ROTATIONAL THROMBOELASTOMETRY

WORKSHOP
Ecaterina Scarlatescu, MD, PhD
Department of Anaesthesia and Intensive Care Medicine
Fundeni Clinical Institute, Bucharest, Romania
 NORMAL TRACES AND REAGENTS

CaCl2 + recombinant tissue factor + polybrene CaCl2 + ellagic acid

CaCl2 + recombinant tissue factor + polybrene +

cytochalasin D CaCl2 + recombinant tissue
factor + polybrene +
aprotinin/tranexamic acid
SINGLE USE REAGENTS AND LIQUID REAGENTS

WITHOUT WITH
POLYBRENE
ROTEM ® trace (“temogram”) displaying the clinically most important parameters and their informative value.
FDPs = fibrin(ogen) split products. Courtesy of Klaus Görlinger, Tem International
AT ONE GLANCE…

Curr Opin Crit Care

2013; 19:605-612
PATHOLOGICAL ROTEM TRACES
We obtained this thromboelastometry in a bleeding situation during
surgery (colo-rectal cancer). In your opinion this patient has:

1.Low platelet number

2.Low fibrinogen level
3.Hyperfibrinolysis
4.Hypercoagulability
5.Normal traces
INTEM • CT=176
This is a ROTEM trace of a non bleeding
• CFT=49 septic patient. Do you think this is:
• α=79
• MCF= 79
1. A normal trace
FIBTEM
• A10=22 2. Hypercoagulable trace
• MCF=25

3. Hyperfibrinolysis
EXTEM 4. Heparin effect
• CT=74
• CFT=58
• α=79
• MCF= 80 5. Thrombocytopenia
• ML=3%
APTEM
• CT=72
• CFT=51
• MCF= 78
INTEM • CT=176
• CFT=49
•
•
α=79
MCF= 79
HYPERCOAGULABILITY
FIBTEM
• A10=22
• MCF=25

EXTEM
• CT=74
• CFT=58
• α=79
• MCF= 80
• ML=3%
APTEM
• CT=72
• CFT=51
• MCF= 78
We obtained this ROTEM trace in a
patient with diffuse bleeding. What is
your treatment approach?

1. Platelet concentrate
2. Fibrinogen concentrate or
cryoprecipitate
3.Tranexamic acid
4.PCC or FFP
5.Protamine
Deficiency of coagulation factors from
extrinsic pathway.

PCC administered and bleeding

stopped
DIAGNOSIS?

1.Deficiency of coagulation
factors from intrinsic
pathway
2.Trombocytopenia
3.Low fibrinogen level
4.Hyperfibrinolysis
5.Heparin effect
This is a thromboelastometry in a pretransplant liver cirrhosis patient. What is
your diagnosis?

1.Deficiency of coagulation
factors from intrinsic
pathway
2.Low platelet number
3.Abnormal fibrin
polymerisation
4.Hyperfibrinolysis
5.Heparin effect
WHAT IS THE DIAGNOSIS?

1.Deficiency of coagulation
factors
2.Low platelet number
3.Abnormal fibrin
polymerisation
4.Hyperfibrinolysis
5.Heparin effect
CLI30,45,60 on
ROTEM and LY30,
60 on TEG ARE NOT
THE SAME!
 Hyperfibrinolysis categorization ( by Schochl et al., 2009)

Total breakdown of the clot between 30 and 60 min

D) Late Fibrinolysis

(Early) Total breakdown of the clot within 30 min

Total breakdown of the clot after 60 min

DIAGNOSIS?

1.Deficiency of coagulation
factors from intrinsic
pathway
2.Low platelet number
3.Low fibrinogen level
4.Hyperfibrinolysis
5.Heparin effect
 HEPARIN
EFFECT-
LOW DOSE
DIAGNOSIS?

1.Deficiency of coagulation
factors from intrinsic
pathway
2.Thrombocytopenia
3.Low fibrinogen level
4. Fulminant
Hyperfibrinolysis
5.Heparin effect
PROTAMINE
Thromboelastometry after graft reperfusion during OLT

In a bleeding patient with this

ROTEM trace what is the first
drug/blood product to administer
for coagulopathy correction?
1. PCC or FFP
2. Factor VIIa
3. Fibrinogen or Cryo
4. Tranexamic acid or other
antifibrinolytic agent
5. Protamine
THIS IS THE REAL WORLD- more then one thing missing!!!

