Phillip Gray
25 January 2016
Thrombelastograph® (TEG®)
Coagulation Analyser
The TEG® System is indicated for use with adult patients when an evaluation of their blood hemostatic properties is desired. Results from the TEG analyser should not be the
sole basis for a patient diagnosis; TEG results should be considered along with a clinical assessment of the patient’s condit ion and other coagulation laboratory tests. For
Professional Use Only.
Haemonetics, TEG, and Thrombelastograph are trademarks or registered trademarks of Haemonetics Corporation in the USA, other countries, or both. PlateletMapping is a
registered trademark of Coramed Technologies, LLC. Effient is a registered trademark of Eli Lilly and Company. Plavix is a trademark of Bristol-Myers Squibb/Sanofi
Pharmaceuticals Partnership.
Please refer to the manuals for Indications for Use, Contraindications, Warnings, Precautions, and Potential Adverse Events.
2 © Haemonetics Corporation
Individual Goal Directed
Coagulation Management
TEG 6s
“Making the Complex Simple”
3 © Haemonetics Corporation
A real time analyser of whole blood allowing for
individualised goal-directed therapy.
Measures the viscoelastic properties of the
haemostasis process functionally, with the end-
result being a haemostatic plug, or clot.
What is TEG®?
4 © Haemonetics Corporation
Clinical Practice: A Constant Struggle…
5 © Haemonetics Corporation
Injury
Disease
Aging Process
Cholesterol
Hardening of Arteries
Vascular Constriction
and Breakdown
Blood Activation by
Turbulence
Upsetting the balance
Natural processes
6 © Haemonetics Corporation
Surgery
Devices – LVADs,
CPB, ECMO
Trauma
Drugs
Stents
Airplane Flights –
DVT
Smoking
Upsetting the balance
Human intervention
7 © Haemonetics Corporation
Multiple systems Cells
56+ proteins
Dynamic
Interactive
Complexity of haemostasis
Copyright © 2011 Haemonetics Corp.
F X
F IXaF IX
F XIaF XI
Surface Contact
Collagen
FXII activator
F XIIaF XII
Intrinsic Pathway
Ca2+
Ca2+
Ca2+ F X
F VIIF VIIa
F III (Tissue
Thromboplastin)
Tissue/Cell Defect
Extrinsic Pathway
Ca2+
Ca2+
FibrinogenFibrin
monomers
Fibrin
polymers
Thrombin IIaProthrombin II
F Xa
Ca2+
Platelet Factor 3
Crosslinked
Fibrin Network
F XIIIa F XIII
F VF Va
F VIIIaF VIII
Yellow lines
indicate
positive
feedback
loops lost in
isolated tests
The Coagulation Cascade
9 © Haemonetics Corporation
Traditional haemostasis monitoring
Traditional
Hemostasis
Tests
Do not define the overall process, just provide pieces of the process!
D-Dimer
10
Cell-Based Model• Reflects in vivo
Occurring on cell surfaces
Tissue factor bearing cells
Platelets
Overlapping phases:
Initiation (TF bearing cells)
Amplification (platelets)
Propagation (platelets)
• The coagulation cascades are still
important, but are cell-based
extrinsic pathway: surface of tissue
factor bearing cells
intrinsic pathway: surface of
platelets
• Routine coagulation tests do not
represent the cell-based model of
hemostasis
[Monroe, DM. et al. Arterioscler Thromb Vasc Biol. 2002;22:1381]
Tissue factor
bearing cells
1. Initiation
Platelets
Activated
platelets
2. Amplification
3. Propagation
IIa
IIa
11 © Haemonetics Corporation
TEG Technology
12 © Haemonetics Corporation
1- INITIATION
Haemostasis made simple with TEG
Reaction
INITIATION
1
13 © Haemonetics Corporation
1- INITIATION 2- STRENGTH
Haemostasis made simple with TEG (2/3)
Maximum clot
STRENGTH
2
Reaction
