THROMBOELASTOGRAPHY FOR

CARDIAC SURGEONS

Andrew Ronald
Consultant Cardiac Anaesthetist
Aberdeen Royal Infirmary,
Aberdeen, UK

alronald@tiscali.co.uk
 THROMBOELASTOGRAPHY

• What is Thromboelastography?

• Where does it “fit into” our usual

coagulation monitoring and what (if any)
new information does it give us

• Why is it useful in Cardiac Surgery?

 WHAT IS THROMBOELASTOGRAPHY
Functional Description

Thromboelastography monitors the thrombodynamic properties of

blood as it is induced to clot under a low shear environment
resembling sluggish venous flow. The patterns of change in
shear-elasticity enable the determination of the kinetics of clot
formation and growth as well as the strength and stability of
the formed clot. The strength and stability of the clot provide
information about the ability of the clot to perform the work of
haemostasis, while the kinetics determine the adequacy of
quantitative factors available to clot formation
 THROMBOELASTOGRAPHY
So what does it do?

• Clot formation

• Clot kinetics

• Clot strength & stability

• Clot resolution
THROMBOELASTOGRAPHY
Basic Principles

• Heated (37C) oscillating cup

• Pin suspended from torsion

wire into blood

• Development of fibrin strands

“couple” motion of cup to pin

• “Coupling” directly
proportional to clot strength

•  tension in wire detected by

EM transducer
THROMBOELASTOGRAPHY
Basic Principles

• Electrical signal amplified to

create TEG trace

• Result displayed graphically

on pen & ink printer or
computer screen

• Deflection of trace increases

as clot strength increases &
decreases as clot strength
decreases
 THROMBOELASTOGRAPHY
Refinements to Technique

TEG accelerants / activators / modifiers

• Celite / Kaolin / TF accelerates initial coagulation

• Reopro (abciximab) blocks platelet component of

coagulation

• Platelet mapping reagents modify TEG to allow analysis of

Aspirin / Clopidigrol effects

Heparinase cups
• Reverse residual heparin in sample
• Use of paired plain / heparinase cups allows identification
of inadequate heparin reversal or sample contamination
 THROMBOELASTOGRAPHY

Where does the TEG fit into

coagulation monitoring and what
new information does it give us?
COAGULATION MONITORING
What is coagulation?
 COAGULATION MONITORING
Conventional tests

Tests of coagulation Tests of fibrinolysis

• Platelets • Degradation
• number products
• function

• Clotting studies
• PT
• APTT
• TCT

• Fibrinogen levels
The TEG gives us dynamic information on
all aspects of conventional coagulation
monitoring
THROMBOELASTOGRAPHY
Sample display
THROMBOELASTOGRAPHY
The “r” time

r time
•represents period of time of latency
from start of test to initial fibrin
formation

•in effect is main part of TEG’s

representation of standard”clotting
studies”

•normal range
• 15 - 23 mins (native blood)
• 5 - 7 mins (kaolin-activated)
 THROMBOELASTOGRAPHY
What affects the “r” time?

r time  by r time  by
• Factor deficiency • Hypercoagulability
• Anti-coagulation syndromes
• Severe
hypofibrinogenaemia
• Severe
thrombocytopenia
THROMBOELASTOGRAPHY
The “k” time

k time
•represents time taken to
achieve a certain level of clot
strength (where r time = time
zero ) - equates to amplitude 20
mm

•normal range
• 5 - 10 mins (native blood)
• 1 - 3 mins (kaolin-activated)
 THROMBOELASTOGRAPHY
What affects the “k” time?

k time  by k time  by
• Factor deficiency • Hypercoagulability
• Thrombocytopenia state
• Thrombocytopathy
• Hypofibrinogenaemia
THROMBOELASTOGRAPHY
The “” angle

 angle
•Measures the rapidity of fibrin
build-up and cross-linking (clot
strengthening)
•assesses rate of clot formation

•normal range
• 22 - 38 (native blood)
• 53 - 67(kaolin-activated)
 THROMBOELASTOGRAPHY
What affects the “” angle?