Fulminant Hyperfibrinolysis-
administer first antifibrinolytic
agent in bleeding patient, then
Fibrinogen concentrate/ Cryo

Re-assessment of Clinical
situation&ROTEM
This is the ROTEM test drawn after
reperfusion of the graft in a liver
transplant patient. The result was printed
at 15 minutes runtime. As the patient had
diffuse bleeding, what is the first
drug/blood product to give for
coagulopathy correction?
1. PCC or FFP
2. Factor VIIa
3. Fibrinogen or Cryo
4. Tranexamic acid or other
antifibrinolytic agent
5. Protamine
 The same ROTEM test, 50 minutes
runtime…

For this bleeding patient:

first antifibrinolytic agent, then Fibrinogen
concentrate/ Cryo

Re-assessment of Clinical
situation&ROTEM
Viscoelastic tests- BLIND SPOTS
HEMATOCRIT LEVEL
Platelet dysfunction/ Antiplatelet influences clot amplitude on
agents ROTEM!!!
von Willebrand Factor
Weak anticoagulants (LMWH)
Vascular pathology
Factor XIII +/-
 INTERACTIVE CASE REPORT

PATIENT HISTORY

• Male, 35 years old, 85 kg, 190 cm

• Without known previous pathology
• Fulminant hepatic failure (FHF) (acute HVB infection)
• Transferred from territorial ICU
• Endotracheal intubation for airway protection
• Hepatic encephalopathy grade 4 ( with normal head CT) GCS 4p
 LABORATORY EVALUATION

• Hepatic :
ALT 1921 IU/L and AST 996 IU/L
Total bilirubin 6.4 mg/dL with direct bilirubin 5.9 mg/dL
Albumin 3.2 g/dL
Cholesterol 90 mg/dL
Hypoglicemia
Lactate levels 2-4.5 mmol/L
• Without renal dysfunction
 SCTs and plasmatic levels of coagulation factors after ICU
admission (day 0)

• INR 4.85 • FII 40% (N>70%)

• PT 51.1 sec (N 10.4-14.3sec)
• Fibrinogen 103.3 mg/dL
• aPTT 76.8 sec (N 22-32 sec)
• Normal platelet count
• Hemoglobin 12.1g/dl
• FV 38% (N>70%)
• FVII 20% (N>55%)
• FX 52% (N>70%)
• Antithrombin III 38% (N>80%)
• Protein C 52% (N>70%)
• Protein S 44% (N>60%)
• D dimers 9040 μg/L (N<550)
 What is your approach for coagulopathy management before
invasive procedures (CVC placement) in this patient?

1. Administer PCC or FFP

2. Administer PCC (or FFP) and Fibrinogen Concentrate (or Cryo)

3. Administer Fibrinogen concentrate or Cryoprecipitate

4. Run a viscoelastic test (ROTEM/TEG) before any hemostatic therapy

MANAGING ALF COAGULOPATHY

• Before invasive procedures, fibrinogen IN THIS CASE WE

concentrations<100 mg/dl should be
corrected with cryoprecipitate or fibrinogen DECIDED TO
concentrate.
Run a viscoelastic test
• Platelet count 50 000/µL is acceptable (ROTEM/TEG) before
any hemostatic therapy
• Moderately elevated INR should not be
corrected before invasive procedures, with
the exception of intracranial pressure monitor
insertion

Kozek-Langenecker et al. Eur J Anaesthesiol 2013

ROTEM DAY 0
What would you give the patient before
CVC and arterial line placement?

1. Fibrinogen concentrate or Cryo

2. FFP or PCC
3. PCC (or FFP) and Fibrinogen
concentrate (or Cryo)
4. Platelet concentrate
5. Nothing
 The patient didn’t show signs of bleeding
tendency.

 We chose not to administer any

procoagulant therapy and the placement
of CVC and arterial line was smooth,
without any bleeding or hematoma.
 ICU THERAPEUTIC APPROACH (Days 1-3)

• Listed for transplantation as priority

• Management of cerebral edema (hyperventilation,
hypernatremia, hypothermia and high flow
haemofiltration) Head CT Day 1 ICU

• Continuous RRT the next 72H with UFH bolus

and continuous infusion (blood clotting in circuit
several times!!)
• Vasopressors for MAP>80 mmHg

Head CT Day 3 ICU

 COAGULATION ASSAYS (Day 3 ICU)
• INR 5.05
• PT 53.3 sec (N 10.4-14.3sec) • Protein C 59% (N>70%)
• Fibrinogen 113 mg/dL • Protein S 39% (N>60%)
• aPTT 71.8 sec (N 22-32 sec) • D dimers>10.320 μg/L (N<550)

• FII 38% (N>70%)

• Normal renal function with CRRT
• FV 28% (N>70%)
• Platelet count 100000-140000/μL
• FVII 18% (N>55%) • Without bleeding signs
• FX 36% (N>70%)
• Antithrombin III 38%(N>80%)
ROTEM on ICU Day 3 At the end of Day 3 ICU a matching liver
was found

What would you administer

prophylactically at the beginning of the
LTx surgery?

