Tag Archives: TEG

Equipment

EAST Guidelines: TEG And ROTEM In Coagulopathic Trauma Patients

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In my last post, I explained why TEG is not so easy to use. Today, I’ll share the new Eastern Association for the Surgery of Trauma (EAST) practice management guidelines for using TEG and its twin, ROTEM for bleeding patients.

TEG first appeared in the trauma literature in 2008. A paper by John Holcomb showed that it was superior to the standard lab tests (PT, aPTT, and activated clotting time) in monitoring hemorrhagic shock in pigs. Since then, research has exploded with TEG papers. There have been about 50 published annually for the last four years.

In this month’s Journal of Trauma, EAST published their most recent practice management guideline, dedicating it to TEG. They identified over 6,000 potential papers and ultimately settled on 38 articles. They used them to attempt to answer three questions regarding use of these devices during resuscitation.

Question 1

In adult trauma patients with ongoing hemorrhage, should TEG/ROTEM be used vs non-TEG/ROTEM monitoring to guide transfusion strategy in order to reduce mortality, blood product transfusions and the need for additional hemostatic interventions such as angioembolization, endoscopy, or operation?

Answer: Only seven studies were found regarding this question. All but one showed no difference in 24 hour and hospital mortality. They also showed an inconsistent effect on blood product usage with some showing no difference and some shower less transfused product.

Nonetheless, EAST “conditionally recommended” the use of TEG/ROTEM. This is based  solely on the presumption that it can reduce the risk of blood transfusions by using a test that is harmless.

Question 2

In adult surgery patients with ongoing hemorrhage, should TEG/ROTEM be used vs non-TEG/ROTEM monitoring to guide transfusion strategy in order to reduce mortality, blood product transfusions and the need for additional hemostatic interventions such as angioembolization, endoscopy, or operation? Note the shift here to non-trauma patients.

Twenty one studies were found addressing this question. Most papers showed no difference in reoperation rate. There were also no consistent differences in transfusion of various blood products. And the vast majority showed no difference in mortality.

But once again, EAST conditionally recommended the use of this test in these patients, mainly because it is believed to be harmless.

Question 3

In adult critically ill patients with ongoing hemorrhage, should TEG/ROTEM be used vs non-TEG/ROTEM monitoring to guide transfusion strategy in order to reduce mortality, blood product transfusions and the need for additional hemostatic interventions such as angioembolization, endoscopy, or operation?

There were only 10 studies relating to this question, and they included patients with a variety of surgical and medical problems. TEG/ROTEM was no better than non-TEG parameters in predicting the need to transfuse, but did somewhat better than clinical judgement. Once again, there was no consistent effect on the number of transfusions given, although some studies showed that use of non-TEG/ROTEM studies resulted in fewer units of red cells, platelets, and cryoprecipitate given.

Interestingly, although there was little difference in the number of units transfused, fewer patients required transfusion using TEG/ROTEM. There was no difference in mortality or interventions to stop bleeding.

Yet again, EAST conditionally recommended use of TEG/ROTEM in these patients despite the very low level of evidence. Again, this is mainly because of the lack of perceived harm in using it, and the possibility that it might reduce exposure to blood products.

Bottom line: Hmm. I remain skeptical. What EAST is saying is that, hey it’s harmless and there’s a chance that it might reduce a patient’s exposure to blood products, so why not? I have a vial of bat wings and eye of newt that might do the same thing. As long as it’s harmless, right?

Well, it may be clinically harmless, but it costs money and time. First, you have to buy the machine. Luckily, they are much cheaper than a CT scanner. But then the manufacturer kills you with the disposables. Like a cheap inkjet printer, you have to keep buying $40 ink cartridges every few weeks to keep it working. Except TEG cartridges cost more than $40.

And don’t overlook the time spent training people in how to interpret the curves. And developing a system to obtain the specimen and pay people to run the equipment. It all adds up, and yet the papers can’t show us any dramatic clinical results.

I’ll probably irritate the TEG/ROTEM true believers, but it still seems like a device searching for a great clinical problem to solve. IMHO we need much more high-quality research to help us figure out how this tool can help us with our trauma / surgical / critical care patients.

Reference: Thromboelastography and rotational thromboelastometry in bleeding patients with coagulopathy: Practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma 89(6):999-1017, 2020.

Device

How To Make TEG / ROTEM Useful

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A lot of papers have been written on the use of thromboelastography in trauma. And pretty much any meeting or course you may attend has at least one talk on it. And I get it. It can be an important tool in treating trauma patients who have some sort of coagulation disturbance. It helps us figure out what specific part of the coagulation process is out of whack and suggests how we can fix it.

