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Overview of Thromboelastography (TEG) and Brief Review of New Anticoagulants Lisa Guerrini, MS, CRNA.

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Presentation on theme: "Overview of Thromboelastography (TEG) and Brief Review of New Anticoagulants Lisa Guerrini, MS, CRNA."— Presentation transcript:

1 Overview of Thromboelastography (TEG) and Brief Review of New Anticoagulants Lisa Guerrini, MS, CRNA

2 2 Disclosure Staff CRNA at William Beaumont Hospital- Troy No conflicts to report *I am NOT an “expert”*

3 3 Objectives  Review Basics of Hemostasis  Understand the History and Principals of Thromboelastography  Identify Applications of TEG in Anesthesia  Overview and Updates of Current Anticoagulants

4 Hemostasis

5 5

6 PT/INR aPTT

7 Routine coagulation tests (RCoT) [ PT, INR, aPTT]  Developed 50+ years ago to monitor hemophilia  Clot Strength  Platelets are responsible for 80% of clot strength  PT and INR only represent <3% of overall clot strength  aPTT represents <10% of clot strength  Thrombin  PT, INR or aPTT stop where fibrin strands begin to form  Represents <5% of overall thrombin production; much more thrombin is needed to produce a stable network of platelet-fibrin polymers  Developed 50+ years ago to monitor hemophilia  Clot Strength  Platelets are responsible for 80% of clot strength  PT and INR only represent <3% of overall clot strength  aPTT represents <10% of clot strength  Thrombin  PT, INR or aPTT stop where fibrin strands begin to form  Represents <5% of overall thrombin production; much more thrombin is needed to produce a stable network of platelet-fibrin polymers

8 8 What is Thromboelastography?  Assessment of viscoelastic properties of clot formation in WHOLE blood  1948: Dr. Hellmut Hartert  1996: thromboelastograph® and TEG® became registered trademarks of the Hemoscope Corp.  Rotational Thromboelastography (”ROTEM”) manufactured by Pentapharm GmbH

9 TEG®

10 min 3-6 min mm “K”

11 Primary Hyperfibrinolysis HypercoagulableNormal Hypocoagulable

12 12 CauseTreatmentR Value K and  angle MA Lack of surgical hemostasis SuturesNormal HemodilutionProduct instead of Crystalloid/Coll oid HighNormal Factor Deficiency FFPHighLow or Normal Fibrinogen Deficiency CryoprecipitateNormalLowLow or Normal Low/dysfunctio nal platelets PlateletsNormal Low Primary Fibrinolysis AntifibrinolyticsNormal Low adapted from

13 13 TEG® Platelet Mapping TM Assay

14 TEG® Platelet Mapping™ result. T. C. Collyer et al. Br. J. Anaesth. 2009;102: © The Author [2009]. Published by Oxford University Press on behalf of The Board of Directors of the British Journal of Anaesthesia. All rights reserved. For Permissions, please Normal

15 TEG® Platelet Mapping™ result. T. C. Collyer et al. Br. J. Anaesth. 2009;102: © The Author [2009]. Published by Oxford University Press on behalf of The Board of Directors of the British Journal of Anaesthesia. All rights reserved. For Permissions, please

16 16 Study Type of patients Number of patients Conclusions Shore-Lesserson et al (1999) Cardiac Surgery 106 Patients with TEG assays received less FFP and PLT transfusions postoperatively than did RCoT patients Manikappa et al (2001) Cardiac Surgery 150 TEG better predicted postoperative hemorrhage and significantly decreased the need for transfusion of PRBC, FFP, and PLT compared to RCoT Johansson et al (2009) Massively bleeding, 21% trauma 832Patients treated according to TEG had significantly lower mortality compared to controls (20% v. 30%) Plotkin et al (2008) Trauma44Maximum amplitude (MA) correlated more strongly with 24hour transfusion requirements than standard RCoT