1. Tranexamic acid
2. PCC/ FFP
3. Fibrinogen concentrate/ Cryo
4. TXA and fibrinogen concentrate/Cryo
5. PCC/FFP and fibrinogen concentrate/Cryo
6. Nothing
ROTEM on ICU Day 3 At the end of Day 3 ICU a matching liver
was found

What would you administer

prophylactically at the beginning of the
LTx surgery?

1. Tranexamic acid
2. PCC/ FFP
3. Fibrinogen concentrate/ Cryo
4. TXA and fibrinogen concentrate/Cryo
5. PCC/FFP and fibrinogen concentrate/Cryo
6. Nothing
 EVOLUTION

• Minimal intraoperative bleeding, LT without blood

products administered
• Deep coma for 48 h after liver transplantation (LT)
• Extubated on ICU Day 6
• Complete neurologic recovery
• Functioning liver graft

Head CT Day 4 ICU (day 1 post LT)

 POST TRANSPLANT COAGULATION ASSAYS
Day 6 ICU Day 7 ICU Day 8 ICU Normal values

INR 1.64 1.65 1.56 0.9-1.2

•Thromboprophylaxis:
PT 17.4 17.5 16.6 10.4-14.3 enoxaparin 40 mg sc daily
Fibrinogen 141 150 140 200-400 after LT
aPTT 52.5 47 43 22-32
FII 62 39 30 >70%
FV 58 35 28 >70%
•Platelet count>80000/μL
FVII 29 26 15 >55%
FX 42 48 42 >70%
ATIII 48 73 68 >80%
Pc 60 44 45 >70%
Ps 44 28 26 >60%
D dimers 15240 >19000 >19000 <550μg/L
 POST TRANSPLANT COAGULATION ASSAYS

ROTEM in Day 6 ROTEM in Day 7

 What would be your choice for venous thromboembolism
prophylaxis after LTx in this patient?

1. LMWH prophylactic dose

2. UFH 15000 IU/24 h continuous iv
3. Only mechanical prophylaxis
4. LMWH or UFH anticoagulant dosage
5. A combination of LMWH or UFH with AT (targeting lower
normal range for AT)
 POSTOPERATIVE EVOLUTION

• Day 7 ICU hepatic arterial resistive index <0.5

• Treatment: Continuous systemic iloprost therapy and oral aspirin

• Day 8 ICU clinical signs of DVT

• Contrast enhanced CT scan revealed incomplete thrombosis at the

level of external iliac and right femoral veins
 What would be your choice for anticoagulant treatment
and monitoring in this case?
Day 7 ICU Day 8 ICU Normal values

INR 1.65 1.56 0.9-1.2 1. UFH continuous infusion/

PT 17.5 16.6 10.4-14.3
Fibrinogen 150 140 200-400
aPTT
aPTT 47 43 22-32 2. LMWH anticoagulant
FII 39 30 >70%
dosage/ anti Xa
FV 35 28 >70%
FVII 26 15 >55% 3. VKA/ INR
FX 48 42 >70%
ATIII 73 68 >80%
4. NOAC/-
Pc 44 45 >70%
Ps 28 26 >60%
D dimers >19000 >19000 <550μg/L
 OUR CHOICE…

• Treatment: UFH continuous iv infusion with aPTT and

anti Xa monitoring
 OUTCOME
Day 9 ICU Day 12 Normal values
ICU •Hepatic arterial resistive index 0.6-
0.75 after day 9
INR 1.68 1.24 0.9-1.2 •Iloprost therapy stopped after 14 days
PT 17.8 13.2 10.4-14.3 •Remission of clinical manifestation of
Fibrinogen 242 330 200-400
venous thrombosis (Doppler flow
present)
FII 44 50 >70%
•From Day 12 LMWH anticoagulant
FV 50 64 >70%
dose started
FVII 30 45 >55% •The patient was discharged to the
FX 52 62 >70% yard in Day 13 ICU (10 days after LT)
ATIII 58 64 >80%

D dimers 12000 8800 <550μg/L

THANK YOU!