SEMINARS _IN Trees. HEMOSTASISSEMINARS IN SEMINARS IN THROMBOSIS THROMBOSIS ‘AND ‘AND HEMOSTASIS HEMOSTASIS iene Recent and Future Issues EBerhard F. Mammen, M.D. ‘Wayne Ste Univers Schoo! of Medicine $340 Bast Canfield Avene ee AAxTioseroL ND sy Volume 20 issues 1998 | derek Got aor Guest Editors Sir Soseph A Capi M.D. BRCfamuvoor years 1 Glos Hosp shore es Cam Gen Es Deparment of Surgery enter 2100 Png Road GCodamnooryeans. Glenview hina 60025 stb Hae ne Coy Gat is Geese! Teaver, MD. PRD. Ce Deparment of Radiation Oncology Yom W- Fon ae Ea Sora Hoptal 206 Madi Spin Volume 21 ses Jeanine M. Walengu, Ph.D. hee dawed Fareed, Pr. et Loyola University Medical Center PLATELET RESPONSE TO ANTLOLATELET Department of Paola) an Pharmacology “ec, eC ora io South Fist Avene Sal Eg a Maywood in 60159 ‘ome tap ae ers Juan 1. Atclus, M.D., Ph.D. ‘ROWERS 1 VASCULAR MEDICINE Howpal of the Anan ot Kom ae a ond Departmen of Sugery Sed Ga, Vale Mag, Spun snes Broce D. Spiess, M.D. ar Univesity of Washington ‘nt H Sar, Ga Er Division of Cardiothoracic Anesthesia ae ‘Seatle, Washington 98195 PEDIATRIC HEMOSTASIS AND THROMBOSIS, sa aa erat Coty a Mae, Pap Mann nea 2M 36 (Lb) nt ep 0 Gy ONS Dt Cah ‘ct rcs Ch ei 06 ryt Ae a Neh ohSEMINARS IN THROMBOSIS HEMOSTASIS Vetume 21 Supple 4, 195 “ 2 ‘Thromboelastography Joseph A. Caprini, M.D., Clara I. Traverso, M.D., Ph.D. Jeanine M. Watenga, Ph.D., Juan I. Arcelus, M.D. Ph.D., Jawed Fareed, Ph.D., and Bruce D. Spiess, MD. ‘The Thromboelastograph and the Thromboelastograph Technique Wayne L. Chandler, M.D. ‘The Normal Thromboelastogram and Its Interpretation (Clara I, Traverso, M.D., Ph.D, Joseph A. Caprini, M.D., FA.CS., and Juan 1 Arcelus, MD, PhD. ‘Thromboelastography: Measuring Statistical Probabilities Joseph A. Caprini, MD., FACS., Juan I. Arcelus, M.D., PhD. Sofia Goldsheyn, M-D., Kevin N. Hoffman, B.A., and Robert W. Coats Il, B.S. ‘Thromboclastography for the Assessment of Hypercouguability During General Surgery Juan 1. Arcelus, M.D.,.Ph.D., Clara 1. Traverso, M.D., Ph.D. and Joseph A. Caprini, M.D., PACS. ‘Thromboclastography and Cardiopulmonary Bypass Bruce D. Spiess, M.D. ‘Thromboctastography in Liver Transplantation Yoosoo Kang, M.D. ‘Thromboclastography and Liver Transplantation Bruce S.A. Gillies, MD. Cominscd {TMIEME MEDICAL PUBLISHERS, INC [NEW YORK, STUTTGART 381 Pa Avene Soth, New York, NY CD16Conn Comin 50 n 6 80 Application of Thromboclastography in Other Medical and Surgical States Clara I. Traverso, M.D., Ph.D., Joseph A. Caprini, MD., FA.CS.,and Juan 1. Arcelus, M.D., PhD. ‘Thromboetastographic Modifications Induced by Intravenous and Subcutaneous Heparin Administration Clara I. Traverso, M.D., Ph.D., Joseph A, Coprini, M.D., PACS. Juan 1 Arcelus, MD., Ph.D., and Ignacio M. Arcelus, M.D., Ph.D. Role of Thromboclastography in Evaluating Other Anticoagulant Agents: Warfarin and Heparin-Dihydroergotamine (Clara 1. Traverso, M.D., Ph.D., Juan I. Arcelus, M.D., PhD. and Joseph A. Capri, MD., FACS. ‘Thromboelastographie Study of Fibrinolytic Agents Louis Sunmaria, Ph.D. ‘The Approach of Thromboetastography in the Monitoring sf New Synthetic Antithrombotic Agents, GIL-822 and GL-2021 Omer Igbal, M.D., Walter Jeske, BS. Debra Hoppensieadt, M.S.. MIVASCP), Jeanine M.Walenga, Ph.D. and Jawed Fareed, Ph.D. Comparison of the Anticoagulant Activities of Thrombin Inhibitors as ‘Assessed by Thromboelastographic Analysis Demetra Callas, B.S., Omer Iqbal, M-D., and Javed Fareed, Ph.D. ‘Thromboelastographic Analysis of Patients Receiving Aprotinin with ‘Comparisons to Platelet Aggregation and Other Assays Michael J. Koza, B.S, Jeanine M, Walenga, Ph.D. Yelena N. Khenkina, MS., Henry J. Sullivan, M.D. Alvaro Montoya, M.D., and Roque Pifarre, M.D. Procoagulant and Anticoagulant Effects of Intravascular Contrast Media as Assessed by Thromboelastography Omer Igbal, M.D., Walter Jeske, B.S. Debra Hoppensieadt. M.S. MTVASCP) Michael Koza, B.S., MTVASCP), Jeanine M. Walenga, PhD. awed Fareed, Ph.D., and Rogelio Moncada, M.D. Perspectives on Thromboelastography Joseph A. Caprini, M.D., F.A.C.S., Clara I. Traverso, M.D, Ph.D., and ua 1 Avcelus, M.D.. PhD.In Memoriam Professor Dr. Hellmut Hartort “Tis supplement o Seminars in Drombosis ond Hemost deve ote we of the tromboets poi rcs lil sting 18 cly appropri {Spay tito investor rfesc Het Hare fro psd ny ite 1983. He dsc the inst Inet in 1948 inthe Kinch Woche "stein Immun mit der Thromelstopapie, tem Seon Uacrachongsterahen" Te procedure lowed or he Fine dhe mestring ot nt raglan gta, bot nfrmaton om wen ed lat, Row i ot an thems cltcvses Hh reveled yale informe Toe for he linn rearing the fnciomabty of he “cao ye, The con rc oh em Imei ut in py and elestoncenineing He tras erpecly involved in bomorboogy and inven {1972 the Rho Salt and BSL te concept of Resonance Trmbsstogrn. ‘at eee DR, Professor Hae was ceri © 18 Tans Ma ts, ak A Set Ne i HY A fesse ad Het ofthe Mofile in Knrsian ‘ina teaching hp of be University of Mai. He ‘wasamemterf romero eat ratizaons. pe ‘ly cate to erecoey,pblsted more 30 scene aris, and sere om the etal foul of {ver sete jure The eit of he Posculle (God Moda tthe eration Congres of Blo (og) in 1983 rowoe is seca aceopisinens “Tn of who ah este krowing Professor Hager omerterhimasskindand arm eared peso, team excelent sit, ad # sap pcan. The ‘Seni coon hs fos one of Het embers Ta gst lnph Capri and eens fe puting this be on trombone, {n moor fe inven Profesor De Hella Hert ead F Mameen, MLD.Pitfalls and Complications [MMA awalule : in the Diagnosis and rere Atlas of iver Pancreas, ‘Management of ‘and Kidney Hepatobiliary and and Sharpen Transplantation Pancreatic Diseases Edie: eB. Kremer Dr Cf Broslch, Se i ad ten Kren, 6, Brow Nak bygidokis ond M. Makuuehi Thee hunted fllcolor, step yr atep Coton. Ma nd i Reman inspite photographs an scemitc wings vil demons sgl cigs and ‘void comman errors pponthe fora onganprocieet—aa we and ptfals when treating ‘the mor quent performed abdominal organ complex hepatobiliary Snplet pede and pancreatic diseases! than 100 work enon ‘peril ths book clei dlp ta tmbing blocks thea kad problemen he manager of beige ralgsnt hepaobiay and pancreatic dese. The most import eons dex ach psc peer techniques fr overcoming cir welcomes ‘ih bleep panna seep Contents Section | Liver Disease isgoose, Imaging and Pathology, Src Manage ‘ment of Benign Leer Disease Sure Management St Malignant iver Dseate Liver aneplarstons, Mesical Management of Livet Dative, Section I: Bilary Disease ingnosi, Imaging, and Pathology: Sarl Manage ment of Benign Biey Disease; Surat Masagement Sf Magnan Bary Dict Mel Managment of Bian Bae, Section I: Pancreatic Disease ‘Diagnosing, and Pathology; Surgical Management of Benign Pancreat Disease Surgical Management of Nalgnnt Papeete Diss Paceas Tranuplasetion: Medel Management of Pancreatic Dene Section IV: Portal Hypertension Diagnosis and maging Suc Manageme of orl Igpeenson: Medial Management Por Hypertension 190557 pz 504-057-407 0250 eee eae es owes nag ect ope cee a 1 rer segment tanplntation 1 ‘obole and segmental pancreatesanpanation f ngreited nd cade donor kidney taneplation Order Today! ‘9p. 6p. co. SEN ABST S15 40.09 Order Form or CALL TOLL-FREE ar ois, Pita an campeon in he ign nt sipemet Haptic ‘raison ‘Oke: ke Lr Panera, nd Ney apna sroastiea i i 1 i 1 i i i 1 i | fine | cea mee i 1 i LE & seemae Preface De Hell Hae consid heir bombo gaphin Germain 88. By ding ened than anew wt is dev tual change he concep of ‘rulhty so much tt Raby coed he phase, “The {Sa Oe teoelsogrepy re he inperance ‘ice bli testnge Deore ‘phy TE) ey th is a eset of ating cul emesed Folin TEO, beh gat of sting a Sty of te ol forned cul be ch eter wnt ony Kt, ba i he mais of he ‘Soo, TEC wos sed, aml nd sd by seer ope maar ah De Nets ne 1950, NC Aur ae Reining of he 1 sa C Raby at ‘€ TEG began with son Kies Capen nth ‘nd mnogo cared ul be 99 ss inthe Una Sr fs on rowing ably ig the Why? Te ver sw ay Invi ling es ime beter curtis by rei ester hin TH, “The gel more of thr fst Se more shart nd the fine TEC semi inte carved wih van eves of ‘Sopncts d fow pla a igh Hagen my ok snr low Rogen sn ih lates. Tse ‘wo have wed is et cally ave snl fe tal eae of he an ceed by TG anes, “Tegal ofthis seo Serna iso each pts conch that can be aiid ath xe ele rosie anf roma nel evan ‘te cue ofthe, The mot peta spc ve may be to pit steno of TE, ich shklprme = er unlotaning pyre fis insig ema a A ube ope Invesigts hve sure Ue Ws honbocstopie ‘perce with and sega abe othe moo, Rote Cot er is casing lors ei cl, ‘an eying te mass, Our hanks ao wo Kevin ot fr having te organ hls Kexpall the pin ocd inthe it dwt aly. Cp Jose A. Carn MD, Cla I. Tver, MD, PAD. SeanineM.Waeng, PRD, Juan. rests MD. PRD. “ved Fas, PAD, ant Brace D Spiess ALD. ss EtSmall Thieme flexibooks are BIG in basic science! Color 4 ache Ada of Cytology, yy amd Micrnseic fiThe Thromboelastograph and the Thromboelastograph Technique WAYNE L. CHANDLER, M.D. ‘Tredimboststograph was igi desea 94h ane Wook by Harr a otis inthe 19508 vale te fet ing factor etc ae slat, dhombscyepei and inl on te hrmboelsgrap am deonsuted tha oul Be ‘Sed a pi empl serena veal omc fneton The thromolsingagh hs fen ed ee tis limi ihe Uae tates ul he 1980 whe dewex somewhat of aed with se dr ver ‘ensplartaton procedures" "Te blood cht hs bth vison and tc roe ‘oluluser storage meduls of eloting Dod. As ig tally decd Wy Hane is ode of samp ‘sony over wide rnp? Figure Iss 3 aga tie sale ection of he roost aad 2 type thomvelaograph cing. Whole lod i paced asp cp. pin aspended by aca feson wie lowered it he sample. To meas te ‘She ror msl of th ample he cp eld ‘Grugh an sgl of #4" vera 10sec ier, inclig | scond et pis athe nd of he on iach ticton to preven vst enor. Te trgae ide cp is tensed fo he pn toh he samp the rugde of sae sour modus ofthe sample. [Lig eb tans le on age fam eo ‘wpin pacing deicton onthe racing sven when thew eodaconty high eck n in peyhemia ‘ce mcrptlinemi) Ashe Hood et Hes con Posed of plats and i ore betwen the eu and Pin tarsmiting porn of he cups rion to the pin, As shown Ler, the higher he pal cowt and Fringe. he bigherthe