MTPOctaplexrFVIIa

Calgary

Massive Transfusion Protocol

Massive Transfusion Protocol

“The treatment for bleeding is to stop the bleeding”

MTP - Trigger

4 units in 4 hours ->6 units in 4 hours

AND

ongoing major bleeding

MTP Pack (1:1:1 Ratio)

• 6 U RBCs• 6 U FFP **• 1 Dose Platelets

MTP - FFP Facts

no typing = 4 units only

thawed product = no delay at FMC and PLC– 30 min delay at RVH

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

MTP - Other Products to Consider

• Cryoprecipitate– Fibrinogen < 1g/L

• Tranexamic Acid• Niastase

MTP Usage 2008-2010

115 activations:• 95 FMC • 12 PLC• 5 ACH• 3 RGH

MTP - Improvements and Future

• no sample• premature activation• premature call for second pack

• ? Tranexamic acid (Crash 2)

Octaplex

Prothrombin Complex concentrate:II, VII, IX, X, protein C and S and heparinsodium citrate

Octaplex Indications

• reversal of warfarin therapy or Vit K deficiency:–major life threatening bleeding– requiring urgent (<6 hour) surgical

procedure

Contraindicated in patients with history of heparin induced thrombocytopenia

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**

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

Octaplex - Monitoring Effect

• INR 15 min post • INR 5-6 hr post

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

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?

rFVIIa (Niastase®)

• recombinant protein• 1996 licensed:

“for prevention of bleeding connected with surgery in pts with hemophilia with inhibitors

to factor VIII”

Is it a waste of time?

Is it dangerous?

+

rFVIIa (NiaStase RT®)

trauma, massive periop bld, obstetrical bleedingAND

transfusion more than one blood volumeAND

massive ongoing bleedingAND

good clinical outcome possible

Niastase

Adequate hemostatic measures taken:AntifibrinolyticsSurgical hemostasisAggressive component support to

INR >1.5Fibrinogen > 1.0 g/LPlatelet count >50

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

Niastase

• Initial dose 40 ug/kg–About 3mg for average adult

• May be repeated at 30 min and 2 hours

Niastase

• Vials are 1, 2, 5 mg• No need for refrigeration (new)