INITIATION
1
14 © Haemonetics Corporation
1- INITIATION 2- STRENGTH 3- STABILITY
Haemostasis made simple with TEG (3/3)
Maximum clot
STRENGTH
2
Reaction
INITIATION
1
Clot degradation
STABILITY
3
15 © Haemonetics Corporation
TEG® Core Assessment
1. INITIATION
2. STRENGTH
3. STABILITY
1 INITIATION
2 STRENGTH 3 STABILITY
16 © Haemonetics Corporation
TEG® Trace – Diagnostic Complex
17 © Haemonetics Corporation
Heparin/Enoxaparin Effect
Plain cup
5.8 2.2 59.1 0.0 56.2 6.4
Heparinase cup
18 © Haemonetics Corporation
Functional Fibrinogen TEG ®
19 © Haemonetics Corporation
Fibrinogen/Platelet Ratio
20 © Haemonetics Corporation
Fibrinogen/Platelet Ratio
21 © Haemonetics Corporation
Tissue Factor and Kaolin Activation –
RAPID test of CLOT STRENGTH and any FIBRINOLYSIS
Also provides RAPID TEG® ACT Result
RapidTEG® Assay
22 © Haemonetics Corporation
Rapid TEG
23 © Haemonetics Corporation
4 TEST CONCEPT
Kaolin Activated
Functional Fibrinogen
Rapid TEG
Heparinase
24 © Haemonetics Corporation
4 TEST CONCEPT - Combination TEST
Kaolin Activated Rapid TEG
Functional Fibrinogen
Early Diagnosis ~10 Min
Fast…Global…Sensitivity to All Phases…
25 © Haemonetics Corporation
The TEG5000 Today
26 © Haemonetics Corporation
The TEG5000 Software Today
27 © Haemonetics Corporation
The TEG6s………. TOMORROW
28 © Haemonetics Corporation
TEG 6s
“Making the Complex Simple!
TEG 6s Test Procedure
30 © Haemonetics Corporation
Patient Test Procedure
31 © Haemonetics Corporation
TEG 6s Stand-Alone Device
32 © Haemonetics Corporation
TEG 6s
Complex Technology
Resonance-frequency viscoelasticity measurements and
disposable multi-channel microfluidic cartridges
33 © Haemonetics Corporation
Sample ring subjected to external vibration
Sample Testing
34 © Haemonetics Corporation
Harmonic motion of sample measured optically
Measurement
Optical detection
35 © Haemonetics Corporation
Click to play
Sample Testing Animation
36 © Haemonetics Corporation
As sample transitions from liquid to gel state,
measurements are plotted: Clot strength vs. Time
Measurement
Time
Clot
strength
Liquid
state
Gel
state
37 © Haemonetics Corporation
TEG 6s
Tests
Kaolin TEG Contact activator in routine use
Heparinase cups Neutralises heparin to allow you to see patients underlying
haemostatic profile
RapidTEG® Tissue Factor and Kaolin Activation – for rapid testing of clot strength
and also provides TEG® ACT Result
Functional
Fibrinogen
Functional fibrinogen reagent provides a functional measurement of
patient fibrinogen level
1. Global hemostasis cartridge (citrated tube - blue top)
2. PlateletMapping cartridge (heparin tube – green top)
PlateletMapping® Gives personalised antiplatelet therapy for both haemorrhagic and
thrombotic condition
3. QC cartridges
Biological QC Level I and II
38 © Haemonetics Corporation
The TEG 6s
Making the Complex Simple
Simplicity in Facilitating the Science of the Cell Based Model
39 © Haemonetics Corporation
TEG 6s
Advances the TEG 5000 legacy through simple,
smart and reliable designSame Simple
Smart Reliable
Assess same physical property/results
40 © Haemonetics Corporation
Kaolin TEG
Rapid TEG
Functional Fibrinogen
TEG
Heparinase effect
Global Haemostasis Assessment
41 © Haemonetics Corporation
TEG 6s COMBINATION TEST CONCEPT
Global Impact: Fast and Specific Sensitivity
Kaolin Activated Rapid TEG
Functional Fibrinogen
Early Diagnosis ~10 Min
Global Haemostasis
42
