Point-of-Care Haemostasis Monitoring

F R de Belder MBBS RAMC

CT1

What is it?

• ROTEM• (Rotational

Thromboelastography)

TEG

(Haemoscope Corp.)

• Real time

• Shear Elasticity measurement of clot

• Whole blood

• Cell-based theory of coagulation

• Simulates low-shear in vivo vasculature

Variables

• Confusing

• TEG & ROTEM have different names for the same things

• NOT interchangeable

• SHAPE of curve most important!

Examples

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)

Patient populations

• Cardiac

Problem=Low clotting factors, high thrombin(unique to cardiac surgery)High thrombin, activated fibrinolysis

Less FFP, more PCC/[fibrinogen]/plateletsBUT: Cochrane review: no change in outcomes!

**recommended by NICE**

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**

Trauma cont.

• Up to 38% are coagulopathic

• A/w 5x mortality increase

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**

**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

Case 1

• 30kg Male• 2hr post explosive incident

• Temp 32c, 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

EXTEM Traces

Initial ED trace After admission to ITU

Ongoing Resuscitation

After 15hrs – 15P.RBC/10FFP/4Plts/1Cryo

After 1 unit of apherised platelets

Case 2

• 65 yr old man

• Unknown time after GSW to right flank

• Initial observations:– Systolic BP -110mmHg / pulse 94 bpm– Tympanic temperature -34.9C– pH = 7.01 / base excess = -17– Hb = 8.4g/dL / plts = 182 x109cells/L– PT = 14.3s / APTT = 83.1s

Initial Trace

HYPERFIBRINOLYSIS

After 1 hr

Completely hypocoagulable state