point of care haemostasis monitoring

1. Point-of-Care Haemostasis
Monitoring
F R de Belder MBBS RAMC
CT1

2. What is it?
• ROTEM
• (Rotational
Thromboelastography)
TEG
(Haemoscope Corp.)

3. • Real time
• Shear Elasticity measurement of clot
• Whole blood
• Cell-based theory of coagulation
• Simulates low-shear in vivo vasculature

5. Variables
• Confusing
• TEG & ROTEM have different names for
the same things
• NOT interchangeable
• SHAPE of curve most important!

8. Examples

9. GOAL?
• Intent: Reduce total blood products given
• Method:
– Goal directed, non-RBC blood products
– Address specific deficiencies
– Rapid: 15 vs 60 mins (comp to lab tests)

10. Patient populations
• Cardiac
Problem=Low clotting factors, high thrombin
(unique to cardiac surgery)
High thrombin, activated fibrinolysis
Less FFP, more PCC/[fibrinogen]/platelets
BUT: Cochrane review: no change in outcomes!
**recommended by NICE**

11. Obstetrics
• Fibrinogen normally rises in 3rd
trimester
• Hypofibrinogenaemia= Inc. risk of PPH
(<2g/l=PPV 100%!)
• Normal ranges have been published
• **Not currently rec by NICE;lack of
evidence**

12. Trauma cont.
• Up to 38% are coagulopathic
• A/w 5x mortality increase

13. Trauma
• Acute trauma coagulopathy
– Tissue factor and activation
– Anticoagulation due to Protein C and
fibrinolysis
– Appears in mod trauma (ISS 10-20)
– ISS > 35 = primary hyperfibrinolysis
• (Side note: Crash-2 ARR 0.8%???)
• **Not rec by NICE: lack of evidence**

14. **Following slides taken from presentation
by Lt Col Wooley et al, RAMC**
Wooley et al(2009, October 2nd
) Feasibility of use of Rotational Thromboelastometry (ROTEM) to
Manage the Coagulopathy of Military Trauma in a Deployed Setting.[PowerPoint slides].
Presented at Nato Medical Conference 2009

15. Case 1
• 30kg Male
• 2hr post explosive
incident
• Temp 32°c, BP -70/30
• pH = 7.01, BE = -18
• Hb - 5.6 / Plt – 236
• PT 18.5 / PTT 58.2
• Over next 18hrs –
16 P.RBC, 10 FFP, 5Plts,
1Cryo

16. EXTEM Traces
Initial ED trace After admission to ITU

17. Ongoing Resuscitation
After 15hrs – 15P.RBC/10FFP/
4Plts/1Cryo
After 1 unit of apherised platelets

18. Case 2
• 65 yr old man
• Unknown time after GSW to right flank
• Initial observations:
– Systolic BP -110mmHg / pulse 94 bpm
– Tympanic temperature -34.9°C
– pH = 7.01 / base excess = -17
– Hb = 8.4g/dL / plts = 182 x109
cells/L
– PT = 14.3s / APTT = 83.1s

19. Initial Trace
HYPERFIBRINOLYSIS

20. After 1 hr
Completely hypocoagulable state