 Angle  by  Angle  by
• Hypercoagulable • Hypofibrinogenemia
state • Thrombocytopenia
 THROMBOELASTOGRAPHY
The “maximum amplitude” (MA)

Maximum amplitude
•MA 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

•Correlates to platelet function

• 80% platelets
• 20% fibrinogen

•normal range
• 47 – 58 mm (native blood)
• 59 - 68 mm (kaolin-activated)
• > 12.5 mm (ReoPro-blood)
 THROMBOELASTOGRAPHY
What affects the “MA” ?

MA  by MA  by
• Hypercoagulable • Thrombocytopenia
state • Thrombocytopathy
• Hypofibrinogenemia
THROMBOELASTOGRAPHY
Fibrinolysis

LY30
•measures % decrease in
amplitude 30 minutes post-MA

•gives measure of degree of

fibrinolysis

•normal range
• < 7.5% (native blood)
• < 7.5% (celite-activated)

•LY60
• 60 minute post-MA data
 THROMBOELASTOGRAPHY
Other measurements of Fibrinolysis

A30 (A60)
• amplitude at 30 (60) mins post-
MA

EPL
•earliest indicator of abnormal lysis

•represents “computer prediction”

of 30 min lysis based on
interrogation of actual rate of
diminution of trace amplitude
commencing 30 secs post-MA

•early EPL>LY30 (30 min EPL=LY30)

•normal EPL < 15%
 THROMBOELASTOGRAPHY
What measurements are affected by fibrinolysis?

Fibrinolysis leads to:

•  LY30 /  LY60
•  EPL
•  A30 /  A60
THROMBOELATOGRAPHY
Quantitative analysis

• Clot formation
– Clotting factors - r, k times

• Clot kinetics
– Clotting factors - r, k times
– Platelets - MA

• Clot strength / stability

– Platelets - MA
– Fibrinogen - Reopro-mod MA

• Clot resolution
– Fibrinolysis - LY30/60; EPL
A30/60
THROMBOELATOGRAPHY
Qualitative analysis
 TEG v CONVENTIONAL STUDIES

Conventional tests TEG

• test various parts of • global functional
coag cascade, but in assessment of coagulation
isolation / fibrinolysis
• out of touch with current • more in touch with
thoughts on coagulation current coagulation
• plasma tests may not be concepts
accurate reflection of • use actual cellular
what actually happens in surfaces to monitor
patient coagulation
• difficult to assess • gives assessment of
platelet function platelet function
• static tests • dynamic tests
• take time to complete  • rapid results  rapid
best guess or delay monitoring of intervention
treatment
Advantages of TEG over conventional
coagulation monitoring

• It is dynamic, giving information on entire

coagulation process, rather than on isolated part

• It gives information on areas which it is normally

difficult to study easily – fibrinolysis and platelet
function in particular

• Near-patient testing means results are rapid

facilitating appropriate intervention

• It is cost effective compared to conventional tests

 THROMBOELATOGRAPHY
Why might it have a role in Cardiac
Surgery?

Because patients bleed postoperatively

It is often difficult to identify exactly

why they are bleeding
 BLEEDING IS A PROBLEM IN
IN CARDIAC SURGERY

• Why do patients bleed postoperatively?

• Can we do anything to prevent/minimize this blood loss

• How is the bleeding patient managed conventionally?

– what factors may force us to readdress this

• How can the TEG change the way we manage the bleeding
patient?

• (Does use of the TEG improve patient care?)

 WHY DO PATIENTS BLEED AFTER
CARDIAC SURGERY?

• Preoperative & pre-CPB factors

• CPB factors

• Post-CPB factors

• Surgical Bleeding
 POSTOPERATIVE BLEEDING
Preoperative / Pre-CPB factors

• Aspirin &/or Clopidigrol - anti-platelet

effects

• Reopro - abciximab; anti GpIIb/IIIa agent

• Warfarin / Heparin anticoagulation

• Pre-existing clotting factor &/or platelet

abnormalities
 POSTOPERATIVE BLEEDING
CPB factors

• Decreased platelet count

• Heparin effect

• Alien contact
 POSTOPERATIVE BLEEDING
Post-CPB factors

• Reversal of heparin

• Non-functional platelet

• Fibrinolysis
 POSTOPERATIVE BLEEDING
Surgical factors

• Type of Surgery
• complicated surgery
• redo surgery

• Cardiac surgery can be bloody!

