TEG: Total Excellence Guaranteed

You have heard me talk and write on how Blood Management is a multi-disciplinary approach which includes many pieces of the puzzle connected together to achieve the full effect. The utilization of point-of-care devices are key puzzle pieces in a Blood Management Program. This newsletter is going to concentrate on the TEG as the center piece of the puzzle and the exceptional value it brings to a Blood Management Program.  But do we really understand the full potential of the tracings in which we receive?

The TEG 5000 Hemostasis Analyzer provides the clinician with a complete picture of an individual patient’s hemostasis profile; thus guiding therapy and a targeted treatment:  Right product, Right does, Right patient, Right time.  This baseline test lets the clinician know if the patient is hypercoagulable, normal, hypocoagulable, or fibrinolytic.  Is the treatment of the patient’s coagulopathy pharmacologic, a coagulation defect which requires a specific blood product, or surgical bleeding?

Another added value in patient care is the Platelet Mapping Assay.  Many of our patients hospital-wide come to surgery on anti-platelet drugs.  Literature and studies have shown that these drugs are associated with high bleeding risk during surgery and, therefore, high blood product transfusion both intra-operatively and postoperatively.  Also, many of our patients prescribe to taking herbal treatments which can also affect platelet function and coagulation status.  Many point-of-care systems only give you what I call a “dirty number.”  Like a spaghetti-western, there is the good, the bad, and the ugly on these devices.  The good is that you are at least using some form of measurement for platelet inhibition.  The bad is that number of 50% inhibition tells you very little on the patient’s baseline risk.  The ugly is that the patient is still at risk for a thrombotic or hemorrhagic event which could affect length-of-stay, vent times, mortality, morbidity, infection and total healthcare costs.  Every patient is not the same, and 50% of patients may have the total opposite diagnosis than other patients.  You have to know the patient’s baseline risk before making a sound clinical decision. Clinicians who use TEG Platelet Mapping as a tool for intervention have experienced great rewards in patient care.

Within the last few months, there was an impressive article in the Journal of the American Heart Association on “Platelet Function Measurement-Based Strategy to Reduce Bleeding and Waiting Time in Clopidogrel Treated Patients Undergoing Coronary Artery Bypass Graft Surgery.”  The conclusion of this study was a strategy using a pre-operative platelet function test from the TEG to determine timing and bleeding of a patient on Clopidogrel.  But wait; does this percent inhibition give us a true diagnosis on every patient?

Recently I, and many other Platelet Mapping customers, have witnessed an Activator F sample where the MA continues to grow much wider than the normal 12 to 20 mm.  This increase in the activator MA may, and can, over-express the % inhibition on the ADP and AA assays.  This scenario has raised many concerns and has been addressed by Haemonetics on the potential causes, actions and additional testing to achieve superior, accurate results.  These increased levels in fibrinogen and clot strength by the TEG are most likely the results of hyperfibrinogenemia.  These patients have a high risk for thrombotic complications and recognizing their condition and modifying the test could have direct results in their outcomes and care.  Many of these patients with hyperfibrinogenemia have been related to VAD devices, artificial hearts, ECMO, pregnancy, AT III deficiency, or chronic or acute hypercoagulability.  Within the last six months, I have witnessed six patients with this phenomenon and tested them with the new TEG Functional Fibrinogen reagent which contains GP IIb/IIIa platelet inhibitor.  By doing so, we get the true diagnosis of the patient and a true percent inhibition.  If not recognized, you may see a false high percent inhibition on the ADP and AA assays.  In March 2012, Haemonetics released the TEG Platelet Mapping Assays with Atypical Activator F Tracings.  I highly recommend that all TEG customers get in touch with their representative and become familiar with this phenomenon and exciting breakthrough.  This is just another example of why I believe that Haemonetics TEG is the gold standard in Blood Management and it has continued to improve their technology in the coagulation arena.