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Hemostasis and TEG® Technology
www.haemoscope.comCopyright © 2001-2003 Haemoscope Corporation
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Hemostasis Issues Facing Clinicians
• Before surgery– Is there a coagulopathy present and how should it be treated– Prophylactic treatment / Autologous platelet plasmapheresis
• During surgery– What coagulopathy is developing
• After surgery– If the patient is bleeding, is it due to
• Surgical• Excess of heparin• Coagulopathy and how it should be treated
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Normal Hemostasis…
… is controlled activation of clot formation and clot lysis that stops hemorrhage without permitting inappropriate clotting (thrombosis).
Laposata et al. University of Pennsylvania Medical School/Mass.General Hospital
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Hemostasis Components
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The Procoagulant
Cascade
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The Hemostasis
Process
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The Clot
• The only end result of the activated coagulation protein is the fibrin strand which, together with activated platelets, forms fibrin-platelet bonding to produce the final clot.
• The strength and stability of the clot, that is its physical properties, determine its ability to do the work of hemostasis, which is to mechanically impede hemorrhage.
• The clot is in essence a damage control device, a temporary stopper, which gradually dissolves during vascular recovery.
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TEG® Technology
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Clot Kinetics
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TEG® Data Related to Pathways
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Formal Definition of TEG® Parameters
R R is the time of latency from the time that the blood was placed in the TEG® analyzer until the initial fibrin formation.
The value measures the rapidity (kinetics) of fibrin build-up and cross-linking, that is, the speed of clot strengthening.
K K time is a measure of the rapidity to reach a certain level of clot strength
MA MA, or Maximum Amplitude, is a direct function of the maximum dynamic properties of fibrin and platelet bonding via GPIIb/IIIa and represents the ultimate strength of the fibrin clot.
CI Coagulation Index is linear combination of the above parameters.
LY30 LY30 measures the rate of amplitude reduction 30 minutes after MA. This measurement gives an indication of the stability of the clot.
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Pattern Recognitio
n
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Recombinant Factor VIIa - before
R K MA3—8 1—3 51—6919.4 5.6 9.4
“Normalization of TEG® tracing and cessation of bleeding after infusion of recombinant Factor VIIa in a child with pulmonary hemorrhage and complex coagulopathy post tissue plasminogen activator infusion”Boshkov et al, abstract presented at Am Soc Hem Dec 2002
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Recombinant Factor VIIa - after
R K MA3—8 1—3 51—698.0 2.1 55.4
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Recombinant Factor VIIa - superimposed
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Sepsis
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Sepsis - after
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Sepsis (superimposed before and after)
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Extreme Hypercoagulability
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Clot Breakdown with Urokinase
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Amicar and Urokinase Combined
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ReoPro Effect
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AMI – before treatment
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AMI – immediately post treatment
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AMI – during recovery
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Mitral Valve Replacement(Complicated history with numerous conditions)
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Mitral Valve Replacement (2)
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Mitral Valve Replacement (3)
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Mitral Valve Replacement (4)
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Mitral Valve Replacement (5)
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Marfan Syndrome/Aneurism
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Marfan Syndrome/Aneurism (2)
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Marfan Syndrome/Aneurism (3)
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Marfan Syndrome/Aneurism (4)
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Marfan Syndrome/Aneurism (5)
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2 mo old baby/Fontan heart surgery -1
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2 mo old baby/Fontan heart surgery -2
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2 mo old baby/Fontan heart surgery -3
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2 mo old baby/Fontan heart surgery -4
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High contractility - 1
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High contractility - 2
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High contractility - 3
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Monitoring Hirudin with TEG® Analysis
0
1
2
3
4
0 2 4Hirudin (ug/ml)
R (m
in)
y= 0.78x + 0.56
r-square = 0.99
Von Kier, Wade, and Royston, Royal Brompton and Harefield NHS Trust, Harefield, UK
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Monitoring Anti-Xa with TEG® Analysis
Klein, et al. Duke University Medical Center
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TEG® Tracing
Schematic
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Standard Protocol for Cardiovascular
Applications
• Baseline tracing on induction– 1 sample with kaolin and heparinase (heparinase in case of
heparin presence or contamination)• At rewarming (approx 36°) on CPB
– 1 sample with kaolin and heparinase • *10 min post protamine, 2 TEG® columns needed
– 1 sample with kaolin and heparinase– 1 sample with kaolin only
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Post Protamine
• Looking at only the R parameter, if the samples with and without heparinase are the same, the patient has received enough protamine to reverse heparin.
• If both tracings are normal and the patient is bleeding, the reason is surgical.
• If the R without heparinase is elongated and the heparinase tracing is normal and the patient is bleeding, the bleeding is due to excess of heparin.