• Big pipes, big holes, big vessels
• Blood and Surgery
• Lung of pig, Pancreas of cow, Sperm of salmon
• Foreign surfaces & cellular trauma
• Drug effects
• Thrombin activation
• Non-functional Platelets
• Altered blood flow
• Abnormal Coagulation & Fibrinolysis
• Inflammatory response to CPB
WHY DO PATIENTS BLEED AFTER
CARDIAC SURGERY?

HOW DO PATIENTS EVER CLOT

AFTER CARDIAC SURGERY?
CAN WE DO ANYTHING TO PREVENT
OR MINIMISE THIS BLOOD LOSS?

• Stop Aspirin / Clopidigrol

• Use of anti-fibrinolytics

• “Cell-salvage” techniques

• Surgical technique

• Blood Component therapy

HOW DO CARDIAC SURGEONS TREAT
POSTOPERATIVE BLEEDING?

• More Stitches / Surgicell / topical

haemostatic agents
• More Protamine
• Tranexamic acid
• Aprotinin /Aprotinin infusion
• Platelets
• FFP
• “Coagulation factor crash packs”
• Blood
• More Protamine
• More Platelets & FFP +/- Cryoprecipitate
• Reopening (5% nationally; 3.5% in ARI)
 PROBLEMS ASSOCIATED WITH
BLOOD & BLOOD PRODUCT USAGE IN
CARDIAC SURGERY
• Drain on donor pool
• supply v demand

• Financial consequences
• direct and indirect

• Patient consequences
• “Hazards of Transfusion”
• Infective / Immunogenic / Thrombogenic
problems
• “Other” problems
• Patients don’t want it
 Can we rationalize usage of blood & blood
products in Cardiac Surgery but still ensure
the right patient gets the right component
he really needs at the right time

We need to move away from the traditional

“carpet bombing” of the coagulation system in the
bleeding postoperative cardiac surgical patient
with all its associated risks towards a more
“targeted” clinical therapeutic approach?

Can we use the TEG to facilitate and support this

change in the management of the bleeding
patient?
We know the problems Can the TEG help us?
• Bloody surgery • Clot formation
• Anticoagulants • Clotting factors

• Clot kinetics
• Clotting factors
• Abnormal platelet • Platelets
function
• Clot strength &
• Damaged / ineffective stability
platelets
• Platelets

• Clot resolution
• Abnormal fibrinolysis
• Fibrinolysis
 CLINICAL STUDIES OF TEG USE
IN CARDIAC SURGERY

• Thromboelastography-guided transfusion algorithm reduces

transfusions in complex cardiac surgery.
Shore-Lesserson, Manspeizer HE, DePerio M et al
Anesth Analg 1999; 88 : 312-9

• Reduced Hemostatic Factor Transfusion using Heparinase

Modified TEG during Cardiopulmonary Bypass.
von Kier S, Royston D
Br J Anaesthesia 2001 ; 86 : 575-8
 Thromboelastography-guided transfusion algorithm
reduces transfusions in complex cardiac surgery
Shore-Lesserson et al, Anesth Analg 1999; 88 : 312-9

• Prospective blinded RCT

• Patients randomized to either routine transfusion practice or

TEG-guided transfusion therapy for post-cardiac surgery
bleeding

• Inclusion surgery types

• single / multiple valve replacement
• combined CABG + valve surgery
• cardiac reoperation
• thoracic aortic surgery

• Standard anaesthetic / CPB management

• routine use of EACA
 Thromboelastography-guided transfusion algorithm
reduces transfusions in complex cardiac surgery
Shore-Lesserson et al, Anesth Analg 1999; 88 : 312-9

