Archives For December 2012

tranexamicThe CRASH-2 trial showed us that Tranexamic acid (TXA) reduces mortality in trauma if given within 8 hours of injury. A new BMJ meta-analysis examined the effect of the drug on surgical bleeding. It failed to show a statistically significant reduction in mortality (though the RR was 0.67), but did result in less blood transfusion (RR 0.62, p<0.001), with no significant adverse effects. Interestingly, the RR for MI was 0.68 (less bleeding, better perfused coronaries), for stroke 1.14, (nether significant, take your pick!).

 

TXA and surgical bleeding Meta A Ker BMJ 12

It makes you wonder why TXA is so underused. It costs $100 per gram, with the unlicensed Factor 7 costing a whopping $1,200,000 per gram, with no evidence of benefit and a strong suggestion of harm. Again, take your pick.

The National Blood Authority‘s excellent Patient Blood Management Guidelines are in production. The Critical Bleeding Massive Transfusion guideline is complete, and recommends tranexamic acid in trauma patients. The Perioperative guideline recommends tranexamic acid for the prevention of major blood loss in cardiac and non-cardiac surgery where there is a high risk of bleeding. Neither guideline recommends the routine use of Factor 7, and both point out that its emergency use, when all else has failed, has no evidence of benefit, and is unlicensed.

We think the NBA guidelines are so good, we’ve given them their own page – under Resources. Enjoy.

Marikawards-oct2012Paul Marik, who has appeared in a few posts on rpaicu.com, gives us another possible game-changer with this meta-analysis on stress ulcer prophylaxis. He found that H2 receptor blockers prevent stress ulcer related bleeding, but only in the subgroup of patients who were not being enterally fed. Stress ulcer prophylaxis had no additional effect in patients receiving enteral nutrition, even if it was inadequate (i.e. not at target rate). Furthermore, in patients who were being fed enterally and received an H2 receptor blocker, the incidence of VAP was increased.

He argues that once your patient is fed, even if you haven’t reached the target rate, you should stop the stress ulcer prophylaxis.

This paper was presented to the CICM ICU Update this year by Prof. Marianne Chapman, who informed the audience that this is now the practice at the RAH…maybe we should follow suit at RPA?

Now, I know we use PPIs rather than H2RBs, but most trials find these agents to be equivalent..

Stop stress ulcer prophylaxis once they’re fed Marik CCM 10

Please post comments below.

JG

RPA throws down the gauntlet!

rpaicu —  December 11, 2012 — 1 Comment

A crack team of ICU Sim warriors is due to take on the world at the SMACC conference (Social Media and Critical Care) SimWars event next March in Sydney. The competition is going to be stiff. If you are interested in being on the team write a comment below or contact Jon Gatward. As part of our entry we had to submit a short video – see below. And register for SMACC – it’s going to be like no other conference before it and will be huge!