"Amchafibrin" y trauma

dramarilloloco

e-mergencista experimentado
Autor #1
El estudio CRASH-2 ya dejaba ver un camino para el politrauma grave parece que se suman nuevos datos...
A ver si la nueva revisión del ATLS/PHTLS lo recoge...
RESEARCH
Effect of tranexamic acid on mortality in patients with traumatic bleeding: prespecified analysis of data from randomised controlled trial
BMJ 2012; 345 doi: 10.1136/bmj.e5839 (Published 11 September 2012)
Cite this as: BMJ 2012;345:e5839
Clinical trials (epidemiology) Epidemiologic studies
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Ian Roberts, professor1, Pablo Perel, senior clinical lecturer1, David Prieto-Merino, lecturer, medical statistics1, Haleema Shakur, senior lecturer in clinical trials1, Tim Coats, professor2, Beverley J Hunt, professor3, Fiona Lecky, professor4, Karim Brohi, professor5, Keith Willett, professor6 on behalf of the CRASH-2 collaborators.
Author Affiliations

Correspondence to: I Roberts ian.roberts@lshtm.ac.uk
Accepted 18 August 2012
Abstract
Objectives To examine whether the effect of tranexamic acid on the risk of death and thrombotic events in patients with traumatic bleeding varies according to baseline risk of death. To assess the extent to which current protocols for treatment with tranexamic acid maximise benefits to patients.

Design Prespecified stratified analysis of data from an international multicentre randomised controlled trial (the CRASH-2 trial) with an estimation of the proportion of premature deaths that could potentially be averted through the administration of tranexamic acid.

Participants 13 273 trauma patients in the CRASH-2 trial who were treated with tranexamic acid or placebo within three hours of injury and trauma patients enrolled in UK Trauma and Audit Research Network, stratified by risk of death at baseline (<6%, 6-20%, 21-50%, >50%).

Intervention Tranexamic acid (1 g over 10 minutes followed by 1 g over eight hours) or matching placebo.

Main outcome measure Odds ratios and 95% confidence intervals for death in hospital within four weeks of injury, deaths from bleeding, and fatal and non-fatal thrombotic events associated with the use of tranexamic acid according to baseline risk of death. Unless there was strong evidence against the null hypothesis of homogeneity of effects (P<0.001), the overall odds ratio was used as the most reliable guide to the odds ratios in all strata.

Results Tranexamic acid was associated with a significant reduction in all cause mortality and deaths from bleeding. In each stratum of baseline risk, there were fewer deaths among patients treated with tranexamic acid. There was no evidence of heterogeneity in the effect of tranexamic acid on all cause mortality (P=0.96 for interaction) or deaths from bleeding (P=0.98 by baseline risk of death. In those treated with tranexamic acid there was a significant reduction in the odds of fatal and non-fatal thrombotic events (odds ratio 0.69, 95% confidence interval 0.53 to 0.89; P=0.005) and a significant reduction in arterial thrombotic events (0.58, 0.40 to 0.83; P=0.003) but no significant reduction in venous thrombotic events (0.83, 0.59 to 1.17; P=0.295). There was no evidence of heterogeneity in the effect of tranexamic acid on the risk of thrombotic events (P=0.74). If the effect of tranexamic acid is assumed to be the same in all risk strata (<6%, 6-20%, 21-50%, >50% risk of death at baseline), the percentage of deaths that could be averted by administration of tranexamic acid within three hours of injury in each group is 17%, 36%, 30%, and 17%, respectively.

Conclusions Tranexamic acid can be administered safely to a wide spectrum of patients with traumatic bleeding and should not be restricted to the most severely injured.
 

Palas Atenea

e-mergencista experimentado
#4
Respuesta: Amchafibrin y trauma

Veo un problema a la hora de administrar este fármaco tanto en los servicios de urgencias como en el medio extrahospitalario.

En la ficha técnica del producto advierten de un riesgo elevado de trombosis, en caso de administración concomitante con derivados del complejo protrombínico o con derivados del factor IX. Los pacientes que sufren de un shock hemorrágico acaban en quirófano y en mi experiencia, si el sangrado es importante, acaban haciendo una coagulopatía. Como anestesióloga suelo atender a este tipo de pacientes en las guardias, y una de las cosas que hago es llamar al hematólogo para que me ayude a reestablecer la coagulación, quien me recomienda administrar octaplex ( factor IX), novoseven ( factor VII), o plasma según estén las analíticas. A muchos pacientes, ,es necesario administrar plaquetas si el sangrado es importante.

Otra contraindicación para la administración de estos fármacos es la aparición de CID. En casos de sangrado masivo he visto a varios pacientes desarrollar esta complicación.


Si administrar amchafibrin va a impedir la administración de forma segura en quirófano de todos estos otros fármacos procoagulantes, ¿vale realmente la pena? Al final lo que realmente importa es el control quirúrgico de la hemorragia...
 

Belladonna

Super Moderator
Miembro del equipo
#5
Respuesta: Amchafibrin y trauma

A proposito del tema:


"Antifibrinolíticos
Los agentes antifibrinolíticos inhiben el sistema fibrinolítico plasminógeno---plasmina, impidiendo la lisis del coágulo lo que puede conducir a una disminución del sangrado. Su eficacia ha quedado claramente documentada en pacientes quirúrgicos, incluyendo pacientes intervenidos de cirugía cardiaca y de trasplante hepático32. Un reciente ensayo clínico controlado y aleatorizado33 compara contra placebo, en forma doble ciego, el uso de ácido tranexámico administrado precozmente, primeras 8 horas tras el traumatismo en dosis de 2 g endovenosos, 1 g en bolo inicial y 1 g en perfusión durante 8 horas, y ha demostrado que disminuye tanto la mortalidad global como la debida a sangrado en pacientespolitraumatizados. El mecanismo por el que este fármaco reduce la mortalidad puede estar relacionado con un efecto antiinflamatorio mediado por plasmina."​

Extraido de Alternativas terapéuticas de la hemorragia masiva , os dejo el adjunto donde podeís ver el articulo completo.​
 

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