ins tesa mls ste manpe neatly trombostastgrpts cotionof the pin was reson slag mior tached hep gt Beam, nd photographie fina of th cing ws de Ij ty the need w develp the im, This has boon Spf i cane sdls by a mschanicalletea! trance and ample which ve pen sorpeic: ing smmeinely wale tains on et sensitive oper ‘eo dig daa fr dpay ona amp teal, Dil verso pace cnet guile cing INTERPRETATION OF ‘THROMBOELASTOGRAPH TRACING Five standard metssements af made om each trombosasgraph racine (iD The reaction ie (Goer vai neaued fom he st OF th acing ‘oie pint where he cue un ne The R alos an be expressed in wo equivalent ways, as. istnce In miller oa tine miter Th cha ape ‘tues uu the stance fmm vied y 2 The Kol sno a whole Blo cloting Sime Prlangation of th Rae acne wi ating factor defences or nin and stooge ch 2 epi. Ar plats rovidete phospho srace for cela ects nthe san hbo. 1p rombocjopenia ay aso proba the vale "Te eral te (valve he distance eine fom te I mm wide pt 1 the 20 wide oT ge) esse cn the ine of thetucing ead ine daw re he Its wae pint tangential othe carve The K ala ale we ine tow ofthe mi faze of le sear moda the sample adhe words, how ft he lt srt ‘nih © Ti Me le ok At Sth No HHA '2 SEMINARS IVTHROMOSIS AND HEMOSTASIS VOL, 2, SUPPL, 4, 195 ‘THROMBOELASTOGRAPHY Instrument ‘Tracing oon Wie Wrote leod isPufte Sn cup forming. These a the mos compen su they are teva in hing factor dfece, pelt dst te, thembncyopen, nd ying, “The forth mesrreent the anima amp (00) The wath of he cre te pt function opel com and ivinogen eek the tual comparcats of he hI atone evi and ypainogoemia, vey fone cltig ies rescind with sever fico deci orn he "The late sor mi fe sample increas expecta npepoonto he pitade ofthe ier beelasognph using Fig?) Basedon Harr iia work, te solve ele soar melo the sample ‘an fe exit fom tombecastogriph ample 6 =[so00aytioo- A) gt ‘trae cup nd amen in a "Tis a ampdeof 100 mm agian os inns dl, ree an ese thea ‘de from 504967 mm equivalent os weld incese fut hasan MA 50a eave wo a elatie Stearman of approximately S08 dy! “Tsp the imc evan of het aah, Hane developed alate cay sale in whieh 8 tena ct with MA ot 30m wat asigned mn ar try late mods of 10a acl by eli <= (ClooayI— A) Bg? ew ith tier ml (ae designed Mi Alter measuring the MA he spite the oud fh cing fe mesie, A stb deste a is Slade compared othe MA inde th rsens of "gic Rio The two most somon pr_NROMBOELASTOCRAPH TECHNIQUE Cus. ‘uo0e dynvew") GE ab ad ab Sd 6 70 08 YEG MAXIMUM AMPLITUDE. ‘om igang moo sn me ne 40 meni te mpi 6 minus ater stating the assy or 60 mints afer MA fea Tho ngst ow wal wo mesure he fl ample, the more ey Sow meio tet weak Shine sev. How log Sos ra fore wearing te Gal smite pends “bose you ant the sny tobe for teas. ‘ovsone proces tach achive cant fon, where rap coain Shunges ocr and sve Fina com, samples may bere every TS futon loeer than 0 mts seldom sea DETERMINANTS OF THE MAXIMUM AMPLITUDE ON. ‘THE THROMBOELASTOGRAPH ‘The lai sear mods i feed by pale oot and fivinopen olin whol bed? Prorstaes Five sh tt the at shear dul i properona tothe fiogen concetrcon of he lt a Bats pe ‘San an psn Stas tae io sth Sle seurmedls is proporional tothe patel our {nthe sample To understand these eles in ore ‘ui, we ome he pst oan snag eve Ad MA in 19 samples of whole ited too! oid ‘hing oop iver tanplnation, Suis en buna ‘bjs ners art coli te elles be Devotion of Hinson a baie ral preps an th ty was approved by te puatenets ‘dooo/uts a3. snerotto Univers of Wisin lama Subjecs Review Com re. Blo war souls by the aon oF 3 nLite ode. [300mm ra Whole ental lod samples were rcled ith ‘robcatgap by alton of 250 mle hated odo 10 Lo 06 piesa hee Samples ttre rjc if hey showed evgnce of bees. (reer han aS mn drop ia simple a 0 mos ‘ous MA) of lao oie fom he whole od Thowed evidence of prin (rome ne rete an {Waeondo The line sear moda adem? as ‘stint fom he MA from ean 1 Te nog ‘Saneneton wa determine ui an Autred Cong SiaonLabratory 100 (ACL 0) an8 PIF rapes from Hatncntion Laboratories (Lexington, MA Pile cous wer pertomed on a Cole STAR Mi ani FL). ‘ovale ts fet of pitt count xiao cn level eprom MA ths ple cunt an oo fe levels the samples be dependent Fgare 3 $ows the low comeaton (@ = 011 Of plate count ‘res iigen level rag ett tes ts ‘anacion eating he lave Independence of these rset ini to samples "Thre was moder comelaon (gue 4. top ‘al teenen the pit court and cite he MA {= 0.9) othe east shae model (2 067, Te ‘Cerelon ws wens teen te Ripe vel Fi tre A mil pl) ander MA (# — Os) or ease ‘Sear mode (@ = 043). The Best eonelain Figure ower pols) was betwen he mpl near ere ‘on io pleco ad ingen ve vers ease." . Q a i A S340 ge a 8 i # £ a © 50 100 150 200 250 300 © > so 100 150 200 280 300 oO) “e007 te 1 4 a i to k a4 : fee 3 aoe ed £8 ay | Eo ao "0 ah abo io ado ooo ato aad 100 ido ato ato abo rentnooen raaznosen w/a) ‘oars eo re 8 a 2 oo: lied i es He we é Hy 2 le : Ba e d °0 #0 20 30 40 50 60 70 60 WA = 0.430%RL1 + 0.0BtHFIB + 15.2 "alaionipbtneen pate ant. Rogen eve dha utarron es fie eve pata sa 2 4 6 6 10 a2 = 22.24PLT + s1.0wr10 - 200{HROMOELASTOGRAPH TECHNIOUE- Cuvouse shes modus (2 = 70), witha some ower cone ion MA (e = 6, ins eget, dis suggests ht bal plates and fiwingen ze portant deermining ck elas fn thi tho MA te anton of th. Tere, om IMA apie may be de 0 low Biogen ces Pst coat oe combination a he te I at {pmo aber factor athough he dato est pitt ply more import oe determining ft las tan does ibn, LABORATORY EVALUATION ‘OF HEMOSTASIS USING ‘THE THROMBOELASTOGRAPH All ronbodtstgegh measurements ae made ot 51°C The cap and pin are mained at 37°C while the insert porn i aps a pas be prewarmed i 37°C prt we. Tis can Be cone By Flncing thes nth aun several es poe String te sy o isa nea ea thes Inet Cold cue or po wl slow the ling ection roicng isl plone valves “wotyper oe and pin sets avaible, esale seins el sts and apse pls se Te spor {hese potty an avarag now se stations ‘Se wheeclening the cp and pin i poe, Whe the sos st ar nly cxpernve ane catta ‘ein nd occsoal pling, gh abe stations they il py oe emsles na Yew mous compared tone coy dpa pas es. "Two font ae alle To ning the anda thombetoogaph asa. Whole ood (350g) con taining no anionglot canbe pied ely athe ‘neruent mal frig dae ab he cing ira ative ne ood wet, or cated Bod ‘npc ante das andthe sample ecaeied t san the pcre. Pritt bod, 10 of prewarmed Dt lactam conde pape ino aprovarod cp flowed by 250 of whale ciated blood it ‘ting Te tacing i tandem the whole hat ‘ond sal tothe ek inthe cap. Placing the Callum inthe cop fst prevents preacvaton ofthe “Aa the ins owered ate samp fogs of ‘nial ol ae plced oa he Sample suc 10 Sal cat Siang poset dying aii, whi appar ar ps, ful en me bn 50 i Bathe naive Holand ellction methods have Boon tied sucess. The aie whole bond ‘eealefon meio and requis athrombecasngrr ‘ncash action oroming he test Eber svat st be vail neath opening xm, meme cae {ii and ward the iomielstpaph est be moved ‘om stew sit te hospital. Moving he obec ogra cambesone ad line crsuning. 81 ‘tes temving the Oiled moter dampers por 0 inoving followed by relist he dampers sd Stument ofr ican Be od agin {Using the cae fion moto te tom beeline mami eatin or sk th cen laboratory for aay We we the hte! reason meh andr the ays in he cea hcl abratry allows ws ora both he thom teclsiogph and standart enaplaon procedares on thesume sample Foretanple espe car be checked for heparin contination sing tia ties the ‘spe stows evens of uapecedl long and K "ales an ow ane. inet cated samples able Toe sever har een trombocasograph assays can te stp with protamine vali te newalie Bean ‘oat chaining 2 ne sme Put of th vale of he tvombiclstopragh is sin ple tape val Inemretion, We devied 2 novel Pet fctiting eas oa eee shy (othe cance Cited ot arp ae dl ‘redo the Ibrory asin adviczd prema te ‘stem (ans tne, min) or by cores A closed Seat tlevison (CCTV) stem fuse 0 end the Imig ofthe trmboclasogrph oe ening ton ‘in rel tine Fp) A signal siting spt ed {odivec he image om th boa to the prope ‘montor Werecommond he ts of cage coup Svs (Ce) canes, Sine the cameras he me age ‘Sst, non CCD cameras ae sie oie ‘min, and OCD meat 8 thie ds pole, "the CCTV sytem hw several vagal embers fhe si ea cat se the sls sing ‘oom: (2) medi bck is vale ian instrament fal the sample canbe stp on ane ast the image sical to he appopetloeaon ) the Incase cr nis cn sant the songlton as the patent ear ee the pre ror 1 the pale Bing moved an (8) be ssn provides rea ime esate mas ambos ne op {a wih te mir pane of robocop Sed wall wiht ming te fsraent Ko cation te eatin The os of te CCTV syste fe imal par withthe expense een oe tna ie Iwelmangraph nsec At preset we an cover Terran and het owatonna yp ‘ay itunes When th ss compteOR TY Moators ooe Olez, ro exp Tae 0 Gh mets ‘Strat tboato. Chaps nerve supe sore 63) rem ie nape of hombosogrp s Katte MA. andy es ov messi andthe ess rep in the aha competr re, ‘QUALITY CONTROL AND QUALITY ASSURANCE ON ‘THE THROMBOELASTOGRAPH ‘ality con oe he tromtocastograph snp "Theft mor arablo motor stmt ‘te. This stout be done in tao ay, Fa ‘ysl tempted aoe te npe ‘Sire cole psi tbe ascent. Tes stp in {ate tangents 40 71°C alte teal deecing ‘aoe pete vaatons In in, sit! ‘omer shool be ul chek the tempera ft Inara day wk to dtc smal sions ‘npr Te nsec chal main» pes ture 7 =O 1 pon of frozen lt ca be da lly eekly Gon Thea shlhennonrachees ech instant asa sana eid spl 10 ermine contol ag, fist hc ce tht he sing te ealbration ol agus cach cha! sh ai -hamels re pcg te sue split for given cast shear modulus. Fly, the ono pls 10 {0 20 times on each canal ever 2 pia ps ‘fxcmine he eapeced ange fark ead MA ‘Once the expt onl ans have Bnei ‘shed, he pln cmt sh ber at et esky ‘neat canal rans in rte ope mye Problems wih te clea ten israel on or stunet eperare. Sl the coals my st of varable apis Between teens oF ‘amet hala tl bleed wih een Soul te ase alt he capt Its als to ert the rblem, more exemve toabeting ose. xed gunty conv saps are not cron a seine Unie Sts ualy sarance on he thbosstgrph pt nary consst af sample gui evan, vasa {us fe wed for ellacting he cate empl the Souk be at est 90% fal dhs ase he ppopine ‘Sate plas he be fot ue eas fan be pang hy exces cht. A slant of Teo bloodcante contifopedto chek for hana. ‘ten bod ide avi mols suring hen ‘odd ly inet iol staton hat nny greactatpstlt Irs ptt cc amples With mexpecey lng R values o sage Us DMA) forth presence of heparin wing obi ae say on plas fo the ial tated ame When apasin is dete @ new sample can He sen or the earn canbe cui with pine aa Tiss parclly wel ring carpumony type whe lege amoas of tern ar present. Inatptuv vl ston of coagilation sats an be aces ing ro ‘amine newaliod thambosttogrn, REFERENCES scr 18 Ste a lag Simi aay ah 7. Car ML Hema: ye md ig_SEQMVARS IN THROMBOSIS AND HEMOSTASIS VOL 21, SUPPL. 