1/17/201411:21 AMID: patientID1
CM Citrated K,KH,RT,FF baseline1/16/2014
11:21
results next tracing
CK
CRT
CKH
CFF
80
60
40
20
00 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
(min)
43
CM Citrated K,KH,RT,FF baseline
R(min)
K(min)
Angle(deg)
MA(mm)
device 1User 1
1/17/201411:21 AMID: patientID1
done tracingsprint
LY30(%)
CK
CRT
CFF
CKH
5.84.6-9.1
2.30-2.6
73.463-78
58.552-69
59.752-70
58.552.3-68.9
19.8-
15-32
1.30.8-2.1
73.460-78
74.964.3-77.1
1.60.8-2.7
1.20.8-1.9
0.30.3-1.1
5.54.3-8.3
1.50-2.2
78.6 !82-152
TEG-ACT(sec)
361.3278-581
FLEV(mg/dl)
1/16/2014
11:21
44
1/17/201411:21 AMID: patientID1
CM Citrated K,KH,RT,FF baseline1/16/2014
11:21
results next tracing
CK
CRT
CKH
CFF
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
45
1/17/201411:21 AMID: patientID1
results next tracing
CK
80
60
40
20
00 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
R 5.8(min) 4.6-9.1
K 1.3(min) 0.8-2.1
Angle 73.4(deg) 63-78
MA 58.5(mm) 52-69
LY30 2.3(%) 0-2.6
(min)
CM Citrated K,KH,RT,FF baseline1/16/2014
11:21
46
1/17/201411:21 AMID: patientID1
results next tracing
CKH
80
60
40
20
00 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
(min)
CM Citrated K,KH,RT,FF baseline1/16/2014
11:21
R 5.5(min) 4.3-8.3
K 1.2(min) 0.8-1.9
Angle 74.9(deg) 64.3-77.1
MA 58.5(mm) 52.3-68.9
47
1/17/201411:21 AMID: patientID1
results next tracing
CRT
80
60
40
20
00 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
(min)
CM Citrated K,KH,RT,FF baseline1/16/2014
11:21
R 0.3(min) 0.3-1.1
K 1.6(min) 0.8-2.7
Angle 73.4(deg) 60-78
MA 59.7(mm) 52-70
LY30 1.5(%) 0-2.2
TEG-ACT 78.6(sec) 82-152
48
1/17/201411:21 AMID: patientID1
results next tracing
CFF
80
60
40
20
00 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
MA 19.8(mm) 15-32
FLEV 361.3(mg/dl) 278-581
(min)
CM Citrated K,KH,RT,FF baseline1/16/2014
11:21
49
50
CM Citrated K,KH,RT,FF baseline
R(min)
K(min)
Angle(deg)
MA(mm)
device 1User 1
1/17/201411:21 AMID: patientID2
done tracingsprint
LY30(%)
CK
CRT
CFF
CKH
5.84.6-9.1
2.30-2.6
73.463-78
58.552-69
59.752-70
58.552.3-68.9
19.8-
15-32
1.30.8-2.1
73.460-78
74.964.3-77.1
1.60.8-2.7
1.20.8-1.9
0.30.3-1.1
5.54.3-8.3
1.50-2.2
78.6 !82-152
TEG-ACT(sec)
361.3278-581
FLEV(mg/dl)
1/16/2014
11:21
51 © Haemonetics Corporation
TEG 6s Case Studies
Case Study 1: Re-warm sample
pre-op INR 2.6
Case Study 1: Re-warm sample
pre-op INR 2.6
Case Study 1:
Post-protamine
Case Study 1:
Post-protamine
Case Study 1: Post-protamine #2
Post-transfusion 1 x plasma, 1 x thrombocyte,
additional protamine
Case Study 1: Post-protamine #2
Post-transfusion 1 x plasma, 1 x thrombocyte,
additional protamine
Case Study 2: Post-protamine
Case Study 2: Post-protamine
60 © Haemonetics Corporation
Aorte Ascendante Post-0p (Dr. Braunberger)
61 © Haemonetics Corporation
Aorte Ascendante Post 1,5 g Fibrinogene
62 © Haemonetics Corporation
Platelet Mapping: Measuring the potential impact of ant-Platelet therapy
Measures Individualized response to drugs!
INDIVIDUAL haemostatic baseline
Individually affected by ANTI-PLATELET DRUGS
63 © Haemonetics Corporation
Antiplatelet drugs ADP receptor inhibitors
Examples: clopidogrel (Plavix®), ticlopidine (Ticlid®) prasugrel (Effient®), ticagrelor (Brilinta®)
Thromboxane pathway inhibitors
Example: aspirin
GPIIb/IIIa inhibitors
Examples: abciximab (Reopro®), tirofiban(Aggrastat®), eptifibatide (Integrilin®)
PlateletMapping®What drugs are monitored?
