Hemostasis Management with the HMS Plus – Literature ... · Alex Robinette Perfusion student at...

AlexRobinettePerfusionstudentatUniversité deMontréal

ProjectatHôpital duSacré-CoeurdeMontréalOctober21th2017

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HemostasisManagementwiththeHMSPlus–Literature/SystematicReview

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

Whychangeawinningformula…?

• AffectsACTtest:• Hemodilution,Hypothermia,Drugs,Platelets,etc.

• ACTisnotspecifictoheparinconcentration• Individual variations• Heparinsensibility/resistance

• HeparinPK/PD=complex• Protamine:• Nonspecificaffinity• Reactions• Anticoagulationeffect

• Since2009,newstandardsbytheFDA…4

Heparincrisistimeline

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AnitaYetal.(2016)

Hepcon/HMSdevice• Heparindose-responsecurve• Weight/Height• Gender• CPBprimingvolume• Heparindoseinprime

• ACT• Heparinconcentration• Protaminedose• Automaticpooling

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HMSbrochure,Medtronic

«Apersonalizeddoseregimen»

8HMSbrochure,Medtronic

Hepcon/HMSdevice• Heparindose-responsecurve• Weight/Height• Gender• CPBprimingvolume• Heparindoseinprime

• ACT• Heparinconcentration• Protaminedose• Automaticpooling

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«ACTinnolongerenough»

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11VS.

Does theuseofHepcon HMScompared toACTallow thereduction ofblood loss andblood transfusionsincardiac

surgery with cardiopulmonary bypass?

Researchquestion

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

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

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

Results

• 8/12studies=N/A• 3/12studies=Heparinreboundbutnodifferencebetweengroups

• 1/12study=Noheparinrebound

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Heparin rebound

Discussionandconclusions

1. Postoperativebloodloss=nodifference2. Bloodtransfusions=nodifference

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HMSvs.ACT


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HMSvs.ACT


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HMSvs.ACT

Futurework

• Research protocol• P:CABGor/andvalvesonCPB• I:HMSPlus• C:ACT• O:Bloodloss andtransfusion• S:RCT

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N=

ICUfollow-upwithHMS

Nextsteps!

• Ethiccommitteeapprobation

• Recruitment(n=150pergroup)

• Collectthedata

• Analysis

• Writeanarticle

31=>Publish inNature!!

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

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