Point of-care haemostasis monitoring
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Point-of-Care Haemostasis Monitoring describes rotational thromboelastography (ROTEM) and thromboelastography (TEG), which measure the viscoelastic properties of whole blood clotting in real time. The shape of the clotting curve is most important. ROTEM and TEG have different names for the same measurements and are not interchangeable. The goal of point-of-care coagulation monitoring is to reduce blood product transfusion by targeting specific clotting factor deficiencies. It has been recommended for cardiac and obstetric patients but not trauma patients due to lack of evidence. Two case studies show ROTEM traces of severely coagulopathic trauma patients and the impact of targeted
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2. Serve as an indicator of patient outcomes and prognosis, as patients with more impaired clot strength on TEG were 3 times more likely to receive blood transfusions and 70% required massive transfusions.
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2. Serve as an indicator of patient outcomes and prognosis, as patients with more impaired clot strength on TEG were 3 times more likely to receive blood transfusions and 70% required massive transfusions.
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https://scanfoam.org/
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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
- 20. After 1 hr Completely hypocoagulable state