Thromboelastography

By
Mike Poullis

Measuring Coagulation Status

Why do it?

Benefits Need to understand the position of TEG in coagulation assessment

Techniques
Full blood count and Coagulation screen (APTT, PT, and fibrinogen)

Whole Blood tests Microaggregation Whole blood analysers Thrombelastography

Purified Platelet tests Microaggregation Macroaggregation Platelet function analysers Skin bleeding time

Advantages of Techniques
Full blood count and Coagulation screen (APTT, PT, and fibrinogen) Quick, easy, reproducible, understandable

Whole Blood tests

MAJOR ADVANTAGE IS NO SAMPLE PREPERATION

Microaggregation, Thrombelastography, and Whole blood analysers Easy Purified Platelet tests Microaggregation Macroaggregation Platelet function analysers Skin bleeding time
Whole body answer

Easy PRECISE DEFECT PRECISE DEFECT

Limitations of Techniques
Full blood count Number not function Coagulation screen (APTT, PT, and fibrinogen) 20 to 30 minutes, no fibrinolytic assessment Whole Blood tests Microaggregation Thrombelastography

No commercial kit ?sensitivity

Purified Platelet tests YOU HAVE TO PREPARE THE PLATELETS Microaggregation No commercial kit Macroaggregation Experienced technician Platelet function analysers ? Skin bleeding time
Invasive, not specific

Principles of Thrombelastography

Celite (Kaolin) activated

Low shear environment resembling sluggish venous flow

Readout

What the numbers/letters mean

R: is a period of time from initiation of the test to the initial fibrin formation k: time from beginning of clot formation until the amplitude of thromboelastogram reaches 20 mm alpha angle: The alpha angle represents the acceleration (kinetics) of fibrin build up and crosslinking MA - Maximum amplitude strength of clot (number function platelets fibrin) MA60: measures the rate of amplitude reduction 60 min. after MA (stability) of the clot

The Numbers and Letters

Tips and Tricks

Heparinase
Adding c7E3 Fab (ReoPro) to the TEG sample will eliminate platelet function from the thromboelastogram. Antifibrinolytic agents such as EpsilonAminocaproic Acid, Tranexamic acid and Aprotinin

Example 1

Example 1 Answer
Diagnosis: Delayed clot formation; suspect 1. heparin effect 2. factor deficiency

Treatment: Measure an activated clotting time (ACT) and repeat TEG with Heparinase. 1. if ACT prolonged: administer protamine 2. repeat TEG with Heparinase: if normal: administer protamine if abnormal or heparin not utilized in case: administer FFP

Example 2

Example 2 Answer
Diagnosis: Hypercoagulable state.
Secondary to aggressive replacement of all factors in platelet rich plasma Chronic dissection of aortic aneurysms Treatment: none

Example 3

Example 3 Answer
Diagnosis: Weak Clot Formation Treatment: FFP, platelets and possible cryoprecipitate.

Adding c7E3 Fab (ReoPro) to the TEG sample will eliminate platelet function from the thromboelastogram. The MA will become a function of fibrinogen activity. A repeat TEG should be performed post treatment.

Example 4
Heparinase

No Heparinase

Example 4 Answer
Diagnosis: Heparin Effect. The top curve represents a TEG with Heparinase (heparin activity eliminated) and the bottom trace is the same sample without Heparinase (an elevated ACT will confirm the diagnosis).
Treatment: Reverse the heparin and repeat the TEG or reverse the heparin and perform an ACT.

Example 5
Heparinase No Heparinase

Example 5 Answer
Diagnosis: Normal Coagulation Profile. This is a TEG from the same patient shown in example 4. The heparin was reversed with protamine. The top curve represents a TEG with Heparinase (heparin activity eliminated) and the bottom trace is the same sample without Heparinase. Since both traces are identical all heparin was reversed by protamine.
Treatment: If there is still bleeding its surgical!

Example 6

Example 6 Answer
Diagnosis: No clot formation Very low factor levels Heparin effect
Treatment: repeat TEG with Heparinase : 1. if TEG normal: reverse heparin with protamine 2. if TEG abnormal: administer FFP

Example 7

Example 7 Answer
Diagnosis: Poor coagulation and fibrinolysis
Treatment: Administer coagulation factors and antifibrinolytics (Tranexamic Acid or Aprotinin). The antifibrinolytics can be added to the TEG to pre-evaluate their effectiveness. Repeat the TEG post treatment.

Example 8

Example 8 Answer
Diagnosis: Technical error in processing TEG or severe coagulopathy (correlate with clinical scenario)
Treatment: Repeat TEG 1. if normal: do nothing 2. if grossly abnormal and clinical bleeding: administer all products (FFP, platelets, cryoprecipitate) and repeat TEG.

Limitations
Still being evaluated Paired pre and post operative TEGs Still do lab tests Celite and mechanical activation not biochemical

Wythenshaw, and Blackpool have TEG but no communication on experience!

Clinical Common Sense

Use same clinical skills to assess the bleeding patient
On Aspirin, Clopidogrel and Fragmin

IGNORE THE TEG