4 185 The Normal Thromboelastogram and Its Interpretation CLARA |. TRAVERSO, M.D., Ph.D., JOSEPH A. CAPRINI, M.D., FACS. ‘and JUAN |, ARCELUS, M.D., Ph.D. “Tomboelorapby CTH) x a acer st for 4 global sy of complain, wi i plays frm the fearing of ht fran ohio als fleas pal functon. TEG proves. simu ‘eso! nfrmaion, sce seo goes beyoa the tne of ont of lting to ses he overlong {ence theo To dept and beter understand he worth ‘sf domboetstogzapie ifomaton, Hare compart ‘he coualton of log oiling howe TEC does ‘te when the fomdton sone hd 6 ere Sage long tts TEC also rls the speedo the Bailing process ads wil hey oe iy song cr fay, hace, TEG measres ot giana ‘Shing sms important, gif clotng which Feotgcedoy the tne coaelon paler ‘words, TEG is mesnrement a he tine pied for Sling, that ents ofthe Forming clo and of Thetenl clot atent that the meal popes ‘se come, eet the nae aspect one ‘THE THROMBOELASTOGRAPHIC TRACING Theeelsngai infomation bid om anvninetope coded acing call he hob topram, wich fk ike agape repeseration of tra of sound open, and soot of te sone ty Groep Ga Sos (CLTE Deron Se ome Rc ra Picanto pu ua ‘tm Tr Datta ‘uf tin i hae Sn (ig (1) An ini tna segment oz of recon lato, thst. crespaedng ote aise paseo ens non, extends rom the begining of cagultion to the fomaton of the it fn sands 2) the Zone f eaglaton set tt ese cd of he Pression rone the masinal seamen of the Fo aymmetial tranches Te poressiv divergence ‘Thee ctv ines eles the frmain o h diiinxinal when the ns compltety sera. eresponds othe visible pate of eoaalon and (3) the ome ffi tart atthe ote ouglaton me itil elected byte show ye progressive pron of het ctv fn the ec as ingen the fon of he vo Paci 8 ie ‘rag ie wold nce ote ht i ‘Alok atthe ones tain provides lob srs ofthe cogusin sate, So cosa 1 Fntresig when ncings rpc or sane, ype ‘Shaul sats gerente robocop wh types of cognac” appearance ig 2). Making Fin asesnet by nena the acing kes TEG an ‘pes heen lara tol ob ested nce ‘a augcal procedures tat dang vata nit ‘ted nantring othe oping rom, sia carcac ‘sary the vestments prose “he themborlsopapi acing mates tomb tasopaic infor permanent lows ea {ng that maybe perfor hy sever eumines. AB ‘sonal theater of Sve well ened armeters make Tan jive est avallows moe ORIGINAL THROMBOELASTOGRAPHIC PARAMETERS Sige 194, eer psametr atin a ven athena eqns have been ppd Be2d the gal const tice by Hatt! the caune of thir ace we ll review al of th, sough ou uy wil be een Toemd on tse Att ae mee fe tii nd the aly of whch os eon ease "TEG measures the tne needed forte cs goer ‘in y two login parameters Rand KR which Iscalled the seston tne by tnt aut elloing Mare’ nomenclte (also alle te thombost. _apic parame of hoopla by Maral ad ix Frnchcllengue, ite dance in mallet oa. ‘he begining of the racing atthe pit whee he eave lesen pT elelted by desing line perpen ttie tw branche tthe 1mm mak (Fg) i cial ote pecan ne de ‘cred before A R provid nfo co tot eer snc yal acts song oth Insc pay and nceanes inary wih neteing the tine of lod thea tet menue of Sette when te ood I plac ate eave when ‘TEC perorme in ve whole ba it ecsey toad mo vals mesa on he tromboeat- gam. Whee TEG ie priormel in dco? bole ‘ond, a teu induced by Ray Hf com nee ha 2m be al beste ote dy batwesn ‘alton snd the sar of he TEG coding. "eal th ct formation time ost authors following Harter ermine ao name hrombocstogrpie panera robin hy Mahal tnd scents the ie Herve i liner flap Between the nd of sod te pit wich de SSsnce between he wo ranches eces 20 mm Ce 3) Thispoint was aan defined by Hae. scones Ponding to the maximal vergence elites n nc Pinel plana sds ametrement fhe i ‘fsa development tom the being ofthe ble Pane of caption oa defied evel ct sent, Te eserbes toes thrombin sctiy and Sn Comat, Iter, the faster he minimum moat of tomb is inlenced by fo I, omnes mecpition, boggen cincenaon and hems rt" RK is another panete ofa ed ch “treo, Rae nat parcafest congo ine rom boiaing to pede ‘ood cat sheath Be 3 ‘The ransereparacter maximal amplitude (MA) Seages® the aia distance a mlintrs een ‘hetwo crag beaches. To deme is parameter «asi tw ple ies ne pr branch the tne that ‘Geoughthe cigar dr: bhp os woldbe ‘med ote thromtolsozam bythe peak of maximum Valve feavhed. The perpedcula ne dan fom one ‘ranch to the tert itrets ath parle ines st {he tromboettogrphic ot of maximum vale cor ‘pnd ote MA (ig 3) A is pot be oa ately fore scoring, MA i reflection of he nal strength of the ibe oat of tbe ox ampetece ote ct formed. case oft vale inermaion oo ality of the clo, MA ie conser thems taper trenbectsopapi ance" Ieinfuceed by bot pce fucon and uae." tl sone of more Ineresing carters wo be ple in earicsrgery ud ct es, a sessed by tisinogen ant thorn conenaton, ii, Factor Xuan rao CLINICAL CORRELATION TO CHANGE IN ‘THROMBOELASTOGRAPHIC PARAMETERS ‘es re wily td pcs oped er Hare bad onthe. Awl be evewed by the flowing alsin thst of Seminar, tes ‘signal constant can Be eve inal o futher Foran, he sight qualitative plat de. fects dr the MA conta obo pena hs 1 be very mare 6 aber MA meets, ati ‘ecommory vatandae sto te Senger K, Afhaageenia genera thombosin am lractied by an tiaelypolngs With ene of the other someon Heptinadrttion ‘ated a dotges bc i the pul core On ‘Sedferiatasenows hain mnitving All he pra ters il berm hres ypeconuiy How fr MA wl be excliely intend if tee 3 fein concerns snd ple ageezation, which ae the bolic slteraion of tat ders, do one may the or two constants In anys fhe gl reading pet ad itis he bt ofthe omboeasogrptic ‘neato ody ADDITIONAL THROMBOELASTOGRAPHIC PARAMETERS. ‘all te intra betwwen the ead of Rand MA, ‘which Te named the parm of snes or te 8 sts ig 3) Tie timing ve code ae ‘ah te phase of iipogen oxguton, a ii ‘roportnal fo he concent of igen, Bosse Ende ned prt Tr los costan ‘coupon, the time taped fom the ese of the tro MA. This wold deere he tine noted {forma table lt. Astor and Sealing als pe ose a menue fm the end of Ko MA, heb Uteyeatod ic pectic conan of rapltionorcontant {These epee ave not ban seep the rane trombrclasoaraptc aay neta, he costa ct eaton of cosa, MA 4's which was ao proposed y Ler son hed! MA denotes the main! pita ff ting seer redtecined ies alr MA ie mesry 101A +950 08 10 Sa ch oe The brine tse fe dames te oe (roa ig a et ts se site see ns ets resales pot ete pe inten scrane ese Cc in ta aes Lev gsc re sectan vince tcomed pec ee aecieateagsee ape get cl orang one ten ep seaestna acarsty wey Mi sm Sr are cet onan haba se at Satin vaknwetaiel cease Py thd tne ap eng Rodi fe neni ty soca bo ‘Sets tae ten eee en ae Tan hee oe MA Pe Rio ey hc Anat Soc Niecatapeame ri nu in are ee tt nod a ‘mpeutts eral tegen Series st oes oer hate vey Pica dey omens aa nian cee lane pe ‘avul aeip ete npn pe kA ay sl ry Soran a sua ae SES oP arenas (atte pony better sy Scatntin Sta! aaa ieacs oe Noite nf come hea Seana ateactroncae tren ee Sar paar se Sn fama cll tin se Stes tng aoc a ne Memetd api tee naa Sopeteresoccied tices SSE anny ce Terre eee towne secant at pet ‘Scout evan wy epg th aie ? H 4 Wi 0.4 Nahe ioe ood and ete eat ole Bec ht tomboetsogreme fore cg) nasal coi of eats, ine, which i 8 ‘akg vale of he MA. There ees tha rovise Fw values ti can be eluted y the equation 100. MATOO~ MA. Sulstiaing NA by Ene and S by Kin the previously mentioned rato, Raby” dened ‘he dynamic expect of coagulation (he TP) the rio Emi. TPL ae been sont be well oie al of nen’ original parameter,” su soe aus have ‘porte goal ull" Some sus” hve ere ‘Sly aed TP he MAVK ra In ny case, MV is nly sed a ew center, tough od res have een reported * Shorty afer Haren, Dally Sant snd Durtoud (0955) propo index of coagulate avn litt ege te esol rmation tis see eguon et ag a-T60, where Te Is ‘ons the lp angle Pete the Wo FOOwing Tne: meine fda by polonging te il sah line of the trea tngent to one fate ofthe "rmbocastgrar tha raw fom te being of Mos aur, however, peer only tows he age. Forsch fly, which i treet malady expand, ut he second ine i gent ‘he sould of he rc instead f caving om the beming oR (Fg 3 Thea thet of ke fermaion, uncon of Reopen, ad cree wih poe Platelet ncn, is capsid a dees. Capita cals vous medi ech sigue in 197, The ew esque, called seated ‘TEG, consists af comparing two sinhanensy per Ferma trombocstgra (Fig the Gre aieole too sremblstogra and the second is pet formed innate whole ln acved with 1% xe (catonacoor et) The ros of evlosing ogee, bya dcr aa he dat bined os ba ‘ere formated as the flowing de To ur know, hes sthestisequtons etch enn fr caeting TE Sct eB fee proozed two of ter 1363, bh band on Hino a conto Kane ct Resets Wangend osc hve pape scope aan sce ey omit Seo ad Barts gen. {tno bumble pvt inoenaton 0 xno ‘St Soest, Hoctn Wang tl coager ly ‘Sis he Seon snd Sune expeson air no Le AL ARR + ABRK + ASM ASA FABRE + "ATRKC + ARMAC + ARC whee Al to AD ae soffit, ad the Clabes te Celte-etiated dmboctsogaphic prance. These Parameter are neared expe’ or ative Whole ‘ond excel fr RC. the end fic the pout at Sehch be to braces are 2 peste Tm ‘Noe thts doesnot ioe Kbutitdoes vole RFK (RK), The ier evauntes the reserve voting Deal by whatCaprn an atin ale th cli. ‘mulang pein oor wondh,by ang eae ‘he activated TED compared the ate wine blood ‘TEG esis acutely the couglaton sta, even ‘hose suton in which aration fcoeston ms ce as compared to that of Raby” The ine bas ‘eencompeensvel asaya cially apis by Cain ancteges with god