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Thromboelastography: Clinical Application, Interpretation, and Transfusion Management
Thromboelastography: Clinical Application, Interpretation, and Transfusion Management
Thromboelastography: Clinical Application, Interpretation, and Transfusion Management
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The coagulation cascade is a dynamic process depen- tion. The ability to measure whole blood coagulation,
dent on many factors. It involves interaction between including platelet function, and not just the number of
primary hemostasis, platelet clot formation, second- platelets, can be critical when a healthcare provider is
ary hemostasis, thrombin generation, and fibrino- determining what products are appropriate for a par-
lysis. The assessment of this process is particularly ticular patient during surgery. One possible solution
important in the surgical patient to properly manage to this deficit in traditional coagulation monitoring is
hemostatic issues. Traditionally, coagulation tests thromboelastography. Thromboelastography provides
used to guide transfusion management have included a more complete picture of coagulation status, tak-
platelet count, activated partial thromboplastin time, ing into account more factors involved in the clotting
prothrombin time, international normalized ratio, and process, including platelet function and temperature.
activated clotting time, among others. Although these
tests provide the practitioner with valuable informa- Keywords: Coagulation, coagulation cascade, hemo-
tion, they lack the ability to measure platelet func- static issues, thromboelastography.
AANA Journal Course No. 36: AANA Journal course will consist of 6 successive articles, each with an objective for the reader and
sources for additional reading. This educational activity is being presented with the understanding that any conflict of interest on behalf
of the planners and presenters has been reported by the author(s). Also, there is no mention of off-label use for drugs or products.
Please visit AANALearn.com for the corresponding exam questions for this article.
K and α Maximum
Coagulation status TEG tracing R value value amplitude Treatment algorithm
Normal hemostasis Normal Normal Normal Attain surgical hemostasis
using sutures
Hemodilution or clotting factor High Low or Low or normal Administer fresh frozen plasma
deficiency normal if indicated
Table 2. Common Clotting Disorders, Thromboelastography (TEG) Tracing Example, Characteristic Values, and
Treatments
can disrupt the ultimate formation of a clot.4,8 system in a number of ways, including hemodilution of
The last major TEG parameter is the LY30, which procoagulants and platelets, a reduction in coagulation
measures the percent of clot lysis 30 minutes after the factors due to the interaction of blood with the surface
MA is achieved (see Figure). This measurement is most of the bypass circuit, the use of heparin, and altered tem-
useful for patients undergoing thrombolytic drug therapy perature.12 Hemodilution of clotting components occurs
or during more advanced stages of disseminated intravas- mainly due to the large amount of crystalloid and colloid
cular coagulation. This can be observed by rapid curve solutions used to prime the bypass circuit.12 Exposure of
convergence.4,8 heparinized circulating blood to the bypass circuit as well
Thromboelastography curves represent the coagula- as the surgical wound activates both the intrinsic and ex-
tion status at the time of blood draw. During changes in trinsic clotting cascade, triggering a prothrombotic reac-
coagulation, such as during active hemorrhage or periods tion. Heparin is administered in large doses, but it cannot
of massive transfusion, this status can change rapidly. prevent this thrombin formation; heparin can only reduce
Thromboelastography offers the ability to monitor mul- the thrombin after it has already been produced. This
tiple consecutive samples all at one time.4,8 constant formation of thrombin leads to what is called a
consumptive coagulopathy due to the exhaustion of clot-
Thromboelastography Clinical Applications ting factors.11 Hypothermia is known to cause multiple
• Cardiopulmonary Bypass. Extracorporeal circulation coagulation abnormalities leading to increased bleeding.
during cardiopulmonary bypass in the surgical patient Low body temperature blocks thromboxane synthesis,
has long been known to cause coagulation disturbanc- which results in decreased platelet aggregation.13
es.12 Cardiopulmonary bypass disrupts the hemostatic Traditionally, coagulation is monitored using the ACT