17  Prospective, Randomized, Controlled, single centre study  Patients (30) undergoing surgical excision of burn wounds on third day following burn trauma Control Group (16): Coagulation management according to clinician’s discretion; included administration of FFP, PLT concentrate, fibrinogen concentrate, prothrombin complex concentrate and tranexamic acid according to clinical judgement; routine coagulation tests as needed Algorithm Group (14): ROTEM analysis, intervention per preset algorithm  Hypothesis: Rapid correction of coagulopathy will decrease allogeneic blood product transfusions during surgical excision of burn wounds  Prospective, Randomized, Controlled, single centre study  Patients (30) undergoing surgical excision of burn wounds on third day following burn trauma Control Group (16): Coagulation management according to clinician’s discretion; included administration of FFP, PLT concentrate, fibrinogen concentrate, prothrombin complex concentrate and tranexamic acid according to clinical judgement; routine coagulation tests as needed Algorithm Group (14): ROTEM analysis, intervention per preset algorithm  Hypothesis: Rapid correction of coagulopathy will decrease allogeneic blood product transfusions during surgical excision of burn wounds Perioperative Treatment Algorithm for Bleeding Burn Patients Reduces Allogeneic Blood Product Requirements E. Scahden, O. Kimberger, P. Kraincuk, D.M. Baron, P.G. Metnitz and S. Kozek-Longnecker British Journal of Anaesthesia, 2012 E. Scahden, O. Kimberger, P. Kraincuk, D.M. Baron, P.G. Metnitz and S. Kozek-Longnecker British Journal of Anaesthesia, 2012

18 Algorithm- based on Austrian Task Force of Perioperative Coagulation ROTEM 1: EXTEM= initial activation and dynamics of clot formation, allows analysis of factor deficiencies  Maximum clot firmness (MCF) of EXTEM= clot strength and stability, very dependent on PLT count and fibrinogen function  Clot strength after 10minutes (A10)= high correlation to MCF, just available faster! FIBTEM is the same test as EXTEM, just has a PLT inhibitor added  FIBTEM MF or A10 represent the contribution of fibrinogen to clot strength APTEM is the same test as EXTEM, just has aprotinin (trasylol) added Improvement in prolonged clotting time (CT) and/or reduced MCF diagnose Hyperfibrinolysis R value/Clot Strength CT ex >100s (problem=inability to form clots) K +  angle A10 EX <45mm A10 FIB <12mm (problem=fibrinogen) Maximum Amplitude A10 EX <45mm A10 FIB >12mm (problem=PLT) Lysis Time A10 AP >A10 EX LY30 ex >10% (problem=clot lysis) FFP 4units Fibrinogen (2g) Platelets (1u) Tranexamic Acid (10mg/kg) ROTEM was preformed preop, intraop and postop in the ICU until the morning after surgery

19 Outcomes  Primary Cumulative number of allogeneic blood units (PRBC, FFP, and PLT concentrates) transfused on the day of the surgical excision of burn wounds  Secondary The use of PRBCs alone, FFP alone, PLT concentrate alone, Prothrombin complex concentrate alone, and tranexamic acid  Primary Cumulative number of allogeneic blood units (PRBC, FFP, and PLT concentrates) transfused on the day of the surgical excision of burn wounds  Secondary The use of PRBCs alone, FFP alone, PLT concentrate alone, Prothrombin complex concentrate alone, and tranexamic acid

20 Control (units/pt) Algorithm (units/pt) P value Allogeneic Blood Product PRBC alone FFP alone 5None given<0.001 Platelet Concentrate alone Overall- 4unitsNone given0.12 Fibrinogen concentrate 8g 0.89 No prothrombin concentrate complex or transexamic acid were give to either group

21 “New” Anticoagulants 21  Prasugrel  Effient®  Dabigatran  Pradaxa®  Rivaroxaban  Xarelto®  Ticagrelor  Brilinta®  Apixaban  Eliquis®

22 22

23 23 Prasugrel (Effient) FDA approved to reduce the risk of MI in angioplasty P2Y 12 Receptor antagonist Single 60mg loading dose; 10mg daily maintenance Time to peak effect: 1hr Metabolism CYP450 -Primarily CYP3A4 and CYP2B6 -Lesser extent CYP2C9 and CYP2C19 Elimination -Half life: 7.4hrs -68% Renal -27% Fecal Recommended coagulation assay: PLT mapping Reversal: PLTs