64 © Haemonetics Corporation
Platelet Mapping – Combination Test
Platelet
Function
Maximum
ZERO
Drug affect
(60% Inhibition)
(100% Aggregation)
(0% Aggregation)
65 © Haemonetics Corporation
What if they are all treated the same? (50% inhibition)
Why PlateletMapping® Assay?
Personalized Platelet Therapy
66 © Haemonetics Corporation
All 50% Inhibition
Why PlateletMapping® Assay?
Personalized Platelet Therapy
67
1/17/201411:21 AMID: patientID1
PM Platelet Mapping baseline1/16/2014
11:21
results next tracing
HKH
ActF
ADP
AA
80
60
40
20
00 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
(min)
68
PM Platelet Mapping baseline
HKH
ActF
AA
ADP
6.64.2-9.8
---0-2.4
68.257-75
61.854-70
R(min)
K(min)
Angle(deg)
MA(mm)
device 1user 1
1/17/201411:21 AMID: patientID1
done tracingsprint
7.62-19
59.644-69
61.937-71
1.71-2.96
LY30(%)
0
95.9
100
4.1
Inhibition(%)
Aggregation(%)
ADP
AA
ADP
AA
1/16/2014
11:21
69
1/17/201411:21 AMID: patientID1
results next tracing
HKH
80
60
40
20
00 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
R 6.6(min) 4.2- 9.8
K 1.7(min) 1- 2.9
Angle 68.2(deg) 57- 75
MA 61.8(mm) 54- 70
LY30 ---(%) 0-2.4
(min)
PM Platelet Mapping baseline1/16/2014
11:21
70
1/17/201411:21 AMID: patientID1
results next tracing
ActF
80
60
40
20
00 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
(min)
PM Platelet Mapping baseline1/16/2014
11:21
MA 7.6(mm) 2-19
71
1/17/201411:21 AMID: patientID1
results next tracing
ADP
80
60
40
20
00 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
(min)
PM Platelet Mapping baseline1/16/2014
11:21
MA 59.6(mm) 44-69
72
1/17/201411:21 AMID: patientID1
results next tracing
AA
80
60
40
20
00 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
(min)
PM Platelet Mapping baseline1/16/2014
11:21
MA 61.9(mm) 37- 71
73 © Haemonetics Corporation
TEG 6s COMBINATION TEST CONCEPT
Global Impact: Fast and Specific Sensitivity
Kaolin Activated Rapid TEG
Functional Fibrinogen
Early Diagnosis ~10 Min
Platelet Function
Maximum
ZERO
Drug affect
(60% Inhibition)
(100%
Aggregation)
(0%
Aggregation)
Global Haemostasis
74 © Haemonetics Corporation
TEGManager
TEG Viewer
+Device Manager
= TEG Manager
75 © Haemonetics Corporation
View real-time and
historical TEG tests on
remote monitors
View multiple TEG
tests per patient
Color-coded by
cartridge
“Share” a view with
others
10 languages to start
TEG Viewer
TEGManager = Two applications
TEG Viewer
TEGViewer:
TEGManager leverages the TEG 6s data
One way communications pull from the
device
Stores clinical test results from a fleet of TEG
devices
Displays active and historical TEG test results
Provides patient trending data across multiple
TEG devices
Available on various screen sizes from iPad
to large screen monitor
Provides clinical and research reports
Allows viewing of active and historical results
on multiple screens & View status of all
TEG 6s devices in the institution (operation,
calibration, status, logs, firmware, cartridge
configuration
TEG Viewer + Device Manager = TEG Manager
TEG Viewer Main Screen
TEGManager = Two applications
Device Manager
Device Manager:
Manages:
User credentials & different level of
access
Network connectivity
Bi-directional connectivity to devices
Connectivity to middleware for Patient
Identification
Device-specific reports (i.e., uptime, error
logs, etc.)