But there are a few problems. And the “friction” that those issues cause overall decreases how useful it is. Here’s a partial list of the problems:

  • The equipment costs money, and the disposables that must be used for every patient do, too.
  • Where do you put the machine? Most hospitals can’t put one unit in every possible area it might be used.
  • How to you get the results to a care area if there is no unit there?
  • There is a significant learning curve for interpreting the results
  • How can it be integrated into the massive transfusion protocol?

The main issue is that the current state of TEG and ROTEM are very similar to the state of electrocardiography shortly after it’s discovery. Here’s what you got then:

In order to get the most from an EKG, you need to combine this tracing with that from other leads, do a bunch of measurements, look for abnormal shapes and elevations/depressions, etc.  This is exactly where we are with TEG and ROTEM today. Relatively crude, and it takes a lot of work to use it.

The tracing below shows where we are with EKGs today. A computer program looks at all the tracings, and rapidly applies a complex set of rules to come to a set of diagnoses. Notice in the image below that this reading is “unconfirmed.” But how many times in your career have you seen a cardiologist correct one of these? The machines are actually very good!

Bottom line: The tracing above is where we need to be with TEG and ROTEM. Instead of a clinician staring at a developing tracing and figuring out what products to give, these machines need to be just like an automated EKG machine. Sure, a human can still stare at the trace. But the machine will automatically monitor it, apply rules about what abnormalities are present and what is needed to correct them. Send off your blood specimen, and within minutes instructions like “infuse 2 units of plasma now” or “give 12u cryo now” appear. These may be displayed on a monitor in the treatment area, or be broadcast to the phone or pager of the responsible clinicians.

Current TEG/ROTEM equipment is what I would consider 1st generation. The next generation will reduce or remove much of the “friction” in the current process and allow us to really integrate TEG/ROTEM meaningfully into the massive transfusion protocol for trauma. And for anyone who develops this 2nd generation equipment, don’t forget my royalty checks for this idea! 

In my next post, I’ll review the new EAST guidelines for the use of TEG and ROTEM.

protocols

TEG And Your Massive Transfusion Protocol

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Thromboelastography (TEG) and its fraternal twin rotational thromboelastometry (ROTEM) are relatively new toys in the trauma community. They allow for (somewhat) rapid assessment of clotting function, and allow the trauma professional to surmise what products might push abnormal clotting characteristics back toward normal.

Many trauma centers already own this technology due to its use by non-trauma services. But there have been a growing number of research presentations on the topic over the last five years, and many centers are clamoring to buy these units for use in their MTP.

But remember, new technology is usually expensive, and isn’t always all it’s cracked up to be. TEG and ROTEM require a (often-times) new machine and a never-ending supply of disposable cartridges for use, like your ink jet printer. Some hospitals are reluctant to provide the funds unless there is a compelling clinical need.

Surgeons at the University of Cincinnati compared the use of TEG with good, old-fashioned point-of-care (POC) INR testing in a series of major trauma patients seen at their Level I center.

Here are the factoids:

  • This was a retrospective review of 628 major trauma patients who received both TEG and POC INR testing using an iSTAT device over a 1.5 year period
  • Median ISS was 13, and there were many sick patients (20% in shock, 21% received blood, 11% died)
  • INR correlated with all TEG values, with better correlation in patients in shock
  • Both INR and TEG correlated well with treatment with blood, plasma, and cryoprecipitate
  • Processing time was 2 minutes for POC INR vs about 30 minutes for TEG
  • Charges for POC INR were $22,000 vs $397,000 for TEG(!!)

Bottom line: Point of care INR testing and TEG both correlated well with the need for blood products in major trauma patients. But POC INR is much cheaper and faster. Granted, the TEG gurus will say that you can tailor the products administered to meet the exact needs of the patient. But in all my travels, I’ve see very few centers that have fully, effectively, and contemporaneously incorporated TEG or ROTEM into their massive transfusion protocol from start to finish.

The area where TEG and ROTEM are most helpful are in the “mop up” phase at the tail end of the MTP. These tools allow trauma professionals to determine exactly which products are needed to normalize parameters, and they frequently diverge from the 1:1:1 to 1:1:2 ratios at that point to achieve this.

If you don’t have one of these toys yet, make sure that you have a very good clinical reason to do so. If you do, think very carefully about how you can meaningfully incorporate it in the massive transfusion process and write it into your protocol.

