ROTEM Guided and Hemostatic Drugs Algorithms vs Standard Coagulation Test and Hemocomponent for Massive Obstetric Hemorrhage
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 发起方
- 入组人数
- 100
- 试验地点
- 1
- 主要终点
- Number of Blood products transfused
研究概览
简要总结
Obstetric Hemorrhage continues to be the first cause of maternal morbidity and mortality around the world especially in middle to low income countriesThe blood components are high value resources; however, its use has been shown to be a risk factor of known complications. The aim of the study is to compare two algorithms of coagulation management in massive obstetric hemorrhage Methods A randomized prospective trial single center two arms study in patients with severe obstetric hemorrhage (PPH > 1000) 2 different transfusion protocols one guided by thromboelastometry and hemostatic drugs (protrombine complex concentrate and fibrinogen concentrate) and the second guided by standard coagulation test and hemocomponents. Sample is calculated to known variance, Analyses are intention-to-treat without imputation, with outcomes will be performed between groups using mixed-effects two level regression models. For binary outcomes, a logistic model will be used and results presented as adjusted odds ratios (ORs) alongside 95% confidence intervals (CIs). Count data will be analysed using Poisson multilevel or negative binomial models.
Primary Outcome Parameter:
Compare between the two protocols:
Number of allogeneic blood products transfused intra-op, within 24h after screening and in-hospital (RBC, Platelets and FFP; separate and overall)
Secondary Outcome Parameter:
Analysis of mortality, lenth of stay admission to the ICU, hysterectomy surgical reintervencion, Transfuse associated circulatory overload, Transfusion associated Acute lung injury, health associated infection will be measured as secondary outcome.
详细描述
Introduction Obstetric Hemorrhage continues to be the first cause of maternal morbidity and mortality around the world especially in middle to low income countries. Copying trauma transfusion therapies now a days algorithms have been developing for 2.1.1 transfusion in massive obstetric hemorrhage. Blood products, play an essential role in the management of these patients, either during resuscitation or definitive treatment. Early transfusion, defined as that required in the first 24 hours after admission, it is required in about 5% that enters the hospital and about 3% comes to require massive transfusion. The blood components are high value resources; however, its use has been shown to be a risk factor for infectious transfusion related immunomodulation, and noninfectious complications (TRALI, TACO), development of systemic inflammatory response, multiple organ failure and death. A liberal transfusion policy can further introduce the risk of a patient who is already committed.
Patient blood management is an evidence-based, multidisciplinary approach to optimizing the care of patients who might need transfusion. PBM encompasses all aspects of patient evaluation and clinical management surrounding the transfusion decision-making process, including the application of appropriate indications, as well as minimization of blood loss and optimization of patient red cell mass.
The aim of the study is to compare two algorithms of coagulation management in massive obstetric hemorrhage Methods A randomized prospective trial single center two arms study in patients with severe obstetric hemorrhage (PPH > 1000) 2 different transfusion protocols one guided by thromboelastometry and hemostatic drugs (protrombine complex concentrate and fibrinogen concentrate) and the second guided by standard coagulation test and hemocomponents.
Randomization for the patients will be made for every obstetric patient that enters the obstetric ward for attention of partum, and will be asked to sign consent, and the patients will be selected for each group of the study. Only does that have severe PPH will be entering the protocol with the algorithm for management previously selected. Demographic caracteristics will include Ethnicity, Body weight (KG), body height (CM) and BMI at hospital admission, Previous deliveries, Previous Caesarean section, Pre-eclampsia during pregnancy, History of obstetric hemorrhage, History of other kind of hemorrhage, Onset of labor (spontaneous, induced, no labor) Multiple gestation (singleton, twins, triplet) Reported cause of obstetric hemorrhage (placenta previa, placenta accreta, placenta abruption, retained placenta, uterine atony, trauma, surgical bleeding Mode of delivery (spontaneous vaginal, instrumental vaginal , elective Caesarean section, non-elective Caesarean section) Baseline Hb, Hct, Plt count, Fibrinogen (Clauss), PT/INR, PTT (at hospital admission) Estimated blood loss at study entry (ML).