Aggregates TEG data from several
Analyzers into a centralized data repository
Provides centralized administration (i.e.,
User IDs)
Connectivity between devices and
middleware (HaemoCommunicator)
TEG Viewer + Device Manager = TEG Manager
TEG Device Manager
View status of all TEG 6s
devices in the institution
(operation, calibration,
status, logs, firmware,
cartridge configuration)
Manage users on devices,
their permissions, full data
access reporting
Model for managing
Haemonetics devices
moving forward
Hospital Network
IT SERVICESWEB Access anywhere from any PC or tablet connect on the network
Or higher
With one of the following browser
Operating room Biologist’s Office Doctor’s officeEverywhere…
Emergency Operating room Satellite Lab Etc.
TEG : IT Architecture in Hospital
Unrivalled performance with TEG6s
ProtocolsWhen to Sample?
How to Treat?
83
Cardiac Surgery TEG Protocol
TEG Protocol When Tube
Global Haemostasis
or
Platelet
Mapping
Either Day before or on induction:
Prior to heparin and hemodilution
Blue Top: Patient Label and
time sample drawn.
Green Top: Patient Label and
time sample drawn
Re-warm Blood Temperature 35-36 Degrees
C (20 minutes prior to coming off
bypass)
Blue Top: Patient Label and
time sample drawn.
Post-Protamine
Ten Minutes post protamine (Same
time ACT drawn) Blue Top: Patient Label and
time sample drawn.
Post Op Two Hour Post protamine (ICU
sample) or upon bleeding
Blue Top: Patient Label and
time sample drawn
84 © Haemonetics Corporation
Adapted from: Agarwal S et al. J Cardiothorac Vasc Anesth. 2014
Pre-Bypass Platelet Function Testing TEG® PlateletMapping
Pre-Bypass Kaolin TEG®
Pre-Bypass Functional Fibrionogen TEG®
Check Kaolin and Heparinase TEG®
Post-Protamine Functional Fibrionogen TEG®
Check Pre-Bypass
Platelet Function Test
Transfuse 2 pools
platelets
Transfuse 1 pool
platelets
Administer 50mg
Protamine
Transfuse 8ml/kg
FFP
Transfuse 16ml/kg
FFP
Transfuse 1 pool
platelets*
Transfuse 1 pool
platelets*
Check Functional Fibrinogen TEG® **
Is
PLM ADP Inhibition
>70%?
Is
PLM ADP Inhibition
>60%?
Transfuse 10 units
Cryoprecipitate
Post-Protamine Kaolin and Heparinase TEG®
Is the
Kaolin R time
>2 Heparinase
R time?
Is the
R time ≥10 and
< 14 min?
Is the R time
> 14 min?
Is MA <40 and
≥25mm?Is MA <25mm?
Is the FLEV < 1g/l?
Is the patient suffering from post-
operative micro-vascular bleeding
Operative Procedure
Resume standard care
If bleeding continues
consider resternotomy
Yes No
No No NoNo
Yes Yes Yes Yes Yes Yes Yes
Yes
No
No
No
No
No
* If not already receiving platelet transfusion from TEG® PlateletMapping (PLM)
** Reverted to Clauss firbrinogen values after first 100 patients
TEG-guided
hemostasis
algorithm in CV
surgery– Liverpool Heart and
Chest Hospital
Liverpool, UK
85 © Haemonetics Corporation COL-COPY-000864-IE(AA)
ECLS et TEG
86 © Haemonetics Corporation COL-COPY-000864-IE(AA)
TEG et CIVD
Septic Patient – DIC?
• Patient presented in ED with suspected Meningitis.
• TEG shows classic Stage 1 DIC tracing
Septic Patient – DIC?
• 2 hours after administration of heparin 10u/kg iv followed by 10u/kg/hr drip. Note that the patient is no longer hypercoagulable under heparin, but when heparin is removed with heparinase, condition reverts (red tracing).
Septic Patient – DIC?
• 12 hours later the heparin effect is more pronounced
(extended R) and normal values on heparinase tracing
(red). Heparin dose can now be reduced.
Septic Patient – DIC?
• 36 hours after treatment with heparin begun. Dose has been reduced to 5u/kg/hr. Note no reversion to hypercoagulable values in heparinase (red tracing). Condition resolved. Patient subsequently extubated and transferred to the floor.
Questions?
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