point of-care haemostasis monitoring
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Point-of-Care Haemostasis Monitoring
F R de Belder MBBS RAMC
CT1
What is it?
• ROTEM• (Rotational
Thromboelastography)
TEG
(Haemoscope Corp.)
• Real time
• Shear Elasticity measurement of clot
• Whole blood
• Cell-based theory of coagulation
• Simulates low-shear in vivo vasculature
Variables
• Confusing
• TEG & ROTEM have different names for the same things
• NOT interchangeable
• SHAPE of curve most important!
Examples
GOAL?
• Intent: Reduce total blood products given
• Method:– Goal directed, non-RBC blood products– Address specific deficiencies– Rapid: 15 vs 60 mins (comp to lab tests)
Patient populations
• Cardiac
Problem=Low clotting factors, high thrombin(unique to cardiac surgery)High thrombin, activated fibrinolysis
Less FFP, more PCC/[fibrinogen]/plateletsBUT: Cochrane review: no change in outcomes!
**recommended by NICE**
Obstetrics
• Fibrinogen normally rises in 3rd trimester
• Hypofibrinogenaemia= Inc. risk of PPH (<2g/l=PPV 100%!)
• Normal ranges have been published
• **Not currently rec by NICE;lack of evidence**
Trauma cont.
• Up to 38% are coagulopathic
• A/w 5x mortality increase
Trauma
• Acute trauma coagulopathy– Tissue factor and activation– Anticoagulation due to Protein C and
fibrinolysis– Appears in mod trauma (ISS 10-20)– ISS > 35 = primary hyperfibrinolysis
• (Side note: Crash-2 ARR 0.8%???)
• **Not rec by NICE: lack of evidence**
**Following slides taken from presentation by Lt Col Wooley et al, RAMC**
Wooley et al(2009, October 2nd) Feasibility of use of Rotational Thromboelastometry (ROTEM) to Manage the Coagulopathy of Military Trauma in a Deployed Setting.[PowerPoint slides]. Presented at Nato Medical Conference 2009
Case 1
• 30kg Male• 2hr post explosive incident
• Temp 32c, BP -70/30• pH = 7.01, BE = -18• Hb - 5.6 / Plt – 236• PT 18.5 / PTT 58.2
• Over next 18hrs –16 P.RBC, 10 FFP, 5Plts,
1Cryo
EXTEM Traces
Initial ED trace After admission to ITU
Ongoing Resuscitation
After 15hrs – 15P.RBC/10FFP/4Plts/1Cryo
After 1 unit of apherised platelets
Case 2
• 65 yr old man
• Unknown time after GSW to right flank
• Initial observations:– Systolic BP -110mmHg / pulse 94 bpm– Tympanic temperature -34.9C– pH = 7.01 / base excess = -17– Hb = 8.4g/dL / plts = 182 x109cells/L– PT = 14.3s / APTT = 83.1s
Initial Trace
HYPERFIBRINOLYSIS
After 1 hr
Completely hypocoagulable state
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