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Coagulopathy and Analgesia

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Topic overview

This podcast is an interactive discussion about the management of coagulopathy, analgesia, sedation, and delirium in critically ill pediatric patients between Dr. Adam Vogel and Dr. Alexander Gibbons.

Intro and outro tracks are adapted from "I dunno" by grapes, featuring J Lang, Morusque. Artist URL: ccmixter.org/files/grapes/16626

  • Introduction

    • Dr. Adam Vogel is a pediatric surgeon at Texas Children’s Hospital and an Associate Professor of Surgery and Pediatrics at Baylor College of Medicine.  He completed fellowships in both Pediatric Surgery and Surgical Critical Care.  His research interests include viscoelastic monitoring techniques in goal-directed hemostatic resuscitation and massive transfusion, as well as optimizing anticoagulation and ventilation during extracorporeal life support.  Dr. Vogel, thank you for joining us.

  • Coagulopathy

    • Case Scenario: 12-year-old helmeted male in a high-speed vehicle vs. bicycle collision.  EMS gave two crystalloid boluses prior to arrival with a transient response.  He was taken to the OR for hypotension and a positive FAST, and massive transfusion protocol was activated.  His bleeding was discovered to be from a liver lac, for which he underwent packing. He is brought to the PICU post-operatively and is noted to have an INR of 2.5 on post-op labs.  How would you manage this patient?
      • See Where You Are
        • What is the trend in values?  The value in the PICU is likely not the first one that was measured. Is the value going up or down?  A single point measure at one point in time is not nearly as helpful as the trend.
        • What products has he received thus far?  What was the ratio in which he received blood products (RBCs:plasma:platelets).
        • What are the other lab values (i.e. PTT, hemoglobin, platelet count, and viscoelastic monitoring)?
      • Initial Therapy
        • In the setting of volume overload, it is important to be truly goal-directed with your therapy.  Viscoelastic monitoring can be used to measure the functionality of platelets, and can help prevent transfusion of more products and volume simply to treat a number.
      • General Management
        • Get the patient warm, evaluate trends with multiple labs and clinical assessments, and normalize coagulopathy with a goal-directed hemostatic therapy approach.
      • What is viscoelastic monitoring?  What role does it play in the pediatric population?
        • Both thromboelastography (TEG) and rotational thromboelastrometry (ROTEM) are different flavors of testing that allow for a global evaluation of the entire coagulation cascade.  It assesses not just how blood clots, but also the fibrinolytic portion of the cascade.
        • The test involves taking a small amount of blood and a reacting agent.  As the blood clots in the machine, the mechanical changes of the blood as it clots are transduced into an electric signal.
        • There are four major phases that these tests allow you to process:
          • Time to clot formation
            • Dependent on factor function
            • Treat an abnormality with plasma
          • How rapidly the clotting process progresses (alpha angle)
            • Dependent on fibrinogen function
            • Treat an abnormality with cryoprecipitate or fibrinogen
          • The strength of the clot (maximum amplitude)
            • Dependent on platelet function
            • Treat an abnormality with platelets or sometimes DDAVP (such as patients with end stage renal disease)
          • Time to lysis of clot (LY30)
            • Dependent on fibrinolytic pathway
            • Treat an abnormality with tranexamic acid or aminocaproic acid
        • Targeted Therapy
          • They allow for a sense of how the whole system is functioning and targeted therapy, which helps prevent volume overload.  Values can also be trended over time to see how a patient is responding to your therapy.
        • Real Time Monitoring
          • They can also be done in real time, allowing for the first three components to be obtained within 5-15 minutes, as opposed to 30-45 minutes for the conventional coagulation tests.  However, this is dependent on the coagulation lab in the hospital system.  The quicker you get the results, the easier it is to incorporate into your resuscitation.
          • These tests can give you very important data very quickly, allowing you to incorporate them into practice.
        • Life in the Fast Lane: https://litfl.com/thromboelastogram-teg/

    • Management of Fibrinolysis

      • Two phenotypes in severely injured children:
        • Hyper-fibrinolytic: rapid fibrinolysis that contributes to coagulopathy; tranexamic acid can be very helpful to this population
        • Fibrinolytic shutdown: smaller percentage; tranexamic acid may be detrimental
        • Viscoelastic monitoring can help differentiate between these two phenotypes (LY30)

    • Balanced Resuscitation

      • Volume alone is not sufficient; administering blood products in a balance of 1 unit of red blood cells to 1 unit of fresh frozen plasma to 1 unit of platelets; randomized controlled trials in adults have shown this decreases morbidity and mortality
      • Efficiency
        • Resuscitation is also more efficient, as coagulopathy is able to be corrected with less overall volume
      • Pediatric Data:
      • Massive transfusion protocols incorporate balanced resuscitation transfusion ratios