ess and tow be dhoed by her are 9th af Sonar Feretample eds win shown tobe ape nr or imavenous heparan” at well as together with te selective tet, for Mryng Suri pate who may Be ot kof Beding Gr decloping dep sein thombosa" Sever thet ftir hive rzllyvopeed good oul wag tht tetmiue© stato also asd 0 Harte’ nga! parents, ‘The now eqn renin tobe eed nc nds bythe ats ADDITIONAL IMPORTANT TECHNICAL POINTS A cial ste repetng TEG inrpecttion is arf inion of noma nes by ath inborn inapprpcterangs retaken referee norton ‘ot ony maybe mie, bt ah, sd mot inno, ‘tay be eon, Te cosequnces red a fe bv Therefore, simp fren aborts ‘Desublsh er own eeaze ranges ot chek ie ‘oma anges blr intern te thom, CCosequenty, we expect every author ofthis ise 10 provide cr or lence anges, red To Bt he Spevines an uchaiga aio To stat ad mp Sz be inporance of ths mate, we have camped in ‘De | some normal anes o woes reper “Anterior regarding TEC at ‘be dration ote econo the inrmation req (Otis Graton il depron which rates ‘oe want ed. In ait oth he duran of TABLE 1. Some Examples of Norma Ranges According tothe “Thrombodastogrephe ‘mane eer Techni Ostcng time wil depend on Beth he specnen and te tc esd, For snc, one wes aie who [or mattng mre prin efor Feed canbe ain! in 15 to 20 minten =" tales’ Pern TEG in dclied whole ood te ates the ele coguton proces hes 6D 1090 owes but bypercgaaiy canbe analyed in 4S 10 mints.” The wd of ils ses 3 {Poa of recoding? The compuersed TEC gray ‘CONCLUDING REMARKS “The flowing artes is thi nue of Seminars wll nazi intertaton povided TEC inser els merging he aval etre and the tars! wn iors Thi a ang eh TEG i Teles ta dogs kaovisge of he nal a eels and howe Fea as well he eating ‘ofthe partes, ar eset ote wndestand why Senin Heme fe ean, a an BS REFERENCES ‘itn hep pens apy i i ee a one Cn Sooner sn 2 REpCi ani ee ei ee «Rika geet a ie gs “PPS «Mc Len, M Sn Le Tomei ap ten Pos ‘re at an hp to ‘ater Tosa drag a hes sn fe, CC ‘Smart ae cat oe ecm dt Se oe ie ‘ema i ence it pet oe Cs en ity aon Sp 1 Ran Mey CA Dea Sia AD Soe eet ee nt cee of Sera oi ey ‘ri, Sp OX ier Mri me Sune a ooo a ne pte de ‘Semen Sco Si hn ‘Stcctangepr ney er een, Aa, ‘mut no pn May, AD eons le ‘Scio Sans Tocmtcatpy Mea sums gens Sr tN ities :Enya Mr, Sn ba ge ‘as pense pie Chane 1 Tne irene ep at as Dimon in il snes, 24 Nato ge nce Mal ‘Shit crcap ne Go op stay, ee 1 Daun tn mun a ions Sci aahesnge nin a Pa 2 fer BY 4 ih RA heal he a on spe pce DYE el Sap). Sk Mate i 4 Gt zat le ae, he See ceseteeere Se oe eee «eri ee pe « Giipetcees can Sunes iccThromboelastography: Measuring Statistical Probabilities JOSEPH A. CAPRINI, M.D., FA.CS., JUAN |, ARCELUS, M.D., Ph.0., SOFIA GOLDSHTEYN, M.D., KEVIN N. HOFFMAN, B.A, and) ROBERT W. COATS Il, BS. he tvomboelsogph deelopedin148by Hl ‘near fom Hedtberprnces got esse ‘met of overlain. fm cl oa hone dott. fr pts sent the iy 0 tive un rl pica of hs pes pets weak ess nan malo psy cloting abnormal sich {slastor VorIX df. one aor levels lowers ‘nd anoters rst net cet onthe bor arp mas be noma fhe dec of soci: fs Spake Aganber of tesa hae sted ‘se thoawelstogaphy for pete agnor tens, whch sii to ache an coun for ‘lack of entaaen arg etna, “Thee of he mtraret es he lo ate of hemeasuremens, ch we combine wih a anda barry os, lacang platen, nog eh, Frat tie, paral thossopttin tine. Soon ‘Seen lipoduts, boner an ben ca em pln sting ie “This peach may be ell in the vation of comple ciel pblews sen as aM year pet ‘edhbowe cancer wh ads ing serge a as he folowing eratlopicabaomalie: dete in pate function dhe to atpltset theay or atnvtann I define diet lack of normal esnse of nore on bowel cancer hie maybe fre om. fat ym prepaon nc etc ich fare rece vitamin K-pn ating actor fv tls an cco congenial eet of sgl sch as a ie ro SNe ws Hop Go on Wis session hemalogie y+ tes ew susnces eine eoseam pode Ing ow rad tovnclr cogs th cle ed iris exersve inal hein, uc to previous peratons, wich may compound th ‘ceding rodtem. Tombectsograi(TEG) aaa in combination withthe oe sts may elp det he exer and ede of tea, depending on the gb Pate rein deceasd plato iting lvls raced oly hsm olwhen mule owt delet ae post ‘Anoter cla ston saseting the ose of ‘ombacttoprapy sed tiga sei aay epic The gat een o one i he tase ta Founding te grat Toe wound was pk thom ‘lasogam ani th aia! hemo fens wee pe Formed, and within 5 itn, te evolving ph ‘aes ht he psa wee face with amar ‘edicon in ptt faction ggrstated by an ase fied fel reponse. They ane ie pling for more than an har wil cme tes dee secesfuly wih dexmopresin, pale packs ang 'tmineapoi a. The puking trv and the Pave sried with one len. The eveng $Symamis of Posts nthe fly heparin pati ‘re kl a een ck ing hoo: Inpapy. Stseqeotnacags helped gad corns restate fons postoperatively and onnton wih ndard hema ese Rp ein 9 The we of dynamic ll enatlgic meas meat (TEO) dug the pera psd pons ‘bal tol i be manger of ses Nes ‘abl Tisisesecaly te then alo Fins dung a operative procedure” Neal evel a cit ding simpy and mos will develop‘nary bys att ay mpc {0°72 hour forse to ben sling a pr ste bodys heling procesn, Paes with hea ‘eats, nln scold nays, may exper ‘ce days bling seve! hou otoperatvely ae {pyrite dalton of fapmentan of thse eee Sve mb. These a the vessel reste, Noo Tow, ‘td cal aon tall tsa may nen tis pce At the ne of operon, a obing mea or Individual acd ves fen found an eps, fer wich the tot recovers unevenly. tsb Fevedaton some ces the venta wee misao dering the gal pean astaly were ot loting tet ernsned weak emote les that dle or ‘Adios fasion slfeing hs sk of bleeding i he postoperative cara ug pte inde rearing Feaxaton of vasspusm and higher lod ese Al thes acters ingress persion ba sy ws ae! ave oral TG cig ding cano- palmanary bps withthe pent fly heprnzes. The ‘amis of le emston and ion canbe me. Sure by ong heparin to he blood specinen So esalzebepartet Figs 2h grossly ao i TEG ean obied ding be tame sage ia he ‘pera nano pent hoa cele Meta $s Ths aon may ns dings comple pean Proce, partriy ope ao vera Slappa ono gt alioal ash int ome vey iia sittons One ay’ herein 8 ‘een patent nd pode scsi napa rel ponoperive dromboss ak fore patentee ‘lilly ite camer was extensive and soompi by ‘dsm metas Tit one example provi an over Temuco deer and wth trombocasogrgt ‘yt in aang be ovrl espose ten. ‘luce a pide, fg eon (R) oo ine one inde, when comping lt and ive may boson with marke byporoaeulay, Both jr ets may sei mar clea, Unt ene ccm ‘nce smitttion of ln pce mayb nase ‘Sy to coovert ements oma neal ves the Tirombncngrap ives 2 very Ayperaplle pat ‘Ga en, despite floagaton of se lating tet, ne may ot Wan pure eplacet hea nt the pte is very loin In sumac. is very comps process and on cession the hmbelsogaph ean be uit efi etn to srt out se complies. CELITE-ACTIVATED. ‘THROMBOELASTOGRAPH IDENTIFICATION OF THE ‘CLEAN SPECIMEN nds in idenifying te party of the Hood specimen ‘hand fr coaguliion aay Tie nes ative ‘thal bod homestay and begin wt ea sigue fvaies scaring te fst Soe 8 ml of Blood Such ae th sed for antes purpose. Te ood Is Cen tog thi-vall 19 ele or ees, fern clan senpanctice wh ilo ture ‘oper amount 1 plypoyene be comaning & ‘Siva cl fled sation hoe pH hasbeen “filtrate This psimen ste for standard oe ting testy and sete ig desi na empty prope ae ap placed ooo ofthe TE cps ‘ao mews. A cup specimens pled Tether TH cup, which comin 6 (ce sls to and the tes ie eg. I the spinon as Be ‘oly can andi ot cmt wi ny se jhce or focgn maa foun ay of te ting he Sing, ce the sotainrs ed to mepor the Blood, then statin of fhe oo shld sec Tas il reetin siiean diffrence betwee he apse tte pave and celieatated tinge Toe me ‘Sesinen wl at ting ler tan he estat ‘Se ad he at of long ac conulion tic IR, ang) wl be towers Speci, The fin ct seh (mann nie (MAD wll be {es inthe nave specie eomyared wth he cate tv sample, Vly sd sated, ese ier cee ae obo eases In which cntaminaton has ‘cored anya ihe stem, thi wil tbe te ‘Thenomaly by orsbot Ree offre acta {pecinan labo e eminent rpesine, ntveeneereont ee : ne parkully when advil of vayiog ale peo thetwo-syings blond daving tecngue wibout poet tring. The presence of sever ptsogesemtion, enpound situation A lag aete paral eb sane PTT) inthe intsive eae sting ay be Stott nconamined specimen preset, bt witost felt sctsted theamboeliopihy (CTE, on en ‘Gdnoue om hat of dsc seo hpi ‘Thc resent ofeach ofthese two Cndins I ery siteen I the case ofp herp ane may over heen done ned or long PTT relingfom 3 rod deaving tc in ery hyperoageole Fat, Bocuse ofthe ase hating cy Poventny require lee erin dose. The og TT "ae ppp seen ifadticeny se exits. One ‘nut be aye of pec coting ble ncloding ‘pecimen ati, thes rely il paets, ‘Stes have been dose in vlc, nicking the poor bad drawing techie and lnseing on "unimansmt theHond a reposts ae of TEC trans The are mmedely obi on pesto of (he waiogs wi he naked ee. With oy Compete ats of the ph, his determination canbe done tw even greater ecson Figs 3.4. Talon, change nthe Rime ne RK in, ‘henge wich ees tera ofthe cogaaton p= wil be sally sir eve the cele ad the tracings afer 4 poor blo ding enue, Silay he MA wl ave he eprom an oe Soll, when here comin inthe sof he a eos oi ration or eevee on he sap, eetng ese rt oft ial Hod dewing proms inubse a vated specimen for analysis This specimen whe i Ietvougt back othe latory afer te nate Hod pat nto the cop sme couse are ‘eigertio wo spate the psi fr the cl st uly possible I portant wo spin door his ‘Spe of ce we lo, sac sts noe Ino née that allowing the els wo ice With regres ay ser the PTT reset ip eve equity of te paral romboplsin Roce, a 7Syearolt woman roosting fon ipopratonssained postoperative sp en then ‘igen tht beet proces a extended. Os Fare oie’ of he sca anon cial yr, tes rend ha play era ad ben te the cle in te ung began wo disave an go mone espera toward he perl sre, proscing ta "Sent ympiome The se rs ming ae that he ve iter On tempi bore er ant st ale She had april tombs tine of 9 second as her de of beparin wafer fr 40 oS Uh ‘When ake oe patent, the fer pin id {PTT of 42 sees wh tal TEG pt wat rosondod and er eparin was creado 00 Fur