From Annette Gaskill, Estes Park Medical Center:
I’m a MT at a small critical care hospital and also am part of our facility’s trauma committee. In our discussions of trauma cases involving patients already anticoagulated, our surgeon has asked me about thromboelastograms. Our coagulation menu is PT, PTT, and D-dimer; anything else is sent out. We only keep packed RBC’s in our blood bank, but are in process of bringing FFP in-house. I don’t foresee us ever keeping platelets or factors here. Our surgeon liked how the TEG gave not only coagulation values, but recommendations on what to give as far as blood products and factors. Just wondering if you could share any insights about coag testing for a small facility like ours, particularly trauma/surgical patients that are already anticoagulated.
By the way, I am to tell you I work with Bill Pierce…..hope that’s a good thing! All joking aside, Bill has been a great blessing to me, both professionally and personally. Thank you.
Hi, Anette, and thanks for your question. Many surgeons, anesthetists, and anesthesiologists swear by the thromboelastograph (TEG). They use it to monitor heparin, and there is at least one recent article, Gorlinger K, Fries D, Dirkmann D, et al. Reduction of FFP requirements by perioperative POC coagulation management with early calculated goal-directed therapy. Transfus Med Hemother 2012; 29: 104–13, that uses the clot strength and fibrinolysis measurements to control hemorrhage with the antifibrinolytic tranexamic acid (TXA, CycloKapron), cryoprecipitate (CRYO, or fibrinogen concentrate in Canada or Northern Europe), an activated prothrombin complex concentrate (FEIBA) and recombinant activated factor VII (NovoSeven), in that order. The Gorlinger article demonstrates better outcomes using as little FFP as possible to avoid transfusion-associated circulatory overload (TACO). TEG clot strength parameters are also used to guide platelet concentrate therapy.
The down side of the TEG is expressed in da Luz LT, Nascimento B, Rizoli S. Thrombelastography (TEG®): practical considerations on its clinical use in trauma resuscitation. Scand J Trauma Resusc Emerg Med. 2013;21:29, an open access journal. They say the TEG only functions as a near-patient assay, requires an experienced operator who can accurately interpret the results, takes as long as conventional assays, and requires frequent daily calibration. On the other hand, they confirm that the TEG is the only commonly available assay that characterizes fibrinolysis.
If your institution’s trauma center manages a lot of patients with acute hemorrhage, is equipped to manage bleeding with the new TXA-CRYO regimen, or even FFP, and if the lab is near the OR, the TEG may be a useful addition to your lab. Alternatively, it may be installed in the OR with the understanding the lab provides QC. On the other hand, if your laboratory director intends to add new coagulation assays, it may make sense to start with the thrombin time, which is being used often these days to screen for dabigatran, the fibrinogen assay, which can also help guide hemorrhage management, and PTT mixing studies.
By the way, please say hello to Bill, and tell him I hope to see him at a meeting soon!