  • Analgesia/Sedation/Delirium

    • Case Scenario: 2-year-old male with neuroblastoma undergoes a laparotomy for resection.  Post-operatively, he has poor pain control.  How would you treat his pain?
      • Causes of pain and distress will be multifactorial, and so treatment should be multimodal
        • Having a Pain Management team from Anesthesia can be very helpful
        • Narcotics
          • Narcotics will certainly play a role, but adjuncts like ketorolac (Toradol) or oral NSAIDs should be given to help reduce opioid use; this can reduce post-operative complications like ileus
        • Regional analgesia
          • Epidurals or ultrasound-guided nerve blocks can help reduce intraoperative opioid use
          • Indwelling catheters that slowly release local anesthetic can also be helpful
      • Anxiety after surgery can be significant in both younger and older children
        • Environmental and non-pharmacologic therapies can help manage pain and stress
          • Child-friendly and family-friendly environments, including pet therapy
          • When children are less stressed, their pain is more manageable
          • In patients requiring multiple complex dressing changes, there are augmented/virtual reality devices that can markedly improve patients’ stress in these situations
    • Case Scenario: During his recovery, the above patient is discovered to be bleeding and is taken back to the operating room for hemostasis.  He remains intubated post-operatively.  What sedation options are available to him?
      • Most intubated post-operative patients are on a combination of sedative medications to help facilitate their interaction with the ventilator and keep them comfortable
        • Benzodiazepines such as midazolam (Ativan) combined with a low-dose narcotic infusion (fentanyl, morphine, or hydromorphone)
        • Dexmedetomidine (Precedex) is very effective for decreasing the anxiety of having an endotracheal tube
        • Multimodal approach is also important for sedation in the ICU environment to minimize the amount and volumes of drugs being administered to your patients
      • There should be at least daily evaluations of pain and sedation in all post-operative patients, using validated scoring systems; this will allow titration of analgesics and sedatives
        • Pain
          • Faces, Legs, Activity, Cry, and Consolability (FLACC) score is typically used for pre-verbal children
          • Faces Pain Scale – Revised
          • Visual Analog Score (VAS)
          • Color Analog Score (CAS)
          • Non-Communicating Children’s Pain Checklist
        • Sedation
          • State Behavioral Scale (SBS) is a sedation scoring system commonly used in pediatric patients
      • Multimodal therapy allows for patient safety without overmedication
      • Sedation Holidays
        • An excellent resource for management of critically ill patients is the Society of Critical Care Medicine’s ABCDEF bundles; they have been extensively studied in adults and are starting to be implemented in pediatric patients
          • A: Assessing pain
          • B: Spontaneous awakening trials coupled with spontaneous breathing trials; in the appropriate patient, having a sedation holiday and spontaneous breathing trial decreases the amount of time they are on sedative medications and on the ventilator
          • C: Choice of analgesia and sedation; escalation and de-escalation protocols developed with the pharmacists are unique to ages and patient populations; minimize benzodiazepine use
          • D: Delirium; see discussion following next case scenario
          • E: Early mobility and exercise; get patients out of bed and working with physical therapy and occupational therapy
          • F: Family engagement; allow patients and their families to play a role in their care
          • http://bit.ly/2rq5P1k

    • Case Scenario: 

    • Over the next day, the above patient is able to be weaned from the ventilator.  After extubation, he is confused and at times combative. Delirium is suspected after other potential causes for his altered mental status are evaluated and ruled out. How should his delirium be managed?
      • ~40% of patients in an ICU will have delirium at some point during their ICU stay; it is a waxing and waning stay in mental status
      • Risk Factors
        • Younger children (<2 years of age), intubation with mechanical ventilation, benzodiazepine and narcotic use, and use of physical restraints
      • Similar to pain and sedation treatment, treatment starts with making an assessment using validated tools
        • Confusion Assessment Method for the ICU (CAM-ICU); developed for adults, but translated to pediatric and pre-school populations
        • Cornell Assessment of Pediatric Delirium (CAPD)
        • Sedation must be evaluated before you can accurately assess delirium
        • These are screening tools, but it is important to first rule out other possible causes for changes in mental status
      • Treatment of delirium is also multimodal
        • Start with non-pharmacologic therapy, such as trying to normalize sleep-wake cycles (lights on at day and lights off at night), having the family at the bedside, consulting Child Life, having pet therapy, etc.
        • Pharmacologic therapy could include melatonin to help manage insomnia and atypical antipsychotics (such as risperidone) at a low dose
        • Assess the patient to identify other factors that may be contributing to delirium each time there is a change in clinical status
      • Prevention of delirium
        • Address the underlying pathophysiology
        • Involve the family early
        • Attempt to normalize sleep-wake cycles

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