24 24 Dabigatran (Pradaxa) FDA approved indications: -Nonvalvular Afib* -VTE prophylaxis following surgery -Treat and prevent DVT and/or PE Direct thrombin inhibitor mg BID [Based on CrCl] Time to peak effect: 2hr Metabolism/Elimination -Half life:12-17hr -80% Renal -20% Fecal Recommended coagulation assay: Dilute TT, anti-factor II Reversal: Dialysis, activated charcoal within 1-2hrs of ingestion

25 25 Rivaroxaban (Xarelto) FDA approved in: -Nonvalvular Afib* -VTE prophylaxis following surgery -Treat and prevent DVT and/or PE Direct Factor Xa Inhibitor 10-20mg Daily Time to peak effect: 3hr Metabolism: Hepatic—33% to inactive metabolites Elimination -Half life: hr -33% Renal -33% Fecal/Biliary Recommended coagulation assay: PT, Anti-Xa Reversal: Activated charcoal within 8hr of ingestion; FFP; PCC; Factor IV; Recombinant factor VIIa

26 26 Ticagrelor (Brilinta) FDA approved to reduce CV death and MI in ACS P2Y 12 Receptor antagonist 90mg BID maintenance dose Time to peak effect: 2-4hr Metabolism: CYP3A4 Elimination: -Half life: 7hrs; 8.5 hrs for active metabolites -Primarily Hepatic Recommended coagulation assay: PLT mapping Reversal: PLTs

27 27 Apixaban (Eliquis) FDA approved for: -Nonvalvular AFib Factor Xa Inhibitor 5mg BID Time to peak effect: 1-3hr Metabolism/Elimination: Half life: 8-15hr 25% Renal Elimination 75% Fecal Metabolism and Elimination Recommended coagulation assay: Anti-Xa, Dilute PT Reversal: Activated charcoal within 3hrs, PLTs

28 What’s Next? 28 Edoxaban (Savaysa) 2 FDA approved (2015) indications: 1.Reducing the risk of stroke in patients who have NONvalvular atrial fibrillation 2.Treating DVT and PE in patients who have already been receiving an anticoagulant by injection or by infusion for 5 to 10days

29 29 Suggested Discontinuation Prior to “High Risk Blood” Loss Surgery  Prasugrel (Effient®)  7 days  Dabigatran (Pradaxa®)  24-48hrs  Rivaroxaban (Xarelto®)  24 hours  Ticagrelor (Brilinta®)  5 days  Apixaban (Eliquis®)  48 hours *Per prescribing guidelines set forth by drug manufacturers, individual hospital policy should be followed

30 apsf Newsletter Spring-Summer 2012

31 31 References: 1.Brazzel C. Thromboelastography-guided transfusion therapy in the trauma patient. AANA Journal. 2013;81(2): Johansson PI, Stensballe J, Ostroski SR. Current management of massive hemorrhage in trauma. Scand J Trauma Resusc Emerg Med. 2012;20(1):47. 3.Spahn S, Bouillon B, Cerny V, et al. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care. 2013;17(2): Johansson PI, Stissing T, Bochsen L, Ostrowski SR. Thromboelastography and tromboelastometry in assessing coagulopathy in trauma. Scand J Trauma Resusc Emerg Med. 2009;17(45): Johansson PI, Sorensen AM, Perner A, et al. Disseminated intravascular coagulation or acute coagulopathy of trauma shock early after trauma? An observational study. Crit Care. 2011;15(6):R Plotkin AJ, Wade CE, Jenkins DH, et al. A reduction in clot formation rate and strength assessed by thrombelastography is indicative of transfusion requirements in patients with penetrating injuries. J Trauma. 2008;64:S64. 7.Benzon HT, Avarm MJ, Green D, Bonow RO. New oral anticoagulants and regional anaesthesia. BJA. 2013; i96- i New Zealand Med Data Sheets 9.APSF


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