Reference: All the bang without the bucks: defining essential point-of-care testing for traumatic coagulopathy. J Trauma 79(1):117-124, 2015.

General

How To Make TEG / ROTEM Useful

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A lot of papers have been written on the use of thromboelastography in trauma. And pretty much any meeting or course you may attend has at least one talk on it. And I get it. It can be an important tool in treating trauma patients who have some sort of coagulation disturbance. It helps us figure out what specific part of the coagulation process is out of whack and suggests how we can fix it.

But there are a few problems, as I mentioned yesterday. And the “friction” that those issues cause overall decreases how useful it is. Here’s a partial list of the problems:

  • The equipment costs money, and the disposables that must be used for every patient do, too.
  • Where do you put the machine? Most hospitals can’t put one unit in every possible area it might be used.
  • How to you get the results to a care area if there is no unit there?
  • There is a significant learning curve for interpreting the results
  • How can it be integrated into the massive transfusion protocol?

The main issue is that the current state of TEG and ROTEM are very similar to the state of electrocardiography shortly after it’s discovery. Here’s what you got then:

In order to get the most from an EKG, you need to combine this tracing with that from other leads, do a bunch of measurements, look for abnormal shapes and elevations/depressions, etc.  This is exactly where we are with TEG and ROTEM today. Relatively crude, and it takes a lot of work to use it.

The tracing below shows where we are with EKGs today. A computer program looks at all the tracings, and rapidly applies a complex set of rules to come to a set of diagnoses. Notice in the image below that this reading is “unconfirmed.” But how many times in your career have you seen a cardiologist correct one of these? The machines are actually very good!

Bottom line: The tracing above is where we need to be with TEG and ROTEM. Instead of a clinician staring at a developing tracing and figuring out what products to give, these machines need to be just like an automated EKG machine. Sure, a human can still stare at the trace. But the machine will automatically monitor it, apply rules about what abnormalities are present and what is needed to correct them. Send off your blood specimen, and within minutes instructions like “infuse 2 units of plasma now” or “give 12u cryo now” appear. These may be displayed on a monitor in the treatment area, or be broadcast to the phone or pager of the responsible clinicians.

Current TEG/ROTEM equipment is what I would consider 1st generation. The next generation will reduce or remove much of the “friction” in the current process and allow us to really integrate TEG/ROTEM meaningfully into the massive transfusion protocol for trauma. And for anyone who develops this 2nd generation equipment, don’t forget my royalty checks for this idea! 

Related post:

General

What If You Don’t Have TEG For Trauma?

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The new hot items in trauma care are thromboelastography (TEG) and ROTEM (thromboelastometry), a new spin on TEG from the TEM Corporation. These tools allow for in-depth assessment of factors that influence clotting. We know that rapidly recognizing and treating coagulopathy in major trauma patients can reduce mortality. So many trauma centers are clamoring to buy this technology, citing improved patient care as the reason.

But new technology is always expensive, and isn’t always all it’s cracked up to be. TEG and ROTEM require an expensive machine and a never-ending supply of disposable cartridges for use. Some hospitals are reluctant to provide the funds unless there is a compelling clinical need.

Surgeons at the University of Cincinnati compared the use of TEG with good, old-fashioned point-of-care (POC) INR testing in a series of major trauma patients seen at their Level I center.

Here are the factoids:

  • This was a retrospective review of 628 major trauma patients who received both TEG and POC INR testing using an iSTAT device over a 1.5 year period
  • Median ISS was 13, and there were many sick patients (20% in shock, 21% received blood, 11% died)
  • INR correlated with all TEG values, with better correlation in patients in shock
  • Both INR and TEG correlated well with treatment with blood, plasma, and cryoprecipitate
  • Processing time was 2 minutes for POC INR vs about 30 minutes for TEG
  • Charges for POC INR were $22,000 vs $397,000 for TEG(!!)

Bottom line: Point of care INR testing and TEG both correlate well with the need for blood products in major trauma patients. But POC INR is much cheaper and faster. Granted, the TEG gurus will say that you can tailor the products administered to meet the exact needs of the patient. But in all my travels, I have never visited a center that has fully and effectively incorporated TEG or ROTEM into their massive transfusion protocol. Before you make the financial leap to buy these new toys, make sure that you have a very good clinical reason to do so.

Related posts:

Reference: All the bang without the bucks: defining essential point-of-care testing for traumatic coagulopathy. J Trauma 79(1):117-124, 2015.