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1 Hemostasis and TEG® Technology Copyright © 2001-2003 Haemoscope Corporation.

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Presentation on theme: "1 Hemostasis and TEG® Technology Copyright © 2001-2003 Haemoscope Corporation."— Presentation transcript:

1 1 Hemostasis and TEG® Technology Copyright © 2001-2003 Haemoscope Corporation

2 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 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

4 4 Hemostasis Components

5 5 The Procoagulant Cascade

6 6 The Hemostasis Process

7 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.

8 8 TEG® Technology

9 9 Clot Kinetics

10 10 TEG® Data Related to Pathways

11 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.

12 12 Pattern Recognition

13 13 Recombinant Factor VIIa - before RKMA 38135169 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 14 Recombinant Factor VIIa - after RKMA 38135169

15 15 Recombinant Factor VIIa - superimposed

16 16 Sepsis

17 17 Sepsis - after

18 18 Sepsis (superimposed before and after)

19 19 Extreme Hypercoagulability

20 20 Clot Breakdown with Urokinase

21 21 Amicar and Urokinase Combined

22 22 ReoPro Effect

23 23 AMI – before treatment

24 24 AMI – immediately post treatment

25 25 AMI – during recovery

26 26 Mitral Valve Replacement (Complicated history with numerous conditions)

27 27 Mitral Valve Replacement (2)

28 28 Mitral Valve Replacement (3)

29 29 Mitral Valve Replacement (4)

30 30 Mitral Valve Replacement (5)

31 31 Marfan Syndrome/Aneurism

32 32 Marfan Syndrome/Aneurism (2)

33 33 Marfan Syndrome/Aneurism (3)

34 34 Marfan Syndrome/Aneurism (4)

35 35 Marfan Syndrome/Aneurism (5)

36 36 2 mo old baby/Fontan heart surgery -1

37 37 2 mo old baby/Fontan heart surgery -2

38 38 2 mo old baby/Fontan heart surgery -3

39 39 2 mo old baby/Fontan heart surgery -4

40 40 High contractility - 1

41 41 High contractility - 2

42 42 High contractility - 3

43 43 Monitoring Hirudin with TEG® Analysis Von Kier, Wade, and Royston, Royal Brompton and Harefield NHS Trust, Harefield, UK

44 44 Monitoring Anti-Xa with TEG® Analysis Klein, et al. Duke University Medical Center

45 45 TEG® Tracing Schematic

46 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 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.

48 48 Suggested Therapy Algorithm Copyright © 2002 Haemoscope Corp.

49 49 Sampling Protocol (Cardiovascular) Sampling Protocol All samples are Kaolin activated Sample # WhenCup type 1On inductionHeparinase bonded (blue) cup and pin 2At rewarming (approx 36°C) on CPBHeparinase bonded (blue) cup and pin 3 & 410 min post protamineSplit sample: Heparinase bonded (blue) cup and pin Plain (clear) cup and pin 5 & 6Post opSplit sample: Heparinase bonded (blue) cup and pin Plain (clear) cup and pin Copyright © 2002 Haemoscope Corp.

50 50 Interpretation TEG® Results Interpretation (If HIT, treat with Hirudin) Sample #MeasuresIfSuggested Treatment 1Baseline hemostasis profileProthrombotic 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. 2Coagulopathy, 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 CoagulopathySee protocol below 5 & 6Post-op hemostasis profileNormalNone Coagulopathy / heparin reboundSee protocol below Copyright © 2002 Haemoscope Corp.

51 51 Suggested Treatment Treatment protocol TEG® valueClinical causeSuggested Treatment R between 7 - 10 min clotting factorsx 1 FFP or 4 ml/kg R between 11-14 min clotting factorsx 2 FFP or 8 ml/kg R greater than 14 min clotting factorsx 4 FFP or 16 ml/kg MA between 49 -54 mm platelet function0.3mcg/kg DDAVP MA between 41 -48 mm platelet functionx5 platelet units MA at 40 mm or less platelet functionx10 platelet units less than 45° fibrinogen level.06 u/kg cryo LY30 at 7.5% or greater, C.I. less than 3.0Primary fibrinolysisantifibrinolytic of choice LY30 at 7.5% or greater, C.I. greater than 3.0Secondary fibrinolysisanticoagulant of choice LY30 less than 7.5%, C.I. greater than 3.0Prothrombotic stateanticoagulant of choice Copyright © 2002 Haemoscope Corp.

52 52 Plavix Monitoring with TEG® Analysis

53 53 Aspirin Monitoring with TEG® Analysis

54 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 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 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 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

58 58 TEG® Applications Liver transplantation Cardiovascular surgery Heart assist device Percutaneous Transluminal Coronary Angioplasty (PTCA) Trauma Obstetrics ICU Orthopedics

59 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

60 60 Connectivity

61 61 TEG® Analyzer 5000 Series

62 62

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