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Tranexamic Acid - TXA (was MTP)

Ian Seppelt seppelt at med.usyd.edu.au
Thu Dec 23 23:07:44 GMT 2010


Inclusion criteria for CRASH2 was haemorrhage or RISK OF haemorrhage -  
so where do you draw the line?!!

Ian

Quoting Karim Brohi <karimbrohi at gmail.com>:

> We're incorporating it into our massive haemorrhage protocol (Code
> Red).  This is not for allcomers with severe trauma but for trauma
> patients who are shocked and fluid non-responders (suspected
> haemorrhage).
>
> Karim
>
> On Thu, Dec 23, 2010 at 22:42, Ian Seppelt <seppelt at med.usyd.edu.au> wrote:
>> So having raised the topic of TXA, who is using it routinely early  
>> in severe trauma (grade 1 evidence of benefit, 20,000 patient RCT)?
>>
>> [declaration of interest: I was a CRASH2 investigator]
>>
>> Ian Seppelt, Sydney
>>
>> Sent from my iPad
>>
>> On 24/12/2010, at 8:42 AM, Karim Brohi <karimbrohi at gmail.com> wrote:
>>
>>> Ron
>>>
>>> I agree.  With no evidence of efficacy (unless you are giving it to
>>> save 2 units of blood) and some evidence of harm (recent meta-analysis
>>> showing increased thromboelmbolic events - though admittedly in
>>> all-comers), it absolutely should not be in the same league as
>>> Tranexamic Acid which has strong evidence of efficacy; an good safety
>>> profile and probably should be given to all shocked patients up-front
>>> and early (late use should be cautioned).
>>>
>>> I do not think anyone should be giving rFVIIa unless you have point of
>>> care coagulation mointoring (by which I mean ROTEM/TEG) and can see
>>> evidence of need and evidence of response (neither of which is well
>>> defined).  Otherwise you're back to Ron's ocean.
>>>
>>> Karim
>>>
>>>
>>>
>>> On Thu, Dec 23, 2010 at 21:31, Gross, Ronald
>>> <Ronald.Gross at baystatehealth.org> wrote:
>>>> "Timing and patient selection, when and to whom remains the big question!"
>>>>
>>>> Not really, Mark.  The question is whether to give it at  
>>>> all.....and I have to tell you that in my experience the use of  
>>>> RFVIIa, with what we know (little) and when we currently use it,  
>>>> is as helpful as peeing into the ocean hoping to raise the tides.
>>>>
>>>> Just my 2 cents,
>>>> Ron
>>>>
>>>>
>>>> -----Original Message-----
>>>> From: trauma-list-bounces at trauma.org  
>>>> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Mark Forrest
>>>> Sent: Thursday, December 23, 2010 4:27 PM
>>>> To: Trauma-List [TRAUMA.ORG]
>>>> Subject: Re: MTP
>>>>
>>>> Stuke
>>>> We have certainly found that you can give it too late. Our  
>>>> original protocol was basically to consider it after 18 units of  
>>>> blood (not quite sure where the figure came from) but at this  
>>>> late stage it never appeared to work in our hands, so we now at  
>>>> least 'consider it' as soon as we activate our massive  
>>>> transfusion protocol and after TXA.
>>>>
>>>> But we also ensure other necessary  factors are present and that  
>>>> a reasonable degree of homeostasis is present or it definitely  
>>>> won't work. Saying that sometimes we do everything by the book  
>>>> and it still doesn't seem to do much!
>>>>
>>>> You can certainly give it too late but also too early too ( Yoram  
>>>> Kluger trialled it with paramedics in Israel with no improvement).
>>>>
>>>> Timing and patient selection, when and to whom remains the big question!
>>>>
>>>> Regards
>>>> Mark
>>>>
>>>>
>>>>
>>>> Sent from my iPhone
>>>>
>>>> On 23 Dec 2010, at 19:39, "Stuke, Lance E." <lstuke at lsuhsc.edu> wrote:
>>>>
>>>>> I've had little success with Factor VIIa, and rarely use it now  
>>>>> at Charity, as I don't believe it works. However, I wonder if  
>>>>> I've been using it incorrectly. For example - I usually give it  
>>>>> as a last-ditch salvage attempt in a trauma patient who is  