bore ly, tests mere repent. (Tey wee| Je ‘THROMBOELASTOGRAPIY Cun ee aN WF pg! Clectint la Hal ae hte an ' dle slo inadvertent eg abt, ‘hich pred an PTT of 90 seconds) Theres rom the een etwas 6 rsd, i al CEG ‘pen Sace the repeal tes ad 9 normal CTEG :Bep, was eoncided that ere was fo couinion ‘tthe specien and at 6 seconds wn 3 vai et ‘ell The patent event made afl esoney. “The reagents anf the fx meade forthe Prt ‘teambopasa une were te ae in beth abr. "The rl of 90 sender he resale) we RDP Hy mma dehy 9 8 6.3, Comper twambesio gt, suggested tha spines ntamiaaion wih dae juice ‘ccd dring he boo dring essing very gh oting ofthe psa a reduc alongeraPTT The {ent wis tombe may recive an nce pu ose ules his phen cote When lovstiguing sek suit pens with stroboeastography adhe ral profilin 96, ‘we encore approxi} TODD insane, oer & pod of tine, sn whch fences fx rts ee en tetween he wo libatrc A peal was eve {mn Pec oF coND Ce 4 he ACRE eT a 8 ape pe eed Timo 2460 ie” to Noa a Ri) ne Nag? tae’ 1 Mae mi Pome 8S ae oe My) couped 1 sol an mir ape fence So ecitee tang te mmber of coer wa cd but prob would nt hve been Meni ‘Stiue CEG. ‘problem ually rie in very sick esi wich 4 polo aP ype por en eh tig eee nays aco dele dae. {ied irvmculr cogs (DIO) crater conkioes. “The THO acing I ah ana inthe vation er itl atop sites, ovine hi with mor di for amin ese compe rob tem The tmnt mt nisin eet ‘con of cine cin ardling probe bot te grag may yield clos veating te icons se nema Sts Fare Sols ind ies Sold fe dme ochtis ths pce sa ie ‘THROMBOELASTOGRAPHY AS AN ADJUNCT TO THE MANAGEMENT OF CARDIAC AND TRANSPLANT PATIENTS. ‘Te trmbacastogrph ponies gph pe sso tl pate of he over ert an Slee sacoguln and ina dup can be ‘taco. Res th process hs ben expand eratns in which be pate silly Beatie sh ‘carps hype, as describe ewer thief Semnors Heparin aed heap fam be asesed ding he pump run, Ako nis Inte. hs ecbology may pede thc who ae a Fisk orposnpetve beeing tr well allow neal poten’ cloning characteris” nie experiment involving plat-ich pla Infusion andthe maniong of hems paters dr ing and fer tyre hive been coc. The nr ‘mmedite psiopertive period se feng se ihe ees try he at ae “snap inte fit 28 48 hr or have oe ore elimina tite eve tt ceed cy, ‘ser alon on conjunction wth ongestne Best at {resi retincacesie postoperative bleeding, ape ‘hh of postopera Boman by eutang these Tass 5 ta reqeain Is a0 acess" The TE Atciaginay pode toed fined postopera the being an possible reopsation Fr sing. See Spin ciehern thin iso amoe d alyas ff TG ws in ontoring patents weeping eadac "When compared wth oa Mas, mow MAS on ‘ne THC racing ih ately aad het {abe danas Tose eflvs have ten Unk sel to vio nd sipped patel con. These ‘hanger may te oti existing eens ‘Sadng compra DIC, by fac dels sn In fates wi advanced aval sete sold with Engst eat fale. Thi rea of vegan ee ‘ing Bsns the THG can meme lal, eae. rg cripatmonsy bypass and in We presence of {al pain, Ase, kay be ole toe eagewie mesures Jung ad ae sry hat ay ‘ultinaredcedindenwof lens pee pont Ccuvly. providing a Insel undenusdig to umbst responses daring and immedi lowing xacrpralcasopalomey ypu "aie resach shoul nla eros ie in pens who ae renpeie 00 for bedi when & ea ssems conte ae pena isl ‘ion of hemosate pg. which asad in sever oars rte fan gradually dsapearing a ps ft heating press What te role fete Xn fining te net f Yen het paps Fly, ring fer ampli, slr dyer esi ‘vei ocur tare compounded he beat pase The importance of plo TEG mesures ing this ‘here compte finaly on TEG. Even a amar (i of EXCA 25010 500mg) wa foun tobe etetve ieeting mot pes of ray bough second ‘kone ay be neces when ener ling ees tbe Dla level of EACA or when an exteney high CPA level pei forpcanaed pid Early aba therapy appear tobe beet beni sink pa ‘ny sletiely destroy fread VL Thee foe cayenne of ty retaces te ned or Pander by maining eves oft facto estes oe for RBC eng leds. ‘TABLE 3, Thvomboslatopraphie Vara nd minimizes wm bohemia of the enpratver by ‘edi the agile ie. Te pope the of EACA tr ase neommended, ROWE. 1 oid “Te hain elles: was decumeed in th 1960s, sca ern fle een maou oe Ud ‘Shee rpm ad may a fo 2 hos" s “dagnosed by tree planet af ePTT, thrombin ‘ime, nd eps, bt he compason of TEs ‘a lod nd Blo weated with protamine sue i nee realest Sheng of econ ine of ood teat wih protamine nate within he Bt 10 0 1 5 Conpuation Poin Patonts WhoW-Smin Sous ‘otonss| $< nent rota. | ‘Apotninse EACA 10. 2. Twmbestegrehis pare of oa amas spel oir wt mines sgget te ned forthe er hepa by {Ge admin of pain suite (2 1030 Ties fer parmaclogic ages sch a po ‘nin and destopresi on cospaaton of patents song vr eanpanaon have bac tated. Apri, © ptt itor of plasmin ad serine pte, a ‘trepoedto oic lu fos uigcatlc srry {tal oer splat ™= pul by tb js by he decease ad improving eston and aggregation of pli" To ie thee fects of oti, TEG was pero twice in $5 pater undergoing ver tansplnaten The die st panos of lod samples nen ring eae Pat stage wee tee Sond (0.38 mL), lod testo with sim erie (NSCIKODS mL of 09% NaClin0.3}ml-o ood, and blo ete wt pet $n (125 LIU 3 min 03 mi of bl). Bla ‘ce! wih apetinn demons roknged ection tine wl alle eo fost ale compared with be in ood samples inal eases Fp Twn average ‘iene of 133 mm end T3, espocvely. Whole ‘sod ot his index wa lag ee than 93% a fe glia wan seen lod amples with pati Fe feprtion ofblondsanpies taken ater reperion “were etd plan od, Mod ted is Na lod ‘wetl with aii, bod wea ith EACA (003 IBLafIEACA in 33 mL of bond, boo! wets wih protamine (0.03 mL of 001% of protamine suite In0.35 mofo). Generalized cology wa seh in plain lod and bod ested wit NACI hi tne, indeed by 2 prolonged easton ine an decreas ‘maximum epttuce, cot fomaton rit, a we "ood elcid. sina ine wa ee thn 130 mines in 50% of patents (39.5 4.3 mina). ‘Bled red with protamine ad increased MA aad cet Feematon re bt he degre of flay was sar "ott a pin bod and lod ite with NaCl. Blood ‘ated Win BACA had iproved MA snd formation Ine od tvacys wat ot en in any cave, Blood treated with apoinn demons shiny Tonge rection tne nd ibn of ivi a cies. The rete of hs oy inde that he ni Beate stay apotinn in ito mar fo Bt Tes than ht of EACA, pony bythe nibion of {PX sci, However per tha poi itis ‘elton by ining Halla, ptt aetvator of ‘Bete XI a wall ther songtion facts ‘Desnopensn aunt, a yc anlage of eghine vasopressin cee the eves of for VI en Wilander (VWEAB). and pliner. hasbeen aodin pens undergo supe) ‘uremia th plies dstinction to pee oagultin by icrening v WE: A ay prog ‘he enditcal lu f acon VIN" Desopesin ny haven sim beet len patents wither nae nd wars a 29 tot wodegsing ler ane Plusaton” THe were performed uring pin Sod {Odom and heed went wih desmepreaa (03m ‘Sf G0010H dexoprein in 33 ml of lod) thee Times dung sugary: Dug the reanbai ae and30 minutes ter eperisin, lond teste wth desme ren showed only amortisation fae, However, a ete with cexmogrein nproved tt TES variable imektely afer operon ec insted by I and MA increated by 9 mm Pg “Tew rls detonate tht desoopresin inproves ‘od cog In vito dering ne ransplntaion oe by activin cogaaton fos ad plas PEDIATRIC LIVER TRANSPLANTATION. CCouguitin in cies endeging liver ane plantation fellows the sae couse see in de Fawever nspestive changes inthe cxgaton pl {nd TG pats of cies appear ob tex marked than the of als severe mboeypens dh so sel wih 70% of adult nls 625% ofc (cn compara wit 825% of al, and ahenai therapy at indetd in 125 of ein compared ‘ith 1% of dae, Tee dferences muy be eae by of eat and possibly bee ga function. ‘CONCLUSION ‘Thar been found oe cellar moi ing nd east of cogaaion and as been np | ea I nt | able forthe nr ampli program ofthe Unive Sty of ittugh, As Sarl ested, “Now cations Seton of sbaulon dfes anita pa oF liver taneplaaton, prety siminiting te hone tings of tiktmae proprio tat were conenon=* ‘TEC featur to Sea deecaogran which doco ate, nce rer atopic on ‘itoos, Coral spe dag ocr patoloy tan b made oly by elaborate acs with iva Inet ofcinbologit Homer te cancer finns inven acetecare stig athe yp fsa, ete level of cari ep adn pet. Sms Ly, TEC poids lian caing forget ws ing liver tania ith rie informatio: dees ‘dlr wt the potenti asec uh REFERENCES:SEMINARS IN TAONOSIS AND HEMOSTASIS—VOL. 2, SUPPL 1995 ag Leh AR MA Rt Bet Eee? get movin! tome ne es img. Ha De: eh fe Ine dee GuectngMsth7 ‘Soi Us ce Ct ar in te, ‘aime ate npc sts) chara tr cane Sed Ne et ts tn See er paar ‘tony ttt Errante Se Gath Me Mite ae ‘comet tis sce ny Tinea ote or ina SSS sre Tat ce SenTien eah mi tee skein an hese Ioan nn eae Soy 33 teem aur ag ‘Moat oe 0 Sermprann taster 190 Bo ‘PM VG Kong ft opr Tapani. An ad Prana Masport ope oy 3 ‘ater Ci ei Wont SC ora of ty ih on soon NeNeLGh APF ye in nity Ran cama ds hen thera Fey Ds Apoinin pve ng fl emon'8 Wo mesa, ¢ Bsn Sne fetmgiesin Lanes ita Soe Ak Reco Aine rT me nea te tno ‘mie hn tee se ty ane SE tin pr $e Wa Aen iso ten fe oA Kato § ape te ‘ens chsThromboelastography and Liver Transplantation BRUCE S.A. GILLIES, M.D. ver wana saat hot oe ‘pin eement ora numberof eases 0 end ae Fer dane (ESUD), Seat apeoveons over be he 10 years th mmission, oan pes on, and operative esq have improved pepe "ive morbity and moray However same pe Teme conse fo his # major impact om eucone. ‘Bleeding and massive a! ts a two of the mar fullest shes sal eas ing ‘he nsoperatie muegenent fee pce, Pasa ‘Sling factor deficeaces ar wll present dc 10 “Serhan fncion demon Ina ‘ton, hyprbrangeenia plat dation, thor ‘Spe sd ongoay Meeting may al be preset fa te pen Wi ESLD.Sugal sete, masive ns “son, oF Infequae rescence, ina chang, Finals, hypterni, and por grt faction my igen is presses couple stops. ‘Contac snd aggenive nantriag of coal ons cesar fora tmbe fess Bod compe teat fet poco ad mie reso. Coalition Ionian fie tonal approach ce. tment therapy, wich i neceuay 1 comet the apo Prt cloting sore, muninie -unesesay Transat ao ransfsio sk, Thomboelstog ‘apy (TE) whole sod vssocasic test felt fr mtn, seth, and dsc as Deca ws with ver transplncon since te ery 198 st api ad le tle method of montonng the dyramic coagulation ‘haigen