• Surgeon / Anaesthetist “blinded” to group - TEG / coag results

reviewed by independent investigator who then instructed
clinicians what to give

• Data collection
• Coagulation studies and TEG data appropriate to each group
• Multiple time point assessment of
• Transfusion requirements
• FFP requirements
• platelet transfusion requirements
• Mediastinal tube drainage (MTD)
 Thromboelastography-guided transfusion algorithm
reduces transfusions in complex cardiac surgery
Shore-Lesserson et al, Anesth Analg 1999; 88 : 312-9

Routine transfusion group

Coagulation tests taken after
Protamine administration used to
direct transfusion therapy in
presence of bleeding

Transfused when Hct <25% (<21%

on CPB)
 Thromboelastography-guided transfusion algorithm
reduces transfusions in complex cardiac surgery
Shore-Lesserson et al, Anesth Analg 1999; 88 : 312-9

TEG-guided group
Platelet count + Celite & TF-
activated TEG’s with heparinase
modification taken at rewarm on CPB
(36C) - result used to order blood
products from lab

TEG samples run after Protamine

administration (celite & TF activated
plus paired plain / heparinase cups)
used to direct actual transfusion
therapy (in the presence of bleeding)

Transfused when Hct <25% (<21%

on CPB)
 Thromboelastography-guided transfusion algorithm
reduces transfusions in complex cardiac surgery
Shore-Lesserson et al, Anesth Analg 1999; 88 : 312-9

Routine transfusion group TEG-guided group

52 patients 53 patients

31/52 (60%) received blood 22/53 (42%) received blood

(p=0.06)

16/52 (31%) received FFP 4/53 (8%) received FFP

(p=0.002)
(p<0.04 for FFP volume)

15/52 (29%) received Platelets 7/53 (13%) received Platelets

(p<0.05)

MTD no statistical difference

 Reduced Hemostatic Factor Transfusion using Heparinase
Modified TEG during Cardiopulmonary Bypass
von Kier S, Royston D, Br J Anaesthesia 2001 ; 86 : 575-8

• Study design
• 2 groups of 60 patients
• Group 1 - conventional v retrospective TEG-predicted therapy
• Group 2 - prospective RCT - clinician-guided v TEG-guided

• Complex surgery
• transplants
• multiple valve / valve + revascularisation
• multiple revascularisation with CPB > 100 mins

• Outcomes
• FFP usage
• Platelet usage
• Mediastinal tube drainage (MTD)
 Reduced Hemostatic Factor Transfusion using Heparinase
Modified TEG during Cardiopulmonary Bypass
von Kier S, Royston D, Br J Anaesthesia 2001 ; 86 : 575-8
Group 1
Microvascular bleeding managed conventionally using standard coag
tests
• Microvascular bleeding
• Blood loss > 400ml in first hour
• Blood loss > 100ml/hr for 4 consecutive hours

• Triggers to treat
• PT & / or APTT ratio >1.5 x normal
• Platelet count < 50,000 /dl
• Fibrinogen concentration < 0.8 mg/dl
• Patients who returned to theatre (3) “replaced” by
additional pts
 Reduced Hemostatic Factor Transfusion using Heparinase
Modified TEG during Cardiopulmonary Bypass
von Kier S, Royston D, Br J Anaesthesia 2001 ; 86 : 575-8

Group 1
Predicted transfusion requirements using TEG algorithm
• Retrospective analysis of TEG data at PW (post-warm) sample
point
 Reduced Hemostatic Factor Transfusion using Heparinase
Modified TEG during Cardiopulmonary Bypass
von Kier S, Royston D, Br J Anaesthesia 2001 ; 86 :
575-8

Group 1 - conventional therapy Group 1 - TEG predicted therapy

60 patients 60 patients

22/60 given blood component 7/60 predicted to need component

therapy therapy (p<0.05)

Actual usage Predicted usage

38 units FFP 6 units FFP

17 units Platelets 2 units Platelets

(p<0.05)
 Reduced Hemostatic Factor Transfusion using Heparinase
Modified TEG during Cardiopulmonary Bypass
von Kier S, Royston D, Br J Anaesthesia 2001 ; 86 : 575-8

