2 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
3 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
7 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.
11 Formal Definition of TEG® Parameters RR 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. KK time is a measure of the rapidity to reach a certain level of clot strength MAMA, 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. CICoagulation Index is linear combination of the above parameters. LY30LY30 measures the rate of amplitude reduction 30 minutes after MA. This measurement gives an indication of the stability of the clot.
13 Recombinant Factor VIIa - before RKMA 38135169 188.8.131.52 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
14 Recombinant Factor VIIa - after RKMA 38135169 8.02.155.4
46 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
47 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.
54 Reduced Hemostatic Factor Transfusion Using Heparinase-modified [TEG® Analysis] During Cardiopulmonary Bypass (CPB) Stephen von Kier and David Royston Group ActualPredicted C (n=30) DT (n=30) C (TEG®) DT (lab) Pts transfused105212 FFP165122 Platelets9118
55 Benefit of Intraoperative TEG® Algorithm to Reduce Platelet Transfusion Associated Adverse Outcome in Higher Risk Cardiac Surgery Patients Mortality Rate With platelets 6/21 patients 28% Without platelets 1/16 patients 6% Stephen von Kier and David Royston
56 Benefit of Intraoperative TEG® Algorithm to Reduce Platelet Transfusion Associated Adverse Outcome in Higher Risk Cardiac Surgery Patients Hospital Stay With platelets 17.6 2.9 days Without platelets 8.8.6 days Stephen von Kier and David Royston
57 [TEG® Analysis] Decreases Transfusion Requirement After Cardiac Surgery Linda Shore-Lesserson MD et al RBC intra RBC post Non- RBC intra Non- RBC post CTD (ml) TEG® analysis 17/5310/535/533/53577 ± 412 Control23/5212/528/5213/52**659 ± 429 ** p < 0.006 TEG® sample vs control
59 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