The document discusses perioperative coagulation monitoring using point-of-care (POC) devices. It covers various types of POC tests including those that monitor heparin anticoagulation, viscoelastic haemostatic assays like ROTEM, and platelet function monitors. It highlights the limitations of standard coagulation tests and how POC devices provide a more complete picture of coagulation in whole blood. The document also addresses challenges in monitoring coagulation in specific diseases and trauma patients, noting the importance of communication between medical professionals when abnormal coagulation is detected.

1. PERIOPERATIVE COAGULATION
MONITORING – POC DEVICES
2nd COAGULATION DAYS / 2. DANI KOAGULACIJE
Zagreb 09 th and 10 th May 2019
Tajana Zah Bogović, MD, PhD
Department of Anesthesiology and Intensive
Care, KABEG Klagenfurt Clinic

2. AGENDA
• Bleeding history tests
• Categorization of POCTs:
- functional assays of monitoring heparin
anticoagulation
- viscoelastic haemostatic assay coagulation
monitoring
- platelet function monitors
- clotting factor tests
• Challenges in specific diseases and groups of
patients
• Conclusion

4. GUIDELINES

5. PERIOPERATIVE COAGULATION
MONITORING
RISK ASSESMENT

6. CHANGE IN PARADIGM
• Approach to preoperative lab.tests secondary
to results of standarised bleeding history
• Awareness of limitations of standard tests

7. Conventional coagulation tests
(PT, INR, aPTT, PLT)
• coagulation tests = coagulation times
• plasmatic coagulation tests
• sample: Not whole blood but plasma + citrate
• activator +/- cofactors and other additives
have two blind spots:
1) FXIII (Sample Stability)
2) Fibrinolysis
standard coagulation tests show an artificial system that
is not reflecting "in vivo„ situation

11. MONITORING OF COAGULATION

12. Types of POC
- functional assays of monitoring heparin
anticoagulation
- viscoelastic haemostatic assay
coagulation monitoring
- platelet function monitors
- clotting factor tests

13. functional assays of monitoring heparin
anticoagulation
• ACT (Activated clotting Time)
• Fresh whole blood is added to
a tube containing negatively
charged particles and timed
for the formation of a clot
• The type of negatively charged
particle affects the „normal“
length of ACT:
• Celite: normal 100-170 sec
• Kaolin: normal 110-190 sec
• Daily calibration checks are
imperative
• Therapeutic range:180-240 sec

14. TEG ROTEM
VISCOELASTIC METHODS

15. Rotational thromboelastometry
(ROTEM)„Targeted Approach“
• Quantitative and qualitative
examination of the blood clot
• A whole blood sample
• ROTEM results in 10-15 min
• H. Hartert 1948
• Bed side

16. Website: www.rotem.de.

17. ROTEM TEG

18. ROTEM/ROTEG Publications: overall 1144
(ROTEM/ROTEG PubMed Search [Title/Abstract])

19. ROTEM analasys
D. Keene, G.R. Nordmann, and T. Woolley. Rotational thromboelastometry-guided trauma
Resuscitation Curr Opin Crit Care 2013, 19:605–612

26. Limitations
• test is performed on a whole blood sample, it is performed
in vitro without the presence of the vascular endothelium -
activation of the vascular endothelium is implicated in the
development of ATC and, therefore, any in-vitro tests must
be interpreted with care
• Asses calcium levels and temperature whenever
interpreting ROTEM as the analysis is performed at 37C
with the addition of calcium to the sample
• The effects of antiplatelet medications such as aspirin and
clopidogrel are not detected by ROTEM as the thrombin
levels generated by test initiation overcome their inhibitory
effects

27. NUMBER OF PLATELETS
In some situations, only the number

28. ANTICOAGULANS PLATELET INHIBITORS

29. PLATELET FUNCTION

32. MultiPlate®
Evaluation of TRC (aggregation) function in heparinized full blood
It is based on impedance aggregation
quick results <15-30 min

33. INTRAOPERATIVELY-
MASSSIVE BLEEDING

34. GUIDELINES

36. POLY-TRAUMA
Coagulopathy in trauma is due to:
-Inflamation
-Hipoperfusion / Shock
-Tissue trauma
40% mortality can be associated
with pronounced coagulopathy
There is a close connection
between the severity of injury and
the degree of coagulopathy
Shock / hypoperfusion are the
main causes of traumatic
coagulopathy
Hess et al. J Trauma 2008.; Brohi
et al. Ann Surg. 2007.

37. COMMUNICATION WITH SURGEONS

43. 2 injury-related fybrinolytic phenotypes
• studies have identified two distinct injury-related
fibrinolytic phenotypes apart from normal physiologic
fibrinolysis, based on values of the thromboelastography
parameter LY30
• Hyperfibrinolysis
• Fibrinolysis shutdown- An LY30 cutoff of 0.8 percent or less
identified fibrinolysis -patients who present with the more
common "shutdown" fibrinolytic phenotype are at higher
risk of thromboembolic complications and long-term organ
failure and thus are conceptually at risk of harm from TXA
treatment
Hyperfibrinolysis, physiologic fibrinolysis, and fibrinolysis shutdown: the spectrum of postinjury fibrinolysis and relevance to antifibrinolytic
therapy.
AUMoore HB, Moore EE, Gonzalez E, Chapman MP, Chin TL, Silliman CC, Banerjee A, Sauaia A SOJ Trauma Acute Care Surg. 2014 Dec;77(6):811-7

44. CONCLUSION
• Preoperative screening for coagulophaties
• Always good: communication with the
patient and communication with the
surgeon
• POC methods
Know local local resources and services!

45. THANK YOU