point of care coagulation testing · microsoft powerpoint - ppt0000004.ppt [read-only] author:...
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POINT OF CARE COAGULATION TESTINGDr Danny MorlandRoyal Victoria Infirmary Newcastle upon Tyne
11th October 2016
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Introduction
Declarations of Interest: None
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CONTENTIntroduction to POCTPrinciplesInterpretationTreatmentLiteratureNUTH Experience
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Point Of Care Testing (POCT)
Medical diagnostic testing at (or near) the point of care.
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POCT
PROS
• Quick• Convenient• Reliable• Efficient
CONS
• Cost (potentially)• Quality• Training• Workload• Recording• Risk of inappropriate
decision-making
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Point of Care Coagulation Testing (POCCT)
Viscoelastic properties of whole blood clot
Thromboelastography = Thromboelastometry (TEG) (ROTEM)
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Purported Benefits over Standard Tests
• Measures whole blood, not just plasma• Looks at clot generation and propagation beyond the
point of clot appearance• Allows comment on clot ‘quality’• Can identify fibrinolysis
FAST –potential information on clotting status within 5mins of test starting
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POCCT vs Standard Lab Tests
POCCT
• Whole blood• Clot beyond first
appearance• Clot quality• Identify fibrinolysis• FAST
LAB
• Highly standardised• Trained, professional staff• Quality control• Well established• Complete picture• Cost
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PRINCIPLES
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Viscoelasticity
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Hardware
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OUTPUTS
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Panel Testing – Normal results
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INTERPRETATION
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Normal
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Low Platelets
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Normal
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Hypo-fibrinogenaemia
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Heparin Effect
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Normal
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TREATMENT
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LIMITATIONS AND WARNINGS
• Treatment should be administered according to the clinical picture (e.g. volume & current rate of blood loss)
• Viscoelastic devices are not uniformly sensitive to all disturbances of coagulation status• e.g. platelet dysfunction, antiplatelets, LMWHs, warfarin, DOACs
• Pre-existing local protocols should be respected, given current level of evidence for POCCT devices.
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Where is it useful?
• Perioperative• Livers, cardiac, unanticipated bleeding
• Trauma• Pre- and in-theatre
• Obstetrics• PPH
• ITU
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Algorithms
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Algorithms
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Algorithms
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Algorithms
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LITERATURE
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TRAUMA
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http://www.c4ts.qmul.ac.uk/bleeding-and-coalgulation/itactic (Accessed on 9/10/16)
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OBSTETRICS
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OBSTETRICS
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OUR EXPERIENCE
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NUTH Experience• Introduced POCCT end of 2014 after an evaluation period
to assess feasibility, reliability and accuracy.
• Trialled TEG 5000, ROTEM Delta in theatre (POCCT), TEG and ROTEM in lab and compared with standard lab tests coag tests.
• Findings• Generally good concordance between POCT and lab tests
• Higher user error for more complicated procedures
• Sending samples to lab could introduce a delay of 50mins over POCT
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NUTH algorithm
Patient has significant on-going bleeding?
YES NO OBSERVE Reassess &
Repeat ROTEM
EXTEM – CT > 90 sec
EXTEM – A10 <40mm
EXTEM – LI30 >5%
FIBTEM A10 <10mm
FIBTEM A10 > 10mm
Give 2 Unit Cryoprecipitate
Give 1 Pool Platelets
Give 4 FFP
Give Tranexamic Acid 1g bolus
YES
YES
YES
NO
+/-
+/-
EXTEM result NORMAL YES Continue as per Major
Haemorrhage Policy
Physiological Targets:
• Temp>36°C
• pH>7.2, Base Excess <-6
• iCa >1.0, K+ <5.5
• Hb >80, Plt > 100, Fib >1.5
NOTE – ROTEM does not reliably detect
effects of,
• Warfarin
• Aspirin, Clopidogrel
• Direct Oral Anticoagulants
• LMWH
Effect of heparin should be assessed
using,
• INTEM & HEPTEM tests
There may be > 1 clotting defect.
Treat all defects simultaneously
RVI ROTEM Treatment Algorithm
Use these Products to supplement NOT replace the Major Haemorrhage Packs Replace ongoing losses + correct specific deficit = Give contents of MHP + additional products as directed by ROTEM
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NUTH Experience since…• Valuable technology, very useful addition to arsenal.• Can be ‘transfusion-sparing’; imparts confidence that
management strategy is correct.• Speed of testing and results
• Issues• Training
• Regular use
• QC
• Interpretation
• IT• Interference with MHP
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When is it useful?
• To confirm that MHP is addressing specific transfusion requirements of patient (e.g. bleed then DIC)
• In cases of slow, steady transfusions that haven’t reached MHP level
• To exclude ‘anaesthetic’ bleeding
• To confirm that transfusion goals have been achieved
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SUMMARY• Viscoelastic, POCCT devices offer the prospect of rapid
assessment and rational, individually tailored transfusion therapy in the management of major haemorrhage.
• Barriers remain to their effective and efficient use, and in many areas a protocolised transfusion strategy may still produce the best outcomes overall.
• Evidence of effectiveness is lacking still, but it is difficult to imagine these devices will not be more widely used in the near future.
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THANK YOU