)• Hypocalcemia ( 1.2 mmol/L)• Hypothermia (35°C)• Heparin Reversal – Protamine• Warfarin Reversal – Octaplex and Vit K• CRF - DDAVP
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MTP - Other Products to Consider
• Cryoprecipitate– Fibrinogen < 1g/L
• Tranexamic Acid• Niastase
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MTP Usage 2008-2010
115 activations:• 95 FMC • 12 PLC• 5 ACH• 3 RGH
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MTP - Improvements and Future
• no sample• premature activation• premature call for second pack
• ? Tranexamic acid (Crash 2)
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Octaplex
Prothrombin Complex concentrate:II, VII, IX, X, protein C and S and heparinsodium citrate
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Octaplex Indications
• reversal of warfarin therapy or Vit K deficiency:–major life threatening bleeding– requiring urgent (<6 hour) surgical
procedure
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Contraindicated in patients with history of heparin induced thrombocytopenia
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Not Recommended
• elective reversal of OAT pre-invasive procedure• tx of INRs without bldg or need for sx • massive transfusion• coagulopathy with liver dysfunction• recent hx thrombosis, MI, ischemic stroke or
DIC
** case by case decisions**
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Octaplex Dosing and Administration
• 1st dose is 1000 IU (2 vials)– 1 ml/min X 10 min then 3ml/min– Vit K 10 mg IV
• 2nd dose of 1000 IU at 15 min prn• 3rd dose requires documentation of INR >1.5
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Octaplex - Monitoring Effect
• INR 15 min post • INR 5-6 hr post
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Octaplex - Calgary Numbers
March 2009 to August 2010• 230 doses (1000 IU) in 216 pts• good response to single dose (INR < 1.6)– 77% overall– 80% CNS hemorrhage– 92% of patients with a N PTT
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Octaplex – Calgary Experience
• suggest increased initial dose (60ml = 1500 IU)– elevated PTT (any abnormal level) (only 65%
corrected)– INR >3.5. (only 38% corrected)
Do we need to also monitor PTT?
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rFVIIa (Niastase®)
• recombinant protein• 1996 licensed:
“for prevention of bleeding connected with surgery in pts with hemophilia with inhibitors
to factor VIII”
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Is it a waste of time?
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Is it dangerous?
+
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rFVIIa (NiaStase RT®)
trauma, massive periop bld, obstetrical bleedingAND
transfusion more than one blood volumeAND
massive ongoing bleedingAND
good clinical outcome possible
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Niastase
Adequate hemostatic measures taken:AntifibrinolyticsSurgical hemostasisAggressive component support to
INR >1.5Fibrinogen > 1.0 g/LPlatelet count >50
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Niastase
High risk populations considered• Age >65• Hx atherosclerosis• Artificial grafts or heart valves• Prev hx VT or AT• Hereditary thrombophilic states• Sickle cell• Sepsis/DIC or other acquired thrombophilic state
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Niastase
• Initial dose 40 ug/kg–About 3mg for average adult
• May be repeated at 30 min and 2 hours
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Niastase
• Vials are 1, 2, 5 mg• No need for refrigeration (new)
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