Thromboelastogram (TEG)

Chris Nickson ● Nov 3, 2020

HOME CCC INVEST IGAT IONS

Reviewed and revised by Hamish Lala and Chris Nickson

OVERVIEW

Thromboelastography (TEG) is a viscoelastic hemostatic assay that measures the

global viscoelastic properties of whole blood clot formation under low shear stress

TEG shows the interaction of platelets with the coagulation cascade (aggregation,
clot strengthening, fibrin cross-linking and fibrinolysis)
does not necessarily correlate with blood tests such as INR, APTT and platelet
count (which are often poorer predictors of bleeding and thrombosis)
This page describes TEG® predominantly, ROTEM® is the alternative viscoelastic
hemostatic assay that is widely available commercially

METHOD

TEG® measures the physical properties of the clot in whole blood via a pin
suspended in a cup (heated to 37C) from a torsion wire connected with a
mechanical-electrical transducer
The elasticity and strength of the developing clot changes the rotation of the pin,
which is converted into electrical signals that a computer uses to create graphical
and numerical output
point of care test (quick, takes around 30min)
can be repeated easily and compared and contrasted
requires calibration 2-3 times daily
 should be performed by trained personnel
susceptible to technical variations
kaolin and more recently kaolin + tissue factor (TF) (RapidTEG®) are used as
activators, NATEM (TEG® using native whole blood) is slower
other tests are available including functional fibrinogen, a measure of fibrin-based
clot function, and Multiplate which evaluates platelet function

TEG6s (Haemonetics)

This newer machine no longer uses the ‘pin-in-cup’ technique (as did its TEG5000
predecessor)
It uses ‘resonance’ where blood is exposed to a fixed vibration frequency range and
the detector measures the vertical motion of blood meniscus under LED
illumination and transforms that movement into tracing of clot dynamics
With pre-prepared cartridges, there is no longer any pipetting required!

USE

Indications

prediction of need for transfusion (maximum amplitude (MA) is a useful predictor

in trauma)
 guide transfusion strategy

Studies show cost-effectiveness and reduction in blood products in:

liver transplantation
cardiac surgery

Maybe useful in:

trauma (reduction in blood product use and mortality in cohort studies)

obstetrics (some data to show that it may decrease transfusion rates; this is
controversial)
early detection of dilutional coagulopathy

Hard to interpret in certain situations:

low molecular weight heparin (LMWH)

aspirin
post cardiac bypass

fibrinolysis
hypercoagulability

NORMAL TEG
Specific parameters represent the 3 phases of the cell-based model of
haemostasis: initiation, amplification, and propagation

R value = reaction time (s)

time of latency from start of test to initial fibrin formation (amplitude of 2mm)
initiation phase
dependent on clotting factors
K = kinetics (s)
time taken to achieve a certain level of clot strength (amplitude of 20mm)
amplification phase
dependent on fibrinogen
alpha = angle (slope of line between R and K)
measures the speed at which fibrin build up and cross-linking takes place, hence
assesses the rate of clot formation
“thrombin burst” / propagation phase
dependent on fibrinogen
TMA = time to maximum amplitude(s)
MA = maximum amplitude (mm)
represents the ultimate strength of the fibrin clot; i.e. overall stability of the clot

dependent on platelets (80%) and fibrin (20%) interacting via GPIIb/IIIa

A30 or LY30 = amplitude at 30 minutes
percentage decrease in amplitude at 30 minutes post-MA
fibrinolysis phase
CLT = clot lysis time (s)

Approximate normal values (kaolin activated TEG, values differ if native blood used,
and between types of assay)

R: 4-8 min
K: 1-4 min
α-Angle: 47-74°
 MA: 55-73mm
LY 30%: 0-8%

Corresponding terminology for ROTEM

ROTEM TEG

Clotting time (CT) R value (reaction time)

α angle and clot formation time (CFT) K value and α angle

Maximum clot firmness (MCF) Maximum amplitude (MA)

Clot lysis (CL) LY30

IMPORTANT PATTERNS
TEG AS A GUIDE TO TREATMENT

Increased R time => FFP

Decreased alpha angle => cryoprecipitate
Decreased MA => platelets (consider DDAVP)
Fibrinolysis =>  tranexamic acid (or aprotinin or aminocaproic acid)

Or use this handy guide (-:

 Source: @DocXology

TEG® VERSUS ROTEM®

Comparison

Two commercial types of viscoelastic tests are available: thromboelastography

=TEG® (developed in 1948, now produced  in the USA) and rotational
thromboelastogram = ROTEM® (from Germany)
differences in diagnostic nomenclature for identical parameters between the two
TEG® operates by moving a cup in a limited arc (±4°45′ every 5s) filled with sample
that engages a pin/wire transduction system as clot formation occur
ROTEM® has an immobile cup wherein the pin/wire transduction system slowly
oscillates (±4°45′every 6s)
results are not directly comparable as different coagulation activators are used
ROTEM® is more resistant to mechanical shock, which may be an advantage in the
clinical setting
Equivalent variables for ROTEM®

