Principles and Practice of Thromboelastography in Clinical Coagulation Management and Transfusion Practice

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In the recent years, thromboelastography has become a popular monitoring device for hemostasis and transfusion management in major surgery, trauma, and hemophilia. Thromboelastography is performed in whole blood and assesses the viscoelastic property of clot formation under low shear condition. Thromboelastography can be performed with a variety of activator and inhibitors at different concentrations representing the most important factors for different intervals and clot formation variables reported in multiple studies and algorithms. Furthermore, fibrinogen levels and platelet counts have a major influence on thromboelastographic variables. In addition, differences in patient populations, devices, and preanalytical conditions contribute to some conflicting findings in different studies.

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Basic Principles of Thromboelastography

Thromboelastography is used to assess viscoelastic changes in clotting whole blood under low shear conditions after adding a specific coagulation activator. The viscoelastic (tensile) force between the cup and the immersed pin results from the interaction between activated platelet glycoprotein (GP) IIb/IIIa receptors and polymerizing fibrin during endogenous thrombin generation and fibrin degradation by fibrinolysis [11], [12], [13], [14], [15]. Thromboelastography had been used to assess

PT/aPTT and Thromboelastography

For practicing clinicians, it is of interest to know whether the results of thromboelastography can be directly correlated with conventional coagulation tests. In particular, correlations between thromboelastographic coagulation time (Table 1, Table 2) and conventional PT and aPTT should be considered. In a recent clinical study of trauma-induced coagulopathy using ROTEM, the correlations between coagulation time in EXTEM/INTEM and PT/aPTT were rather poor (r = 0.47-0.53) [45]. Similarly, only

Fibrinolysis and Thromboelastography

In the presence of systemic fibrinolysis (eg, release or use of tissue plasminogen activator [tPA]), the thromboelastographic amplitude may rapidly decrease after maximal amplitude (compare traces in Fig 5A and C). When the decrease of the amplitude over 1 hour is more than 15% of maximal amplitude, hyperfibrinolysis is suspected. Using the ROTEM system, a specific assay containing aprotinin (APTEM test) might confirm the presence of hyperfibrinolysis [6]. The release of tPA from endothelial

Effects of Hematocrit on Thromboelastography

In the flowing (arterial) blood, platelets are preferentially distributed near the vessel wall (margination) because of the red cell mass [82]. The platelet count measured in a static blood sample does not reflect in vivo platelet concentration by the injured vessel wall, and this may explain a relatively low incidence of spontaneous bleeding until the platelet count is below 10 000/μL [83]. In addition, the red blood cells facilitate platelet aggregation by releasing adenosine diphosphate

Hypercoagulability and Thromboelastography

Thromboelastography is substantially influenced by the platelet count [29], platelet-fibrin interaction, and fibrin polymerization [11], [62]. Enhanced clot formation on thromboelastography may be associated with a hypercoagulable state. Indeed, maximal clot amplitude and coagulation index, derived from an equation including R time, K time, maximal amplitude, and angle α [89], were found to be higher in surgical patients with thrombotic events than in healthy controls [90]. However, the

Clinical Algorithms for Bleeding Management

Thromboelastography-guided transfusion algorithms have successfully been implemented in the treatment of bleeding patients after major surgery [16], [24], [72], [96], [97]. An example of a transfusion algorithm based on ROTEM is shown in Figure 6. It must be clearly stated that this algorithm has not yet been validated. In general, EXTEM and FIBTEM are used primarily to evaluate overall clot stability and fibrin polymerization, respectively (Fig 2). Thromboelastography-based cutoff values are

Conclusion

Thromboelastography seems to be valuable for a rapid assessment of hemostatic clot stability, providing reliable and clinically valuable information on coagulation processes, and implementing goal-directed transfusion therapy in bleeding patients in major surgery and trauma and, with some limitations, in bleeding hemophilic patients. Perioperatively, physicians might therefore use thromboelastography as a unique window into complex coagulopathy. As with other laboratory tests, these in vitro

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    Conflicts of interest: DB received honoraria for lecturing from TEM International, Munich, Germany. KAT served on the advisory board for TEM International, Munich, Germany.

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