acne wah proce The efcay of the TEG ara cnkall acl monitor bs Den xa lished with umber operate proces ining liver tanplntion ae aie mer proven neste ofthe ped and egth oft fain ‘overall ascsomen of th pale cagulaoa pron cascade meron Specie defences in congulaion ‘eo, Sige, othe amount of ptlet ystuncoa ‘nc nt qeantaivey measure wih TE tech of ‘hese abnormalities shows qualitve casee iste ‘romboratgram: The are rcs oft oman ‘oeloretacion or at sf reset may be obsrved ‘vik TEG. Te inal norton genera ro te TTEG te rply bine and may Beal gsi replacement tea. "Te iaveter small art of bod laced ‘na sda evvete. pisos ped in he Blood Sample Tecovete roars tas edad aed {nad angle with evra roatn of piston a ‘Setormaon ocars The rotons coats ‘vit the vce song af th ct fore ud eat {e mesurd and record taf of ine ging the tote characterise TEC ting (Pig. 1 owe parunctsresommenly ined om he TEC racing. Brtly, the econ time or va, fncoaly he Fi eration snd ead othe ty of lating ators and abt, sich x pin if reset TRe ‘alu reset he cit orton ean ere ffx lor strength The K ale coca wah Sn frocelinking. The o ale fa are ofthe speed lt formation 1 spay reed 0 fbviogen eneenraton snd ibe pelt neato. The MA “aloe reset the meximum anpltade of he TE Tring Iie rela ote alse eo surg and i {ct mew of he dys pen of plat os vin alae aly ee ltl aoe ‘mae At the TEC also wel nthe apeosi ‘finial I bionyiss present whe reed Ih he TEG a slow of pon rt. The degree of psy be untidy th lt inde CH) TO ‘nee sd rom the TG by aig te quotient the amplitde 60 nus (AD) eho MA and the MA, expressed a poee: “TRO tequen et conjrction wih seve rouine oaplaton sl eraalope ete ing Tver ‘oslo tung te paienbin (1), por1 e+ til rmbepasin ine (PF, bin tne CT. eioge evel: pil ck ad fiinogen) Feta ow produ (FDP) The rings evel provides out ely give inonaton aoa the acu place umber 1 et a meas of he ptt fn ‘ysfaetion ta rye pee intents wi er ‘hess, FDP ar fen pte a pat of aie ‘Te inormaton ined on FDP mess on lear al patos agg sugery wil show sme ‘eve levels f FDP inthe Mond ek ration ‘cur. This maybe the eas even wit even of fitimiysis The P,P an Tae tests on ated ‘eotged pln. Tes tony provid formation tout specie apt ofthe coin een Ty ae meauemens of he tie oot he orton ‘evel itd out be ipo plates non ese hie Tain theme aes obi ifston ‘om the rine soguaon poe may range ayher ‘fom 48 mister. Susana hangs In he ates cogulo stata ny have str enn the ffomaton ess wal A complete EG wil ake ‘proximately mus: wen the nel atra ton ohne onthe TEG aay be val is gross mel 1 025 mines the TEC ting senate ‘tin he eering roam Ibray is en 1 the main congo labora. The Univesity of Washington Medal Cer sesso sit ore slon tem format tie observation of fe TG tn ‘This dese elsewhere ssc The hobo letagh instruments ar ced inthe cen lane toes pearly fx quiy onl nse, Each ve tampa rom equipped nth leven mars opal of soning 0 TEG tings each in ea ie PERIOFERATIVE MONITORING Copan faction i patio with ESLD pe semi to ver nplantton vanes wih ype and sed Sante foes atm atte Se Trt Sep er" vesy of ses. Mot patos have general defers inthe coaton pie, eling nan onl hypo ‘ule sie Coneaaons of prin cog Fates ae ually ow xcept far VI niin gen wchareaten nmol coven ead Kanget = ve chanctsed he perpen casuaton sanses insevea ses of ter tampa ptt They fund tthe roatn coat ftom es poles a us ‘ly snarl wth ronson: the Pan Lin ost pants Paton with disci sates chanced ‘by hepellardestacton show he tt int rangement Patents wi pinay opis the liver ten al nel eogustan profiles Tomboy {opie hypeplenisonne ns paes ‘sR ESLD and often accompanied ptt pine "oo, idence fr pinay vio has bec sh tobe preset nb anya 1510 30 f pets” Te ‘ype repeat hungesie TEC ar sown gue 27" TEG shows the expected pongton of the ‘eat tine and he cot femora racers ‘low pti cling factors a pics. The MA is en areas, eetng eter he resem beeyipenpitlt dsfnction or bth, Ever tsplaaion has teen desetbed 8 os ing in tree mao phases (2) precpertiey a ‘moval ofthe eed ver) the apt pase 10 ‘eperison; and) ater resilaton As ated pe ‘owl te peeing cngsopthy may hese th aly worse daring th operative proce, Te dais ‘hangs in coagulation func te nalactoal Bic ing fom sical iweton, dn eet ood los and replace, Hvis nd tides se the mos common ists augmenting the cgay iy. Throating coagulation remake shen ais pin and des nochange icant nl wel ‘fr repertison. is iy wih be exception of bo {en evel an pst cont ae nce pial ‘teoe of regulation anges ecu verte come: ‘ves eons x mene by TEC, shown in Figure 3" The marked changes othe TEC eto the mule polgie changes shale med. Te eet ofthe pressing naples dsebed bo heite ina pase of neplaition is hed by seis, oun replacement on xs th oeglopathy wih onal cages in soagalstn fc: an pls ets This mses ne TEC a a rte olga ho reacton tee oct femaon an detente (FFP) lacks an erepresitate bed specie TEG cera hs ben shown 0 Be fl nnn ' TEG wich ahstorcal coil group in which factor and ‘raolation test snd cla judgment” Alo te sty sof fen he coe of hata oes TO pp ed yer of ama Espn ine a. Ae of he a as experience and venovencus bypass probably cot ted to impovad besos and ecto a led Ins, Veonenes bypass ei econ i lod las by decompression ofthe ol venous eye osu cal below he camping of tebe University of Washington Medical Ceter between Jan sy 991 snd Deseer1992concenng eed prot "zation ae sown in Tal, Blo ros pace meat ep a sooulton management were pide rial by TE ingen level and ptt Sout ye "eser een emetone‘Over mean fe el al oop ination ws onset withthe THG-nared soap inte Kang Sta? sy The redsto np ua Hor 19901 1992 probably els or concern ft ropes to hypercnguiiy and pose pa trombon, whch cones in he popes pr ‘Aethe ibinly may be ch a & mabe a sets Activators of plainogen sich sta psi ge attr ('PA) may be presenta afte Injury bedi. FDP relator ach protein ‘may alo enti to vis. Wh ate de ‘ion ad olan ofthe dns iver dag epic lernce of aetna may rele Circling levee of Tnhbes of plasminogen soc are anpasmin a ‘ray redaet Te insider and na ce of aivatorso inhboef oaglaton td mee atic anges inating costal oscar pean rec and anhepaie pss resis inthe socal ‘xplosive ints. ae shown i the TEG ties in eure 3 The popeny to iin mnie set marked roducon inthe CLL A tbe of sie, ito ter anspnmavon and cade sugecy have Inoked aire panmeoli pm tet is nels using THO as mene of reaps" Pe Sties with TEG, heapy was empl ant therapete pins were undefined. Bath eaniocapie sit {ACA and aptnn hve been wel wath comers Success an er teeplntion® No al il bath ‘heaples show a sigan reaction in the dee of ‘bsnlys bt they sso fad considera impt on the eae of eng inthe post eeeston pase ‘Became he use famine wget could pro ‘ets of conte clea ay ‘Asian hte seal fotereronion ‘th compat petal eto Ri bats ue to harmo ances owed Ie the as, Df the new er: een severe Ryall if reser ype, Bld ons maybe comer st isp an nal eet may Be sapenmposed Sete age snus of a eee ferent Freguen TE re bind with cach ape tr ‘ation ome umes tani sto dee od Product Uieation prope wansason therapy. Bat Gr! sd Kane {a0 hive shown that oer cose fon a ‘Boole ex hen pone st spony 301045 mites long eperosin Lovet psn engoltion facts the toed begin toe cee et factor Vand VI comesponding to recovery ofsythete fanstion othe gafe er TEC varies exon ine (Ba, MA and Adal show conical inners Pecans may haves mated eet th TEG real TEC vecorgs with sveetrombosytpeni and ‘ce tasfskn with 10 U of plat ae sown in Figae In the prose of sigan ondary esi cto hypanplnian,howeve ile Deve scived ah conto plate sts. Inisease, ws with FFP oer may manifest mote ofa eet on he TEC te sere ‘tarconl rise sling, ts tly once ‘ay to rane ore than 6 40 #U of lah in he ‘tecltin pe ‘Comin! ipeovement i coalition fenton ve cars wth cere of brea cts wih poe tment inthe fncton of te ae Wasa eI rovement in th roving coun ws bei ocr Sib postcireaaion pane but may fem sigs. any Sino As he cegultion profess to Tetum onomal be TEC my beast dsicgusbing eoween susan eagubpie cues of ein. lore vation ‘Aes waren of ‘tc 200008 0. « ‘Thromboronape ats bare tae ‘oo a ate Wap omenyo Inte absence of significant uae abaemalies in ‘he TEG uacng a sre ease f tei soul preset ‘Nc ics presen fr ner ansplanstion ave mor durangemens cout fncon. A siren epee with pte nary have ruber of deus may presen within anes or ‘tor nmal anton act. thee te sever ess, ‘Bda.Cha sy and patents with pear pte ello tamaes, for exam who may pest with Iypereoogulabe pote ypercoagulaity can Peet ‘tet esing TG. Shr seston tines, fot spe of ‘Sttornation, and ard ieee MA ahalinarks ty ineteive in making he diagnosis TEG may be set if tose patents require anol therapy ‘er splat” pathy cual deo mada rf tn. Types TEG ass un one csguaion ess show defi ‘sin poten oaglton factors nd thombeyopen, epicenter ls ber af vests tae awa ht a propensity ‘hypetcoaguade sate may occu lathe pte Fev"? Thrombosis pti rei aston fall Coninaas monitoring ofthe TEG may ep 0 he dagnosis and prevention of his complication ‘SUMMARY “EG payedan ipa pant inthe root ver apa Te En ate ney of transplan would be th sever anya Ec rise of the operation pers to hae bt pedicle fod anexpces shane in lot dy. Te re tos and aval procongulns elec ial roe the podocton of asl cl. The TEG isa unigle gos testo eet ste perfects tothe tangs doing tre tampon, The inl powering werk ig line wanspataton ha inp he work of eis ‘ea uc eso explore iy. Thee ial ‘Sout hat ts al wily fas ot et be ee Many ‘eons i remain wih ear olive canara, New mesicatos ach apetinin wl be apt is roc overheat fw yeas Wht fet tse new "aan wil neon etorage ce hobie o ‘asclar anastomoses yet to Be adoeselyexplere ‘New evaeness apps be vag ta tml ‘acesively byprcaglable str cold ont Stch hombres, TEC astrology wil cerily nto a ume fat sts cl ae ‘hich wil ena he cond tne rspanton ine fe REFERENCES ‘Miers anesthe: ae on fe ie Pec Soa cit mete apn "tinge narnia ‘Aion pansy sy (it ‘ee senor: Rny Se Metco eet An Kan AM De Wl, § Ag Come LR Mai Stas cn most Sg montana onApplication of Thromboelastography in Other Medical and Surgical States CLARA |. TRAVERSO, M.D., Ph.D., JOSEPH A. CAPRINI, M.D., FACS., ‘and JUAN |. ARCELUS, M.D., Ph.D. Since uombosatogrphy CTE) kas bee pli othe sly of numer il, fe nt fene ease al teach partici sn vim ‘Aces. thal ville te ae of TEC instnyig thn linea sats tha a ned In MALIGNANCIES ‘Thetis wo doubt regain the roe of TE in decingnewaned coapslbiliy wBihs consid he ‘now impseane aang of ts sym” Based ‘on this chats, TEG haw oon Wen elie in onto hati: coud be follows peeve Ditty ore wie ypercosgubiy ayes Pa ents wit lignans conte sich stato, ad socancer is oe thecnter of une dere tic tice. ‘We pied tht TG is able oa nly ety ‘navi witha ought aaa ‘timate ween nora Realty poplions anes ‘nih prota maigeancs Use the ele acted Ahrmboclisogrphic csc inoue by which ‘Sines sae whole tae! TEG ond cect’ TEG, 181 somal persons on a9 meson were cos pared to 21 camer patents, Ress were eee Showing 310% spe ani 7% senvy of TE. Ins paral experonal say, we he ound EG to et ion tA ante re se he tap We shige te ‘nt npane beta Dstt Raina “tat tag ota a Soe reflect quately the presence of crsinama Analy Ingctidond cancer Hatha ny bad previa ‘spond nt cele copula, dete by ‘TEG, was mere offen son Into asin Which the isa Was demic, awl st ele tah Tanah stdy we compare th findings of He hayay an ays ih sul found by Raby ad Pepe, ‘ho vsed decid whole and ative whe ord espace ore ocstogaphe ‘ation mela cogalbilty the ae to pet laos, hey sais ee cans pes rom tt comparison as conse tthe fee "rmbcclaogapic pruners proposed by the te Sept poups vetoes the ae lo Inge proces were seo essen can lain ahigh erento easy. Never ties, celieaeivated TEG prvi nore wef mation tan i ave Whe blood TEG ines, ‘Using cet scat TEG, ht wing elif whe boo instal of mative whole Das Aznar and ae ts ste 18 pets ith pon gyeslogc ale ranses. They pond TEG Tobe tl el fo Finina pei veo ye ca sing UalocantlyhisRid of schedule soc wi ‘ouside vata i lasna tomboltc nti. Nevertheless ely til nde fed doe sched tes werefacve nin he it 197 tee tre pproved by he Fd sod rg Air for "he eect of dep via rombons and ulna em tele Alsi it 197s newer echiqas were deve: oper lcllyaninirng ombolcugent wich ve reed ie moral abs in ae ect 2g of weted pans" Thi echoes Been no nests eperasn i 6 10 80% of moos Infrtion poten, lean to improved care fone fin" However thi pe of wean was salle (© only small peceage of ocd pate. Thi tin sla iret on he one a, ow Anos Prt ee, Coit 10 ho Mee Pe, 38 Fe ee Sah a oY At a Inthe use of totem, hoe intavenows SK tet Spy ano he er his for th we of mare specie {lle ape Haan se pani ‘pen actor (UPA) was ist old fom mana ‘lls. Is bn ses sno pode by mecrbiant DNA tensor hs on shown avery eflecte agent for ten coonry tebe tna varity of clin le cred ot ding the pet few year However, lage quanti of thi deg a= rege, wd tis extealy expensive An aye pl: fnopen SK complex (APSAC) hs ao ben repre, Sencha spec ané hasbeen evaluated In aniaals an peas Wi, to, i very expense (ts crvatves of SK have Den prepre, sch te Bech SK compos ad the unpsingen SK co pion, br ty te not ben lilly eased. How ‘er thy have boo exeniey carte och tally have Ben shown ob effstve i proce In ro lt ead have been eve osm lo sss” Tei popes ave ent boot ‘evewodcrtemively™A po UK, which sasinglecha frocusc of UK has also re sated" pe ‘ie ough hein pei fem hat 9 {EPA Rha been shown toe flectve cially ‘Aldus efocive ibs pecentage of pate sit of dese gs fall acieveroertoionin ast 20% of patented a ely aetna occ a {0 29% of er, Par of he essanon pole sds {oe me tha plas play, he mrp Fenres ‘tie irs. the shor a of amboltic agen, indie rombogens pope of te roms sueace iors trol ocean have al combined et ‘es ilrng aap pale ass pi, ‘us, The main sik in sing tes coined tga. isthe wl rein easel eeding Ts a the more reason for devsloping metodsogy chat wl, ‘Selo te pte’ bose ye oh Before4 SEMINARS IN THROMBOSIS AND HEWOSTASIS-VOL 21, SUPPL 4, 1998 ugg weaent 15 a0 ingot hve em tatean used compare dle habs age There ave ees very few pune sis, oth i nnn ito n whch det emparons fhe vac teva ate Boe mae ' Sse tat a Bsn in xine for more tha 40 year was we moe thin IS yer ago to Serine ant: SKevesin tortoises ell so mor tients andergong Movi rennet * Tat mato Itvomboetatgraphy and hgh ts hele et ge seen aselmostexcosely tometer pat "eof ual, amy wer ut youre i 1986 sng ths tsuneo mete pnts of Mili We toand tht trembocstogy ne ‘ol conde set quantita emp: platings ‘vas, but could hs be aed odie te ane {wilt conte! of whole bor ne ui ad securely thn eter mets now sing a. THROMBOELASTOGRAPHY Four su, load was dawn bythe twostinge ‘ecg om pet nn wee canister om Tetley a rm abr prnen ith ot ‘nal congulsten-ibso tie pat. Thombs "epapywasinine witha 6 ites ering te biood ar prepara oa was andcogaied wih 1 At sodium ean the plas was removed !Merceniugatonst 128 ro Owns ad sre A070. For paletsch plasma (PRP). he sample as cenitged an TBC cemtae a 900 er 10 ‘mins arom eect. Foe pet rps, ‘he sample was cntfoped na Soll RCS sen S000 pn for 10 ses tC 1 te violet act, he slated ‘ample inte tombe svete wl je nd the two recoded ymnetialbsares et ematy revaln afr ll weedeat ts gh ne The rameters alin be ane eh asim ang {ode inioum mpi, erent ss an ss me By adding aq of pssaopen attr, sack a SK. Bein SK comple, and pan SK compl 0 ‘enh covet consiningfeshly dawn blood We wer thle mesure the dere of ysis poded by each ‘qamly of vat By metering the ample it ferent tine pers aftr the alto of each acta, ve ere abet tt ceuray the evel of ah SK ety foe SK acta, andthe lvl ini) ety of he bagi em presen ech ape This thonbocasgrpty metho Was wed Wo compe SK. Bein SK compe, ptmin SK cole, min Plasminogen SK compe kine, and PA. Ais Were cared ut using ole blood, pooled mal pasa PNP), and PRP ure 12 eombecastsapic pate showing the prunes of conuaton nd alas Te ea ote shen rh sat fe pater sn ampliue of 2mm i weld and ea meee of the Coting tine. The iseumen dese so that 2 iim segtaeat fue: Thema isthe asa Simple (MA) stained (fet lt the min Ashe Inia ample or poi of ys Cagguaton aca Un th MA's each nino cere er he MA ireache ular pe sacred Sie the bili system acted ering the stgulton phase (pecaly when asta abled). the fos {ime Is eld from th etn of eeu to the min A. The pce! can beac ay interval between MA aah min A, by the fom T0086 ~ in ANA, ACTIVATOR ACTIVITIES OF PLASMINOGEN ACTIVATORS Te plasminogen ator att of ac ctor reprtion vod was dered in analy ay ting Gi plsminogn athe saharte” Asana ‘ive was determi wings stand cnc SK ep faton (Kain) wth tata 0f 100000 Ha [All actor aio of Sk deatives were expec ‘lave tothe SK sand. “tinsiyeperamatars Trp scene sete sree oa ean Sirs ese mae tena mn mg enue nineFF “TABLE 1. Plasminogen Actvetor Active of Sx Activators Determined y's Cosine Aen in pid Et fon [eames Gates Ra Forcomparnive purposes lf te aioe wor saved atin gate mab! wing bovine ings (Pemen bovine trombin (Pees), and aman LYS. asmiogce Kai) a acopsnesion of 2210 per pie "The specie ity pr liga of poten ee sett priliter of satiate eso inTbl 1 The datermised specie aves of th psn SK Compl th min amine SK campo the ha-SK complex were 32300 IU pein, $4.00, [Wimg proein, an 65000 ing rot spot ‘The atiy ofthe lnc wokins peprstion as Acermined 9 be 3760001 pe ia wich we 0 experinetleor of ie ane SKM athe Ine Sins of 100.000 fit of tse ve ater were repre os sock sluts and ware std at 10°C at bis coneataion. The acivity of he CPA pepuaon was determined in is say ster tobe 86 TUL and Is prepratom stores 70a seoncenaon ‘whic accounts To th ow acti of th pain, ‘ice nas boen shown naan contra fs ‘THROMBOELASTOGRAPHIC. COMPARISON OF PLASMINOGEN ACTIVATORS USING WHOLE BLOOD ere prepare in 4 23% glyeeolOU8 AE Ts ble oto ye soltns of 100, 80, 600, 00, 200 130, 109,50, 25,125, and6.2 Un. Ai pinay oly ‘rete prepued ad ese. Al actor ditions ere Soced we 17C and thawed ine bree, For 8 ‘peste arly, 30 lof each stator slain was sd 0330 lf whole lo sing #50 pL syrngs The tvoabecastgraph pin was moved wad down 1 eso esas complete mixing andthe Sere ys ‘vt he messed neck sample The pater sho [i Bgue 2 nda he diteert tonboslng ie ‘exposes cbuned when ncreng ans of SK wer ‘i 0 whole loo “The pers in positon the norm patem mes cng congultion snd cotined no SK. Potions 23, ‘Sd 6 comand SK abgot at 125, 2,50, 100 ‘150 yn Te conten cotespnd 1.0 6 125 1U of SKinL of bled. Colao flowed by ‘loci cure in pters 2,34, an, wes the ay 1G.2_ Tomaodlromaghieana of hoe bool dot Utotskintatsioain 68 Smt oond wore raed ‘Sgomupaanainan ier aesight tin in pate 6 indicted compete inion of Coaguion, The MA in parm 2 ia at pater I bu Iss ogi aer eI eed. Pat tee 3,4 and Sw thts slr MA te enced Tolowedhy shonerand shorelines with aes Preanieary experiments wer canis 0M sig any ile stv ons so hath pina one ‘ul be compar. Tes epimers were cael oat {ng re loo dn rm pats sched fo we dg dmb rap. With ac of tee pets, ‘SKC vas always evatased at conto, none eer ‘ivan wus analyz an comma fo SK Wi his ‘metho and ese patents we Wete ale deurine early the level of ani-SK any, fn SK tes ane), th amouat of erly ae, he tinal oe of setter ope i io et ane Propet betvatort be sed in tenn ute However snc the an SK andy tr showed sme dep vt ‘oa ins eoup of pices one aber employee than argo vel fat SK aby (75,00 a 5K on) wat est eu doors tt a seta cold te compar oe od sample “As ee in Fp 2 by ing MA messes varios tie nr cla the peer ys feo ria could be elelt the time for plete ss old be determined wah each concn {hon of sear However, hve determinations dl ot [wove w bea cert for clealting the hbo oa {Eno whoe Hooda sng he owen coment of Stator pred cpl ibiton coagulation (gh temtocasigapie pater), Muti, tte us of atiaor pe miler of lod tes the ood vome ofa pate pce! he inhibitor cont we blood. The srs pater tne wih cach eaminogen ata appends be very laren ‘wiht A. Wh PA, presng suns rode et Sanatie change in the MA nd Is tan da hr betas, but eompleeibiton of soe venta obtained This was ntsc, the gue gly of -PA is that PA is a expected rolac eines an neo bation of cogulaton was obtained with 73 TU of CPA pet litera eto "Tie shows thingie dts plasmin 1 scttor ening themboslsogigtic ays on ‘hol to rm ene nie The mt fa at “ato fund waste B-SK comple Tw or mes ‘iin as SK