Clotting time (CT) = R value (reaction time)

α angle and clot formation time (CFT) = K value and α angle
Maximum clot firmness (MCF)  = Maximum amplitude (MA)
Clot lysis (CL)  = LY30

COMPARISON WITH PLASMA CLOTTING TESTS

Pros of viscoelastic hemostatic assays

assessment of global haemostatic potential provides more information than time

to fibrin formation
can readily differentiate a coagulopathy due to low fibrinogen from one due to
thrombocytopenia
point-of-care (POC) device with rapid  turnaround times so that many results
available within 5–10 min of starting the test

Cons of viscoelastic hemostatic assays

variable availability and user familiarity

marked inter-operator variability and poor precision

UK NEQAS data suggests coefficients of variance ranging from 7.1% to 39.9%
for TEG® and 7.0% to 83.6% for ROTEM®
may require specialist staff to perform

EVIDENCE

Cochrane review (2015)of the use of TEG and ROTEM in traumatic bleeding
advised that they should be used for research only, due to a lack of evidence for
the accuracy of the assays.

References and Links

Journal articles

Afshari A, Wikkelsø A, Brok J, Møller AM, Wetterslev J. Thrombelastography (TEG)

or thromboelastometry (ROTEM) to monitor haemotherapy versus usual care in
patients with massive transfusion. Cochrane Database Syst Rev. 2011 Mar 16;
(3):CD007871
Bolliger D, Seeberger MD, Tanaka KA. Principles and practice of
thromboelastography in clinical coagulation management and transfusion
practice. Transfus Med Rev. 2012 Jan;26(1):1-13
da Luz LT, Nascimento B, Rizoli S. Thrombelastography (TEG(R)): practical
considerations on its clinical use in trauma resuscitation. Scand J Trauma Resusc
Emerg Med. 2013 Apr 16;21(1):29.
Ganter MT, Hofer CK. Coagulation monitoring: current techniques and clinical use
of viscoelastic point-of-care coagulation devices. Anesth Analg. 2008
May;106(5):1366-75
Hunt H, Stanworth S, Curry N, Woolley T, Cooper C, Ukoumunne O, Zhelev Z, Hyde C.
TEG and ROTEM for diagnosing trauma‑induced coagulopathy (disorder of the
clotting system) in adult trauma patients with bleeding. Cochcane Review. 2015
Tapia NM et al. TEG-guided resuscitation is superior to standardized MTP
resuscitation in massively transfused penetrating trauma patients. J Trauma
Acute Care Surg. 2013;74:378-386.
Thakur M, Ahmed AB. A review of thromboelastography. Int J Periop Ultrasound
Appl Technol 2012;1(1):25-29.

FOAM and web resources

ICN — SMACC: Hurn on TEG/ROTEM in the Real World (2013)

Joe Elbeery on Youtube — TEG basics video (2013)
Maryland CCP — The Use of TEG & Goal Directed Blood Component Therapy by
John Walsh (2013)
Practical-Hemostasis.com — TEG and ROTEM
The websites for the ROTEM and TEG provide a comprehensive explanation of the
waveforms generated in various disorders.
 Critical Care
Compendium

…more CCC

Chris Nickson
Chris is an Intensivist and ECMO specialist at the Alf red ICU in Melbourne. He is also the
Innovation Lead f or the Australian Centre f or Health Innovation at Alf red Health and
Clinical Adjunct Associate Prof essor at Monash University. He is a co- f ounder of
the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead f or
the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors f or
the Intensive Care Foundation and is a First Part Examiner f or the College of Intensive Care
Medicine. He is an internationally recognised Clinician Educator with a passion f or helping
clinicians learn and f or improving the clinical perf ormance of individuals and collectives.

Af ter finishing his medical degree at the University of Auckland, he continued post-
graduate training in New Zealand as well as Australia’s Northern Territory, Perth and
Melbourne. He has completed f ellowship training in both intensive care medicine and
emergency medicine, as well as post- graduate training in biochemistry, clinical toxicology,
clinical epidemiology, and health prof essional education.

He is actively involved in in using translational simulation to improve patient care and the
design of processes and systems at Alf red Health. He coordinates the Alf red ICU’s
education and simulation programmes and runs the unit’s education website, INTENSIVE. 
He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the
world. He is one of the f ounders of the FOAM movement (Free Open- Access Medical
education) and is co- creator of  litfl.com, the RAGE podcast, the Resuscitology course, and
the SMACC conf erence.
 His one great achievement is being the f ather of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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