>>>>> already severely coagulopathic after I've operated on them in a  
>>>>> damage-control situation. These patients have usually had  
>>>>> several blood volumes replaced and are requiring ongoing blood  
>>>>> product replacement. I suspect most of us have used it in a  
>>>>> similar fashion.
>>>>>
>>>>> What if we gave it in the operating room immediately after  
>>>>> getting control of surgical bleeding instead of waiting until  
>>>>> the patient is near extremis? Has anybody tried this already?  
>>>>>  It may be something to consider in a multi-institutional trial  
>>>>> in trauma centers with high rates of operative trauma (Charity,  
>>>>> BenTaub, Grady, etc). Perhaps giving it early instead of late in  
>>>>> the course of resuscitation will improve its efficacy. I doubt  
>>>>> it, and I'm not a fan, but a study like this could put the issue  
>>>>> to rest.
>>>>>
>>>>> Stuke
>>>>>
>>>>> Lance Stuke, MD, MPH
>>>>> Spirit of Charity Trauma Center
>>>>> Assistant Professor of Surgery
>>>>> LSU Department of Surgery
>>>>> New Orleans, LA
>>>>>
>>>>>
>>>>> ________________________________
>>>>>
>>>>> From: trauma-list-bounces at trauma.org on behalf of Karim Brohi
>>>>> Sent: Thu 12/23/2010 1:51 AM
>>>>> To: Trauma-List [TRAUMA.ORG]
>>>>> Subject: Re: MTP
>>>>>
>>>>>
>>>>>
>>>>> We never really used Factor VIIa routinely in trauma haemorrhage - we
>>>>> were part of both the Phase II and Phase III (CONTROL) factor 7 trials
>>>>> and it was used occasionally in extremis with variable effect.  It was
>>>>> never included in our protocols because we felt we did not know where
>>>>> it's place was in the transfusion/coagulopathy armamentarium.
>>>>> Unfortunately I think that is still the case.
>>>>>
>>>>> Fundamentally the design of CONTROL was flawed and based on limited
>>>>> available data.  Many always expected CONTROL to be negative because
>>>>> of the low acuity of the target population (changed from the Phase II
>>>>> study).  (This is similar to the positive to negative switch in the
>>>>> PROWESS to ADDRESS in the activated protein C studies).
>>>>>
>>>>> Lack of effect in CONTROL  (above the identified reduction in
>>>>> transfusion requirements) does not necessarily mean rFVIIa has no
>>>>> effect in trauma patients.  We still don't know A) Which trauma
>>>>> patients develop low coagulation factor levels, what induces this and
>>>>> when it occurs during haemorrhage and B) which trauma patients respond
>>>>> optimally to procoagulant therapy (F7a, PCC, Fibrinogen or FFP), when
>>>>> and in what dose.
>>>>>
>>>>> So I wouldn't use rVIIa in trauma patients at the moment but I
>>>>> wouldn't write it (or its newer analogues) off yet, there's a lot more
>>>>> to learn.
>>>>>
>>>>> Karim
>>>>>
>>>>> On Wed, Dec 22, 2010 at 13:28, Juan Duchesne <jduchesn at tulane.edu> wrote:
>>>>>> No. Since we instituted DCR into our MTP back in 06-07, we've  
>>>>>> used factor 7 rarely ( 2-3 times a year).
>>>>>> J
>>>>>>
>>>>>> Sent from my iPhone from Spirit of Charity Trauma Center, NOLA
>>>>>>
>>>>>>
>>>>>> On Dec 22, 2010, at 1:10, Tchaka Shepherd  
>>>>>> <tshepherdmd at hotmail.com> wrote:
>>>>>>
>>>>>>>
>>>>>>> Has anyone found it advantageous to add factor seven or factor  
>>>>>>> nine to their MTP?
>>>>>>>
>>>>>>>
>>>>>>> NOTHING  SPLENDID Has Ever Been Achieved Except By Those Who  
>>>>>>> DARED BELIEVE THAT SOMETHING INSIDE THEM  Was Superior to  
>>>>>>> CIRCUMSTANCE
>>>>>>>
>>>>>>>
>>>>>>>
>>>>>>>
>>>>>>>
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Ian Seppelt FANZCA FJFICM
Senior Staff Specialist
Dept of Intensive Care Medicine
The Nepean Hospital, PO Box 63 Penrith NSW 2751
Director of Clinical Research, Sydney West AHS
Clinical Lecturer, University of Sydney



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