egg oly one Kurs as many eis [5 5K to prevent completely fomation a alts be Sronbochstopant cap In thi lod amps, te at BS iter was 18600 cospaed with 75000 fr SK The min pasmingen SK comps was alot fice the BSK complex an Ue tines re efi ha SK. The plasmin SK complex wisely slighly re lien un SK and waste ine es efit tam B-SK tPA wat 1.73 dine afi a SK bl wa les than hal fie B-SK. Thea Patino ye ter of whole ond mas 43,401 compare with 7840 ant-SK itty wns, The pore alate vas UX Tae at UC iat te a 3,00 {hd i omy ne forth ay lice SK a nly ‘neste a lista BS. Tet se ave fMfciencie were detemined on may bod spe titer cach activator was compord nay eat ‘THROMBOELASTOGRAPHIC DETERMINATION OF ANTI-FBRINOLYTIC. INHIBITORY ACTIVITY OF WHOLE BLOOD Neat lions conan an Kies 4 wel ssxatualy cctrgplasmininibitor od plasminogen Ips preset eng sedto dni ioe {Ercones™” We td the tomboy meiod {© dacrmine the atinny cota fb in 28 ets who were cand for rombnye terp. Since the trombochistograpkdplned sori tout ofthe ampli, vas ot wees to wai i the ales wax complet which woul ba eed pproxmatly ? hour. Renin of re pad we ‘dtemined every 3a, and veal was ale 1s othe prope dose of setatr ane wich parle stvtor tous within 20 miner ne od ‘asda, Shown in Tbe ar th vice eal for the ampitade oes patent's lo ample comparing SK. tnd UK. ‘Wi his ate and SK sed a 4.2 1. of Nod he ages ample ws eed at 29 mts felowed by pra ys a 30 mien With $4 Tin. (fSK, ss bean at 15 mints and wa cope by 25 mines Compe eto of latin oced with 168 TU of SK. Wat the same patie 1681 ‘nl of UK proce no disemible Has Wik 0 1 ‘nL of UK, armch smaee MA was ecb ftowed typist 20 mine, bat ven wi 67TUL comple Inhibition coagulation was taut raced However, i ts ech a joer cold made wan 15 ‘nines aniohow mich SK orUK seared {nd which homely agent old he hos Using his thrombesstgrah metas, we deter inc tn an iby yn 2 pans a ‘hea UX nso sei pukstesveguety ‘eed with tomboy tery. Tale 4st he alt ener by tebocttgranhis amyl hse po Fl“TABLE 2, lative Elnces of Sx Plasminogen Activators Using “Tombodtestoganhy and Whee Blood apne 8 ateleni iae 33 TABLE 2. Comparison of Trombedastoraphy Ampitudos on Whole Bod wih Srepioknace TABLE 4 ThromboslastographieTraton of Stoptouiners and Urotnee ahibor Levels of Ibo Blood in Trombolte Therapy Patents 127000 ="5p00 W of SK aa he range wa 40.000 1 340.001. The avenge ant-UK laity acy te $2900) + 108,000 a the rings an 17000 T0000, "wen to he 28 patent ad rye low 270010 of SK, whereas noe of he U4 pets teed Mad te below 2100001 of UK “A sana Sk resance clot i wa sso wed to deems te an SK intr sty in several Potent sig pe sy, tons of aca (rer deo plas, na iogepasminngen Tee was dtd wit ombin it te ator ce. porated mothe el Although his any was oly ua Ive and volvedexrooltin to zr ie, he acl Soe dtr for SK ve ptt sed as i Taro tat dcermined aiag th tonbelsogapic anal ‘THROMBOELASTOGRAPHIC COMPARISONS OF PLASMINOGEN ‘ACTIVATORS USING PLASMA PNP fom oo of 20 doer an invite plasma samples were asyaed fran Ie atibody Hes and ‘tint sey 50 Ha comparisons Betwecs ‘us ad whole aod cool be me Coing tines ‘ith pusma thot were comparable to those who ‘ond were aie by ang 285 uf pasa othe ‘trombosatopapic cp lowe by 30 pf cv teand 4p of 04S caliumcloe, fv aetivaor tas to Be tad 30 of 04 M pope Bale. pH “Tones igure shows mbt is ates th SK aed to whole lod, PNP and PRP From ane ie "ine snow gic’ coxgulaon difrnce ob served aut ool reser MA of le Bod in fared o PRE The slr ample of PNP oul not emcee y inking ouglation ih higher cleum ence or sing womb. Fes plasma showed“ SEMINARS IN THROMBOSIS AND HEMOSTASIS—VOL. 2, SUP 4,195 att ae i mgr MA ta rove nd tae plasm. PRP was ‘undo haveapeterMA than wholblo, The ple ‘nt fe PRP was ound to be 1.73 ties the amet ft plats in whole Boo. The pet ext PNP ‘tu dermis to be 300 Since esto foe ator conicng othe MA, dhe ester amps: ‘shered may Bed tis plist Teton. By a6 Ale Bods he MA ws duced foe ta at of PRP but was sil ound be per an whole Bod. The most sine difeence In bsnl acen mae ond PRP, PNP a het le blood. The an SK anibody er was found {e approcimtely 10.00 SKC uns for PRP ad PNP mpd with 75,100 unis or oe ows Ti ight PNP was wie and eomgared o whole loo. The os cxpessing tela eficences of dle aca. ‘ere same repress of wher PNPor whole Bod ‘COMPARISON OF PLASHINOGEN ‘ACTIVATORS USING THE FIBRIN PLATE ASSAY ‘compare hse plasminogen aan. The dee ee of ysis was stint ater 18 hous by squaring the ‘tere ado Shenae SK war ned the ard ejraon. The sae aun of naan wns of ‘ach svaor was aay using the ates ofeach Scat sown in ier on oro Tae 3, Ths, the designate ternal uns pr ial wax we or ‘is of plasmia-SK, miniplasminogen SK, and B SK were ‘od prepare ck sins rm whch ares Ge ‘ons were pepe. The slope of te poof th aca of ‘ch trator and te al othe soper neers ‘Thereof te li pate nay were completly ier om ress singombselstgape a Iyrs antes. Inthe cn plate say, UK wae the most Shen as SK. The plasm SK complex was sims "ficiency to Sk, wheres the mnplsingen SK co let SK compen and CPA were al equal and Mfc ss UK. Therese between SK ad pl tnt. al B'SK and misplsninogon SK wore Si Tarn both assays bowever, he dfetence betteen UK fd SK in the two aay sowed early 140d concLusions Athoogh hromboltiherapy haben a ort Faia eed fo ee elective hme get tat ‘il achive tomb fanaa in ihe cet te af pes, Yor beter schol of adminstaten, a fer beter mets of eating new agents analyses was it itoduedis 1951 Tae oboe ‘raph messes he yumi ie woe od Eeerution teaming wih he ad st whe sol Eloi med a prvi sip pesentin of the roves of ct reaction and asi We toed Trombncasogrpy wo compare de ficcy of varios nsmiogen cringing whale alts {hu pls co ad in dtermining the atti Ino activity of whol ne We found that the B SK compl an he miiplsminogn Sk complex were he mow efile activators wre hey ed ‘tre ts to four times more ect han SK. The pissin SK eoplex a erty the same eficieny a SKK and miniplawnnngenSK wee ea ie 7 |7 “TABLE 5, Relative Etileno of Six Plasminogen Activator Using the vin Plate Aso EO Fam Mpa BE sient as UK, The dfn we obterved wing whole ‘ond ay be dep oe deren catceien sie of each aiaor and pay to he fleeces im Senses oe ut-SK abd. The le asm Inhibitors was aati by comparing the vn topic rele wih he on pte any. Sie the ‘inp asy aso itr component I cannet te comdced st releton of homie ees Tithe abe of inbiors UK war fond oe marly {Stine fiat ae B SK and UPA, and 34 es ‘ey fests have bea pore comparing SK rts devas wh CPA and the vin pate 59 ‘here fa ma of! asabo by thromol [pic stale ng wae Bled, wea foued 3p roimssy he same vate. B SK al miilsine omSK were 17 10 23 tines mow effet than CP, Stee UPA was igh more efieat dn SK and even tines mor ffi han UK-One eiceney i ‘he tombrlasoarapic method aia sac and ‘Sele system ad docs not ea fb spotty ‘ceequenly, pseu CPA may be mor ef ‘Set eave SK ifapothe system Were ted mes Se hte two agent Progresive ching inthe pater of nays ‘canbe mons ty hr a inseaing coer trons of actor ae aod to whole bod before ‘eo Many pametr lating to Pinoys cn be eer rom ee says We se hs roel topnphc method t rete 28 pets who were sub only este with ool erp se po ‘ety aa nto ofthe SK or UK dons determin bye methd in call ce proce ery hah systemic Mio spo “The hrombeelatopraghic aoa method works vith PNP aswel swith fle Mo, Using PNP the Comparative elicenis of tes avalos wee the Same a wih whole tho, ad is was We fr both Fresh ad tozen PNP- Hower, ferences were eed ‘cen PNP an lo both in tes of MA sitessces fn th ate of iis Bl as a approxi twofold greater ample han PNP where PRP has ‘even prea ample han blood. Tis pebsbly de othe ht ttn proce y the ptt Wah The sane consiaton of cit, we found ha a plete ns ook appeal wie ng with PNP [with whole Bo. Tie wo indict th rl cls uy play ce enol by eenng face at {id te ye post Howe there cl fle my ly be one of bing he Forman of» ae in Slob being pein the Sk snd twee. ote ‘rplanton may be at tte wi eter coke of {nto PNP th we No, since the smo f PNP tee conti more pla tan was pret the wl od sample. ‘Someuhat dif! results were observed cag tie uombeclasgrapc saan ung tPA. AIOE "ous compan of CPA pred spt ‘em sila o SK, the ae ot wich yn cued wa ower with 94, Sine PA fe specie sc {sams hat ome vin ato fr sore PANG ‘cate psbminogan hs might account To this layed ys However, wih increasing amounts of FPA, we cd ‘each a ot of omg inition of costo ins ‘tng semi atvton of pasingen td bn ‘Epon This occned sect how ain Igo ter f 4 SO01U, Wid spat sti of 100.00 ‘mg ts would inst coccnraton of 0. 1 0.2 Ineo! PAIL of od won proce pte Ve making PA only ites eicot in proc However ste ese of CPA i pot a ey 0 cca fo a in vio syste a in 0S, act the at at er eft reatng in ‘ood specter PA and ete ae rece. ses in ‘he lverta ply move PA." Roth hese tor: Feiptoascust orth extremely short al Meo fae‘This study shows at the thombochstographic meth can poi insight noe vio} sty diferent scar and sppments the knowlege hind hy otha aay made Clini ae of re {ed atvair dove my fr resuce Dlingcom plcaons whe providing legis tobi fers. “Ts metnod would all pid niin of get tnd sae foreach patina ea Petro fol tan svg al patents thee done he sre ‘trator ean pte ap weg se ed oer Chara. Tis meth lo apes be sel tessch oo oligo tenn with known ‘re trombone REFERENCES, ‘sping apn ys Ase a ps ‘steep eh tec este AN Ata Str. Gone, anne ‘cei oe ba «6 facpn ne Sa Grp Sin Tate [Ae ha eae Sern nae | ase ti stn i a a fn Lan inte eae ie ona AO ek Oc enh er 10 San § My alo pi he Ge A Fini Te G8 Sn ‘Sessa weno onde Cena 3350 Mua up at R) Shor My ‘Shit neta emia ‘the enh oa 6 enero ae ae eee tener: a eo lies ‘intowm wn teoone Snir ato Stee Heiacnen ote Maso 2 eR ce meme matic | 2 eavene Cece ean es eee Eas Se rcornancecer ai Sennen muecenrndentemae maeors earner oie Sees Se Sao726 AND HBRINOLYTIC AGENTS Sousa coma) nbc Try Ga Sn, New ‘meee at Sp hh fess St a wr Sora) Sane Yn Pgh 1A Cag vi ‘Serene sa of pone a ‘Seca ci em rn of ale ‘etter mse i ps anit smn ii ie ar dente kes ma a Ct ‘Stee eg ahd a one een en ‘iu oi mpi ew mpc ho ‘Sisco ry nr van rene Ste fete a oa isa Mio fn wpe ese Sete ms sc a ite tcp an