Thromboelastography

By

Mike Poullis
 Measuring Coagulation Status

• Why do it?

• Benefits

• Need to understand the position of TEG in

coagulation assessment
 Techniques
• Full blood count and Coagulation screen (APTT, PT, and
fibrinogen)

• Whole Blood tests

– Microaggregation
– Whole blood analysers
– Thrombelastography

• Purified Platelet tests

– Microaggregation
– Macroaggregation
– Platelet function analysers

• Skin bleeding time

 Advantages of Techniques
• Full blood count and Coagulation screen (APTT, PT, and fibrinogen)
– Quick, easy, reproducible, understandable

• Whole Blood tests

• MAJOR ADVANTAGE IS NO SAMPLE PREPERATION
– Microaggregation, Thrombelastography, and Whole blood analysers

– Easy

• Purified Platelet tests

– Microaggregation Easy
– Macroaggregation PRECISE DEFECT
– Platelet function analysers PRECISE DEFECT

• Skin bleeding time

– Whole body answer
 Limitations of Techniques
• Full blood count
– Number not function
• Coagulation screen (APTT, PT, and fibrinogen)
– 20 to 30 minutes, no fibrinolytic assessment

• Whole Blood tests

– Microaggregation No commercial kit
– Thrombelastography ?sensitivity

• Purified Platelet tests

• YOU HAVE TO PREPARE THE PLATELETS
– Microaggregation No commercial kit
– Macroaggregation Experienced technician
– Platelet function analysers ?

• Skin bleeding time

– Invasive, not specific
 Principles of
Thrombelastography

Celite (Kaolin) activated

Low shear environment

resembling sluggish
venous flow
Readout
 What the numbers/letters mean
• R: is a period of time from initiation of the test to the
initial fibrin formation
• k: time from beginning of clot formation until the
amplitude of thromboelastogram reaches 20 mm
• alpha angle: The alpha angle represents the acceleration
(kinetics) of fibrin build up and cross-linking
• MA - Maximum amplitude strength of clot (number
function platelets fibrin)
• MA60: measures the rate of amplitude reduction 60 min.
after MA (stability) of the clot
The Numbers and Letters
 Tips and Tricks
• Heparinase

• Adding c7E3 Fab (ReoPro) to the TEG sample

will eliminate platelet function from the
thromboelastogram.

• Antifibrinolytic agents such as Epsilon-

Aminocaproic Acid, Tranexamic acid and
Aprotinin
Example 1
 Example 1 Answer
• Diagnosis: Delayed clot formation; suspect
1.  heparin effect
2.  factor deficiency

• Treatment: Measure an activated clotting time (ACT) and

repeat TEG with Heparinase.
1.  if ACT prolonged: administer protamine
2.  repeat TEG with Heparinase:
•  if normal: administer protamine
•  if abnormal or heparin not utilized in case: administer FFP
Example 2
 Example 2 Answer
• Diagnosis: Hypercoagulable state.

•  Secondary to aggressive replacement of all

factors in platelet rich plasma
•  Chronic dissection of aortic aneurysms

• Treatment: none
Example 3
 Example 3 Answer
• Diagnosis: Weak Clot Formation

• Treatment: FFP, platelets and possible cryoprecipitate.

• Adding c7E3 Fab (ReoPro) to the TEG sample will

eliminate platelet function from the thromboelastogram.
The MA will become a function of fibrinogen activity.

• A repeat TEG should be performed post treatment.

Example 4
Heparinase

No Heparinase
 Example 4 Answer
• Diagnosis: Heparin Effect. The top curve
represents a TEG with Heparinase (heparin
activity eliminated) and the bottom trace is the
same sample without Heparinase (an elevated
ACT will confirm the diagnosis).

• Treatment: Reverse the heparin and repeat the

TEG or reverse the heparin and perform an ACT.
Example 5
Heparinase
No Heparinase
 Example 5 Answer
• Diagnosis: Normal Coagulation Profile. This is a
TEG from the same patient shown in example 4.
The heparin was reversed with protamine. The top
curve represents a TEG with Heparinase (heparin
activity eliminated) and the bottom trace is the
same sample without Heparinase. Since both
traces are identical all heparin was reversed by
protamine.

• Treatment: If there is still bleeding its surgical!

Example 6
 Example 6 Answer
• Diagnosis: No clot formation
•  Very low factor levels
•  Heparin effect

• Treatment:
•  repeat TEG with Heparinase :
1.  if TEG normal: reverse heparin with protamine
2.  if TEG abnormal: administer FFP
Example 7
 Example 7 Answer
• Diagnosis: Poor coagulation and fibrinolysis

• Treatment: Administer coagulation factors and

antifibrinolytics (Tranexamic Acid or Aprotinin).
• The antifibrinolytics can be added to the TEG to
pre-evaluate their effectiveness.
• Repeat the TEG post treatment.
Example 8
 Example 8 Answer
• Diagnosis: Technical error in processing TEG or
severe coagulopathy (correlate with clinical
scenario)

• Treatment: Repeat TEG

1.  if normal: do nothing
2.  if grossly abnormal and clinical bleeding:
administer all products (FFP, platelets,
cryoprecipitate) and repeat TEG.
 Limitations
• Still being evaluated
• Paired pre and post operative TEGs
• Still do lab tests
• Celite and mechanical activation not
biochemical

• Wythenshaw, and Blackpool have TEG but

no communication on experience!
 Clinical Common Sense
• Use same clinical skills to assess the
bleeding patient

• On Aspirin, Clopidogrel and Fragmin

• IGNORE THE TEG