TEG – MONITORING & TREATING BLEEDING PATIENTS
Transcript of TEG – MONITORING & TREATING BLEEDING PATIENTS
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TEG – MONITORING & TREATING BLEEDING PATIENTS
Naomi Rahimi-Levene MD, MHADirector of the Blood Bank
Assaf Harofeh Medical Center Zerifin, Israel
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The Versailles wedding hall collapse Jerusalem 2001
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The Versailles wedding hall collapse Jerusalem 2001
• Wedding hall collapses
• 13 people killed
• Hundreds injured
• Injured were sent to distant hospitals as closer ones were saturated
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Sample Arrives Blood Bank
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TEG in the Blood Bank
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TEG in the Blood Bank
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TEG viewed in my office
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TEG viewed at home
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TEG viewed at home
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TEG® analyzerFeatures
Two independent
channels
Temperature display &
control
Computerized data collection
& storage
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The TEG® analyzer
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TEG® TechnologyHow it works
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Interactive
Coagulation Proteins
Hemostasis Components:
Virchow’s triad
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Platelet function
Clot strength
Clotting
time
Clot
kineticsClot stability
Clot breakdown
TEG® TechnologyHemostasis profile
Time (min)
Pin
Ro
tati
on
Am
plit
ud
e (m
m)
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Clot Parameters
Enzymatic pathways(reaction time)
Platelets + fibrinogen (80/20)(maximum amplitude)
Clot breakdown
Clot development (kinetics, rate)
CI = global coagulation index (linear expression of R, MA, K, angle)
Time (min)
Am
plit
ud
e
(mm
)
LY30
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®
LY30 measures the rate of amplitude reduction 30 minutes after MA. This measurement gives an indication of the stability of the clot.
LY30
(EPL)
MA, or Maximum Amplitude, is a direct function of the maximum dynamic properties of fibrin and platelet bonding and represents the ultimate strength of the fibrin clot.
MA
K time is a measure of the rapidity to reach a certain level of clot strength.K
The value measures the rapidity (kinetics) of fibrin build-up and cross-linking, that is, the speed of clot strengthening.
R is the time of latency from the time that the blood was placed in the TEG® analyzer until the initial fibrin formation.
R
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TEG® value Clinical Cause Suggested Treatment
R between 7 - 10 min clotting factors x 1 FFP or 4 ml/kg
R between 11-14 min clotting factors x 2 FFP or 8 ml/kg
R greater than 14 min clotting factors x 4 FFP or 16 ml/kg
MA between 49 -54 mm platelet function 0.3mcg/kg DDAVP
MA between 41 -48 mm platelet function x5 platelet units
MA at 40 mm or less platelet function
x10 platelet units
α less than 47 fibrinogen level .06 u/kg cryo
LY30 7.5% or greater, CI less than 3.0 Primary fibrinolysis antifibrinolytic of choice
LY30 7.5% or greater, CI greater than 3.0 Secondary fibrinolysis anticoagulant of choice
LY30 less than 7.5%, C.I. greater than 3.0 Prothrombotic state anticoagulant of choice
Treatment Protocol
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Pattern Recognition
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–
–
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TEG decision tree
US Patent 6,787,363
Hemorrhagic
Thrombotic
Fibrinolytic
Developed from a number of clinical studies
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33 years old women with epidural catheter after childbirth 67000 plts
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63 years old patient with normal coagulation tests,
bleeding after prostatectomy
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Bleeding patient with pathologic coagulation tests –prolonged INR & APTT – coumadin overdose
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The same patient after component treatment
received 7FFP and 2pc
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Intensive care patient, massive bleeding, prolonged PT and thrombocytopenia -
received 4pc+10FFP+10 cryo+10plts
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Intensive care patient, massive bleeding, prolonged PT and thrombocytopenia
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Same patient after 12pc+14FFP+10cryo+15 plts
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Patient with hematological malignancy – all coagulation tests pathological – bleeding from stomach received
25pc+16FFP+25cryo+30plts
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56 years old patient with acute on chronic renal failure, Diabetes mellitus, Morbid obesity, Copd with acute
exacerbation, Mechanical ventilation
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Same patient with heparinase
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Same patient after component treatment
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72 years old patient after TKR with bleeding in knee, PT mildly prolonged and corrected with vit k, PTT,
fibrinogen normal, platelets normal
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TEG (1)
• In a catastrophic event many massively bleeding patients will have to be treated simultaneously, sharing available resources
• Conventional blood tests will not provide a swift enough answer to guide decision making as they can be lengthy and do not necessarily represent the in vivo picture
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TEG (2)
• In our hospital TEG is performed in the blood bank and can be viewed online in remote sites (including the operating theater)
• The anesthetists have been tutored in interpreting the TEG and in a short time the need for FFP, cryoprecipitate (fibrinogen) and platelet concentrates can be assessed, allowing prompt on time decision making
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TEG (3)
• In an event in which communication online is cutoff the TEG can be transferred and setup in the operating theater, allowing decision making on the spot
• The test can be repeated until the patient is stabilized and has received proper replacement therapy
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TEG Blood Bank
TEG OR
TEG office
TEG home
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Study Proposal
• Trauma patients – massively bleeding
• TEG on entry OR
• After receiving 1st pack - TEG
• If bleeding continues reevaluate TEG
• TEG when patient stabilizes
• In parallel – CBC, PT, APTT, fibrinogen