hemostasis management with the hms plus – literature ... · alex robinette perfusion student at...
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AlexRobinettePerfusionstudentatUniversité deMontréal
ProjectatHôpital duSacré-CoeurdeMontréalOctober21th2017
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HemostasisManagementwiththeHMSPlus–Literature/SystematicReview
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AlexRobinette:Ideclarenoconflictofinterest
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Introduction• Conventionalanticoagulation• Heparindose:300-400U/kg• ACT:400-480sec• ACTtestevery 20-30minutes
• Heparinneutralization• Protaminedose:ratio1:1(protamine:heparine)• ACTtestafter~ 5minutes• BaselineACT
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JayMcLean
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Whychangeawinningformula…?
• AffectsACTtest:• Hemodilution,Hypothermia,Drugs,Platelets,etc.
• ACTisnotspecifictoheparinconcentration• Individual variations• Heparinsensibility/resistance
• HeparinPK/PD=complex• Protamine:• Nonspecificaffinity• Reactions• Anticoagulationeffect
• Since2009,newstandardsbytheFDA…4
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Heparincrisistimeline
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AnitaYetal.(2016)
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Hepcon/HMSdevice• Heparindose-responsecurve• Weight/Height• Gender• CPBprimingvolume• Heparindoseinprime
• ACT• Heparinconcentration• Protaminedose• Automaticpooling
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HMSbrochure,Medtronic
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«Apersonalizeddoseregimen»
8HMSbrochure,Medtronic
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Hepcon/HMSdevice• Heparindose-responsecurve• Weight/Height• Gender• CPBprimingvolume• Heparindoseinprime
• ACT• Heparinconcentration• Protaminedose• Automaticpooling
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HMSbrochure,Medtronic
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«ACTinnolongerenough»
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HMSbrochure,Medtronic
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11VS.
Does theuseofHepcon HMScompared toACTallow thereduction ofblood loss andblood transfusionsincardiac
surgery with cardiopulmonary bypass?
Researchquestion
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MethodsResearchstrategy(MEDLINE)• P:ElectivepatientswhoneedcardiacsurgeryonCPB(CABGand/orvalves)
• I:Hepcon HMSuse• C:StandardACTuseonly• O:Bloodlossandbloodtransfusions• S:RCT,prospectiveandobservational
• Exclusions:Emergency,clottingfactorsdeficiencyorhemostaticdisorders,OPCABG,otherdevicethanHMS,otherlanguagethanEnglishorFrench.
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MethodologyResearchstrategy (MEDLINE)
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Studiescharacteristics
• 12studies• 6RCTs• 4prospectiveandrandomised• 1observationalandcomparative
• 1notmentioned
• 1002patients• HMSn=504• ACTn=498 14
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Results
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Results
• 9/12studies=nosignificantdifference• 2/12studies=morebloodlossinACTgroup• Noui etal.(2012):HMS(804± 29mL)andACT(1416± 1103mL)
• Vonk etal.(2014):HMS=12%andACT=42%
• 1/12studies=morebloodlossinHMSgroup• Hoenicka etal.(2015):HMS420mL(337.5-605)andACT345mL(230-482.5)
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Hepcon HMSPlususedoes notreduce postoperative blood loss
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Results
• 8/12studies=nosignificantdifference• 2/12studies=moretransfusionsinACTgroup• Pappalardo etal.(2006):HMS(0%)andACT(27,3%)• Noui etal.(2012):HMS=11units(4patients)andACT=32units(11patients) (p=0,054)
• 2/12studies=N/A• Shigetaetal.(1999)excludedtransfusedpatients• Vonk etal.(2014)notransfusionresult
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Hepcon HMSPlusdoes notreduce theneed forblood transfusions
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Results
• 8/12studies=N/A• 3/12studies=Heparinreboundbutnodifferencebetweengroups
• 1/12study=Noheparinrebound
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Heparin rebound
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Discussionandconclusions
1. Postoperativebloodloss=nodifference2. Bloodtransfusions=nodifference
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HMSvs.ACT
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Discussionandconclusions
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HMSvs.ACT
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Discussionandconclusions
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HMSvs.ACT
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Futurework
• Research protocol• P:CABGor/andvalvesonCPB• I:HMSPlus• C:ACT• O:Bloodloss andtransfusion• S:RCT
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N=
ICUfollow-upwithHMS
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Nextsteps!
• Ethiccommitteeapprobation
• Recruitment(n=150pergroup)
• Collectthedata
• Analysis
• Writeanarticle
31=>Publish inNature!!
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Acknowledgement• Dr.HughesJeanmart• Eric Couturier• FannyLange• Hosham Assed• Marie-SoleilBrosseau
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Thankyou!Questions?
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Weaknessofthereview
• Pubmed researchonly• GRADEapproach• Biasinthestudies• ACTtarget• Heparin/protaminedose• T°ConCPB• ATSuse
• Thromboelastography 34