Treatment algorithms are evidence based and the management of coagulopathy is based on treat first what kills fist (ATLS proposal)
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Treatment
- 盲法
- None
入排标准
- 年龄范围
- 18 Years 至 45 Years（Adult）
- 性别
- Female
- 接受健康志愿者
- 否
入选标准
- •Patients with severe obstetric hemorrhage of any cause
排除标准
- •obstetric hemorrhage patients derived from other hospitals Patients with less than 1000 ml of estimated blood loss those who do not want to participate in the study
研究组 & 干预措施
Thromboelastometry
Decision to treat will be guided with thromboelastometry results, for fribrinogen deficiency the investigators will treat with fibrinogen concentrate (human), for correction of factor deficiency Prothrombin Complex Concentrates, Platelets with the use of platelets and Red Blood Cells for correcting hemoglobin levels
干预措施: Thromboelastometry (Diagnostic Test)
Thromboelastometry
Decision to treat will be guided with thromboelastometry results, for fribrinogen deficiency the investigators will treat with fibrinogen concentrate (human), for correction of factor deficiency Prothrombin Complex Concentrates, Platelets with the use of platelets and Red Blood Cells for correcting hemoglobin levels
干预措施: Fibrinogen Concentrate Human (Drug)
Thromboelastometry
Decision to treat will be guided with thromboelastometry results, for fribrinogen deficiency the investigators will treat with fibrinogen concentrate (human), for correction of factor deficiency Prothrombin Complex Concentrates, Platelets with the use of platelets and Red Blood Cells for correcting hemoglobin levels
干预措施: Prothrombin Complex Concentrates (Drug)
Thromboelastometry
Decision to treat will be guided with thromboelastometry results, for fribrinogen deficiency the investigators will treat with fibrinogen concentrate (human), for correction of factor deficiency Prothrombin Complex Concentrates, Platelets with the use of platelets and Red Blood Cells for correcting hemoglobin levels
干预措施: Platelets (Other)
Thromboelastometry
Decision to treat will be guided with thromboelastometry results, for fribrinogen deficiency the investigators will treat with fibrinogen concentrate (human), for correction of factor deficiency Prothrombin Complex Concentrates, Platelets with the use of platelets and Red Blood Cells for correcting hemoglobin levels
干预措施: Red Blood Cells (Other)
STANDARD COAGULATION TEST ALGORITHM
Decision to treat will be guided by standard cogulation lab test (Thrombine time, Active Thromboplastine time, Clauss fibrinogen, platelets count etc) for fribrinogen deficiency the investigators will treat with cryoprecipitates, for correction of factor deficiency fresh frozen plasma, Platelets with the use of platelets and Red Blood Cells for correcting hemoglobin levels
干预措施: Standard Coagulation Test (Diagnostic Test)
STANDARD COAGULATION TEST ALGORITHM
Decision to treat will be guided by standard cogulation lab test (Thrombine time, Active Thromboplastine time, Clauss fibrinogen, platelets count etc) for fribrinogen deficiency the investigators will treat with cryoprecipitates, for correction of factor deficiency fresh frozen plasma, Platelets with the use of platelets and Red Blood Cells for correcting hemoglobin levels
干预措施: Platelets (Other)
STANDARD COAGULATION TEST ALGORITHM
Decision to treat will be guided by standard cogulation lab test (Thrombine time, Active Thromboplastine time, Clauss fibrinogen, platelets count etc) for fribrinogen deficiency the investigators will treat with cryoprecipitates, for correction of factor deficiency fresh frozen plasma, Platelets with the use of platelets and Red Blood Cells for correcting hemoglobin levels
干预措施: Red Blood Cells (Other)
STANDARD COAGULATION TEST ALGORITHM
Decision to treat will be guided by standard cogulation lab test (Thrombine time, Active Thromboplastine time, Clauss fibrinogen, platelets count etc) for fribrinogen deficiency the investigators will treat with cryoprecipitates, for correction of factor deficiency fresh frozen plasma, Platelets with the use of platelets and Red Blood Cells for correcting hemoglobin levels
干预措施: Fresh Frozen Plasma (Other)
STANDARD COAGULATION TEST ALGORITHM
Decision to treat will be guided by standard cogulation lab test (Thrombine time, Active Thromboplastine time, Clauss fibrinogen, platelets count etc) for fribrinogen deficiency the investigators will treat with cryoprecipitates, for correction of factor deficiency fresh frozen plasma, Platelets with the use of platelets and Red Blood Cells for correcting hemoglobin levels
干预措施: cryoprecipitates (Other)
结局指标
主要结局
Number of Blood products transfused
时间窗: 24 hrs
Number of allogeneic blood products transfused intra-op, within 24h after screening and in-hospital (RBC, Platelets and FFP; separate and overall)
次要结局
- Incidence of Red Blood Cells transfusion (RBC)(day 0 to day 15)
- Incidence of Transfused associated circulatory overload(day 0 to day 15)
- Incidence of hysterectomy(day 0 to day 15)
- Incidence of surgical site infection or sepsis(day 0 to day 15)
- Number of hemocomponents or fibrinogen concentrates needed to treat hypofibrinogenemia(day 0 to day 15)
- estimated blood loss(day 0 to day 15)
- Time to bleeding control(24 hrs)
- Incidence of Massive Red Blood Cells transfusion (RBC)(day 0 to day 15)
- Incidence of ICU admission(day 0 to day 15)
- Incidence of coagulopathy(day 0 to day 15)
- Incidence of re-surgery(day 0 to day 15)
- In-hospital mortality(day 0 to day 15)
研究者
Angel Augusto Perez Calatayud
Head Intensive Care Unit Hospital de Especialidades del Niño y la Mujer Dr Felipe Nuñez Lara
Grupo Mexicano para el Estudio de la Medicina Intensiva