The Role Of Point of Care Coagulation Testing (POCCT) in Patient Blood Management

Elham Khalaf Adeli

Overview 

PBM , bleeding management, Coagulation POC TestingReview of laboratory conventional coagulation TestsestsReview of coagulation Point of care( POCCT) testingtesting Clinical efficacy of Coagulation  POCC Testing and PBMPBMConclusion

What is Patient What is Patient Blood Blood ManagementManagement

Preventative medical or surgeries strategies to conserve the Pateint s own blood to reduce orconserve the Pateint,s own blood to reduce or avoid the need for a blood transfusion and improve patient outcomeimprove patient outcome.

Optimize Optimize MinimizeMinimizeoptimize optimize

Optimize Optimize erythroerythro--poieispoieis

MinimizeMinimizebleeding bleeding & & blood lossblood loss

physiologic physiologic tolerance tolerance of anemiaof anemia

© Axel Hofmann/Shannon Farmer –SHEF Meeting Perth August 2010

pp blood lossblood loss of anemiaof anemia

Multifactorial Causes for Coagulopathy/   Bleeding t i S imanagement  in Surgeries

C l th Bl di N d t T f i

● Disturbances of primary hemostasis

Coagulopathy Bleeding Need to Transfusion

● Abnormalities of blood plasma, e.g., clotting-factor deficiency , anticoagulants

● Complex coagulopathies, e.g., hyperfibrinolysis.

Blood clotting is conventionally tested with two global tests, the PT,International Normalized Ratio (INR) and the activated partial thromboplastin time (aPTT) along with the platelet count and inthromboplastin time (aPTT), along with the platelet count and, in some cases, the fibrinogen concentration.

Intrinsic pathway

XIIaCascade Model

TF

Extrinsic PathwayXIa

ProthrombinVIIa

TF

IXa

XaVa

VIIIa

Fibrinogen Fibrin( and Platelet)Thrombin Soft clot

g ( )XIIIa

FibrinHard clot

I i i hThis model explains the laboratory

XIIa

Intrinsic pathway coagulation tests

PT

TFExtrinsic PathwayXIa

VIIa

TF

IXa

XaVa

VIIIa

Fibrinogen Fibrin(Soft clot)Thrombing

XIIIa

Fibrin (hard Clot)

I i i hThis model explains the laboratory

PTT

XIIa

Intrinsic pathway coagulation tests

TFExtrinsic PathwayXIa

VIIa

TF

IXa

XaVa

VIIIa

Fibrinogen Fibrin(Soft clot)Thrombing

XIIIa

Fibrin (hard Clot)

I i i hThis model explains the laboratory

XIIa

Intrinsic pathway coagulation tests (In Vitro)

TFExtrinsic PathwayXIa

VIIa

TF

IXa

XaVa

VIIIa

TT

Fibrinogen Fibrin(Soft clot)Thrombing

XIIIa

Fibrin (hard Clot)

Intrinsic pathway Laboratory TestsXIIa

Laboratory Tests

TFExtrinsic PathwayXIa

Clot Firmness & Stability

VIIa

TF

IXaVIII

XaVa

VIIIa

Anionic phospholipid ( platelet)

??

??Fibrinogen Fibrin monomer Thrombin

XIIIa

Anionic phospholipid ( platelet)

Polymer

??

??XIIIa

Fibrin (hard Clot)

??

Really , how Really , how does hemostasis does hemostasis

work In vivowork In vivo

Coagulation Coagulation ……….

system is system is dynamicdynamic

Disadvantages of Conventional  Coagulation Tests

Reflect only the initial formation of thrombin in plasmaConvey clot in static condition not dynamicNor do the conventional coagulation tests conveyNor do the conventional coagulation tests convey any information about clot stability over timeNot a true reflection of what happens in theNot a true reflection of what happens in the body

Disadvantages of Conventional  Coagulation Tests

Golden time in management of bleeding will be lost Turnaround Time????be lost . Turnaround Time????