Group 2
• Prospective RCT arm of study

• 60 patients randomly allocated to one of two groups

• Clinician-directed therapy
• products given for bleeding as judged clinically
by clinical team responsible for case

• TEG algorithm-directed therapy

• products given for bleeding as directed by TEG-
driven protocol

• Patients who returned to theatre for bleeding (1 in each group)

were “replaced” with additional patients
 Reduced Hemostatic Factor Transfusion using Heparinase
Modified TEG during Cardiopulmonary Bypass
von Kier S, Royston D, Br J Anaesthesia 2001 ; 86 : 575-8

Sampling protocol
• all celite-activated heparinase modified samples
• Baseline (BL)
• Post-warm (PW)
• Post-protamine (PP) + celite-activated plain sample

TEG treatment algorithm

r>7 min but <10.5 min mild  clotting factors 1 FFP
r>10.5 min but <14 min mod  clotting factors 2 FFP
r>14min severe  clotting factors 4 FFP
MA<48mm mod  in platelet no / function 1 platelet pool
MA<40mm severe  in platelet no / function 2 platelets pools
LY30 >7.5%  fibrinolysis Aprotinin
 Reduced Hemostatic Factor Transfusion using Heparinase
Modified TEG during Cardiopulmonary Bypass
von Kier S, Royston D, Br J Anaesthesia 2001 ; 86 : 575-8

Group 2 - Clinician-directed Group 2 - TEG directed

30 patients 30 patients

10/30 received blood component 5/30 given blood component

therapy therapy (p<0.05)
16 units FFP 5 units FFP

9 units Platelets 1 unit Platelets

(p<0.05)

12 hour MTD losses 12 hour MTD losses

[median (lower & upper quartile)] [median (lower & upper quartile)]
390 (240, 820) 470 (295, 820)
(NS)
There appears to be good clinical evidence
that TEG can guide therapy and
decrease our blood product usage
 TEG studies - caveats

• studies looked at wide range of procedures & patient management -

difficult to extrapolate study findings to all units

• considerable variability in pre-study management across units

• concomitant introduction of postoperative transfusion protocols at

same time as TEG may cloud TEG outcomes

• variability in TEG-guided protocols and sources of derived data-

what exactly is normal in post-cardiac surgery population?

• by its very nature use of TEG facilitates early intervention, whereas

use of conventional tests delays intervention. Is this enough in itself
to explain apparent differences?
THROMBOELASTOGRAPHY

How do I use it?

THROMBOELASTOGRAPHY IN PRACTICE

Sampling protocol
• all kaolin-activated heparinase modified samples
– Baseline (BL)
– Post-warm (PW)
– Post-protamine (PP) + kaolin-activated plain
sample

– further paired CITU samples for bleeding if

required
Is the patient bleeding?
• Check samples running / already run = PW, PP, CITU
• “Eyeballing” of trends

PP r-Plain > r-Heparinase Inadequate heparin reversal Protamine

r>9-10 min  clotting factors FFP
MA<48mm  platelet no / function Platelets
LY30 >7.5% (or EPL > 15%) Hyperfibrinolysis Antifibrinolytic

Still bleeding?
• repeat TEG
• still abnormal  further factors as indicated
• normal  consider surgical bleeding
Thromboelastography in practice
Residual Heparin
Thromboelastography in practice
Long r time - clotting factor deficiency
Thromboelastography in practice
Low MA - Platelet dysfunction
Thromboelastography in practice
Fibrinolysis
 THROMBOELASTOGRAPHY
Summary

• Thromboelastography (TEG) provides near-patient, real-

time, dynamic measurements of coagulation and fibrinolysis

• It is ideally designed to provide useful information amidst

the cauldron of factors which contribute to post-cardiac
surgical bleeding

• Use of TEG to drive post-cardiac surgery protocols for

management of bleeding has been shown to be cost-
effective and will decrease the patient’s exposure to blood
and blood component therapy with its concomitant well-
documented risks

• Appropriate use of TEG can result in genuine cost savings in

Cardiac Surgery patients
Quand on ne sait pas,
on a peur

When you don’t know,

you are afraid

TEG=Clotting knowledge