• If the tracing with heparinase shows a coagulopathy, the patient is treated accordingly. Most likely coagulopathies will be consistent with those observed during monitoring while the patient is on the pump.
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Suggested Therapy Algorithm
Copyright © 2002 Haemoscope Corp.
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Sampling Protocol (Cardiovascular)
Sampling Protocol — All samples are Kaolin activated
Sample # When Cup type
1 On induction Heparinase bonded (blue) cup and pin
2 At rewarming (approx 36°C) on CPB Heparinase bonded (blue) cup and pin
3 & 4 10 min post protamine Split sample:Heparinase bonded (blue) cup and pinPlain (clear) cup and pin
5 & 6 Post op Split sample:Heparinase bonded (blue) cup and pinPlain (clear) cup and pin
Copyright © 2002 Haemoscope Corp.
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InterpretationTEG® Results Interpretation (If HIT, treat with Hirudin)
Sample # Measures If Suggested Treatment
1 Baseline hemostasis profile Prothrombotic state: AT III deficiency or others
(To test for AT III deficiency, see AT III protocol)
AT III or FFP Antifibrinolytic drugs are contraindicated unless
patient treated with Plavix, ReoPro, Aggrastat, or Integrilin, in which case Aprotinin is recommended.
2 Coagulopathy, if any, developed during bypass phase
Coagulopathy Treat hyperfibrinolysis. See protocol below. Order blood product. See protocol below.
3 & 4 Post-CPB hemostasis profile
Heparin reversal
Heparinase R and Plain R are within normal limits, heparin is effectively reversed
None
Heparinase R normal, Plain R above normal limits, heparin is not completely reversed
Protamine
Coagulopathy See protocol below
5 & 6 Post-op hemostasis profile Normal None
Coagulopathy / heparin rebound See protocol below
Copyright © 2002 Haemoscope Corp.
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Suggested TreatmentTreatment protocol
TEG® value Clinical cause Suggested Treatment
R between 7 - 10 min clotting factors x 1 FFP or 4 ml/kg
R between 11-14 min clotting factors x 2 FFP or 8 ml/kg
R greater than 14 min clotting factors x 4 FFP or 16 ml/kg
MA between 49 -54 mm platelet function 0.3mcg/kg DDAVP
MA between 41 -48 mm platelet function x5 platelet units
MA at 40 mm or less platelet function x10 platelet units
less than 45° fibrinogen level .06 u/kg cryo
LY30 at 7.5% or greater, C.I. less than 3.0 Primary fibrinolysis antifibrinolytic of choice
LY30 at 7.5% or greater, C.I. greater than 3.0 Secondary fibrinolysis anticoagulant of choice
LY30 less than 7.5%, C.I. greater than 3.0 Prothrombotic state anticoagulant of choice
Copyright © 2002 Haemoscope Corp.
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Plavix Monitoring with TEG® Analysis
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Aspirin Monitoring with TEG® Analysis
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Reduced Hemostatic Factor Transfusion Using Heparinase-
modified [TEG® Analysis] During Cardiopulmonary Bypass (CPB)
Stephen von Kier and David Royston
GroupActual Predicted
C(n=30)
DT(n=30)
C(TEG®)
DT(lab)
Pts transfused 10 5 2 12
FFP 16 5 1 22
Platelets 9 1 1 8
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Benefit of Intraoperative TEG® Algorithm to Reduce Platelet Transfusion Associated
Adverse Outcome in Higher Risk Cardiac Surgery Patients
Mortality RateWith platelets 6/21 patients 28%
Without platelets 1/16 patients 6%
Stephen von Kier and David Royston
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Benefit of Intraoperative TEG® Algorithm to Reduce Platelet Transfusion Associated
Adverse Outcome in Higher Risk Cardiac Surgery Patients
Hospital StayWith platelets 17.6 2.9 days
Without platelets 8.8 .6 days
Stephen von Kier and David Royston
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[TEG® Analysis] Decreases Transfusion Requirement After
Cardiac SurgeryLinda Shore-Lesserson MD et al
RBCintra
RBCpost
Non-RBCintra
Non-RBCpost
CTD(ml)
TEG® analysis
17/53 10/53 5/53 3/53 577 ± 412
Control 23/52 12/52 8/52 13/52** 659 ± 429
** p < 0.006 TEG® sample vs control
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TEG® Applications• Liver transplantation• Cardiovascular surgery• Heart assist device• Percutaneous Transluminal
Coronary Angioplasty (PTCA)
• Trauma• Obstetrics• ICU• Orthopedics
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TEG® System
TEG® Analytical Software• Software-assisted diagnosis• Early projected values• Full report capability• Automated QC management• Additional data entry• Full peer-to-peer network
support• Standard Windows interface• Touch screen and barcode• Smoothing algorithm
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Connectivity
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TEG® Analyzer
5000 Series
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