Test Order 

Test Processing

Test Result application

Patient Management 

40 to 60 minutes!!!! after blood drawing.This turnaround time is so long that the resultsThis turnaround time is so long that the results

may not reflect the current state of the coagulation system and lead to inappropriate treatment

Toulon P, et al:Point-of-care versus central laboratory coagulation testing during haemorrhagic surgery. A multicenter study. Thromb Haemost 2009

Viscoelastic Techniques as POCCTsRoles of Thromboelastometry and thromboelastography for patient Blood Management/ Bleeding Management/ Surgeries

Bollinger et,al. Transfuse Med Rev .2013 Oct:27(4):213-20

-It was first developed in 1948 by Dr Hullmut Hartert Blood collected as whole bloodBlood collected as whole blood Citrated tubes Tested at 37°C Graphic results are availableGraphic results are available in real time on screen

Takes ≤20 min until first results areTakes ≤20 min until first results are available

Clot formation(CT/R) :

KineticsKinetics of the clotof the clot-Clotting factors-Anticoagulant Kinetics Kinetics of the clotof the clotg

Clot strength/Stability(MCF/MA)-Fibrinogen-Fibrinogen-Platelets

Cl t L i (LI30/ML)Clot Lysis(LI30/ML)- Hyperfibrinolysis

Millid Thakur,et al.A Review of Thromboelastography.IJPUT.2012;1(1):25-29

INTEM: coagulation is activated via the contact phase

HEPTEM: coagulation is activated as in INTEM in the presence of heparins. p

EXTEM: coagulation is activated by tissue factor to monitor the coagulation process via thecoagulation process via the extrinsic pathway.

FIBTEM: coagulation is activated as in EXTEM to monitor the clot firmness after blocking platelet contribution to the clot firmness.

APTEM: coagulation is also activated as in EXTEM. Intend to monitor the clot firmness after blocking hyperfibrinolysis by aprotinin.

FFPPOC-Based Algorithm for Bleeding management

Clotting Factors

management FFP PCC VII

Clot Formation

r VIIAnticoagulant

Protamine sulfateant

Fibrinogen

Fibrinogen concentrate

Clot strength/ Stability

Fibrinogen

Plt C t t

DDAVP

Platelet Plt Concentrate

Antifibrinolytic

Clot LysisHyperfibrin

olysis

Agents

XIII Concentrate

FFPPOC-Based Algorithm for Bleeding management

Clotting Factors

management FFP PCC VII

Clot Formation

r VIIAnticoagulant

Protamine sulfate

ant

Fibrinogen

Fibrinogen concentrate

Clot strength/ Stability

Fibrinogen

Plt Concentrate

DDAVP

Platelet

Antifibrinolytic

VWF concentrate

Clot LysisHyperfibrin

olysis

AntifibrinolyticAgents

XIII Concentrate

First‐line Therapy with factor Drug&Concentrate Drug&Concentrate

InterventionDrugFactorBlood Product DrugFactor 

concentrateBlood Product 

AntifibrinolyticFibrinogen      FFP

DDAVPPCCCryoprecipitate

Protamine sulfate 

rVIIPlatelet 

FXIII concentrate

vWF concentrate

Rotational Thromboelastometry (ROTEM)-Based Coagulation Management in Cardiac Surgery and Major TraumaKenichi A. et al,Journal of Cardiothoracic and Vascular Anesthesia, 2012

Make your Own Algorithm• First‐line Therapy with factor Concentrate and drug 

• Several hemostatic products are discussed inSeveral hemostatic products are discussed in relation to ROTEM parameters, but the availability of products differs amongavailability of products differs among institutions and countries. Therefore you must  have your own algorithm for your institution.have your own algorithm for your institution.

• Consider Cost &Benefit for your algorithm in Bleeding ManagementBleeding Management

• Evaluate the efficacy of algorithmRotational Thromboelastometry (ROTEM)-Based Coagulation Management in Cardiac Surgery and Major TraumaKenichi A. et al,Journal of Cardiothoracic and Vascular Anesthesia, 2012

I l t ti f POCCT B dImplementation of POCCT Based protocol for Bleeding Management

(n=1056)(n=1120)Blood  Product 12 Months POCT12 Months Prior 

POCT

35%(370)47%(524)RBC 35%(370)47%(524)RBC

14.5%(153)34%(380)Platelets      

9.4(99) 26%(291)FFP           

Implementation of POCCT BasedImplementation of POCCT Based protocol for Bleeding Management

Diff( 1056)( 1120)Bl d P d Difference(n=1056)Post POCCT

(n=1120)Pre POCCT

Blood Product 

981-18592840      RBC

‐607359966Platelet

‐11314001531FFP

Conclusion

• Bleeding management as a important pillar in PBMBleeding management as a important pillar in PBM• Detect and treat coagulopathy early • Monitor coagulation bed side with POC devices• Monitor coagulation bed side with POC devices • Use factor concentrates to avoid the adverse effects of transfusionof transfusion 

• Having a coagulation algorithm at your hospital is mandatorymandatory