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Basic Clinician Training Module 2

Basic Clinician Training Module 2. TEG ® Technology. Hemostasis monitoring Routine coagulation tests: PT, aPTT. Based on cascade model of coagulation Measure coagulation factors interaction in solution (plasma)

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Basic Clinician Training Module 2

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  1. Basic Clinician TrainingModule 2 TEG® Technology

  2. Hemostasis monitoringRoutine coagulation tests: PT, aPTT • Based on cascade model of coagulation • Measure coagulation factors interaction in solution (plasma) • Determine if adequate levels of coagulation factors are present for clot formation • Do not reflect the roles of cells or contributions of local vascular and tissue conditions • Plasma-based assays miss the impact of platelets and platelet activation on thrombin generation. • Plasma-based assays use static endpoints (e.g. fibrin formation) - miss impact of altered thrombin generation on platelet function and clot structure.

  3. Hemostasis monitoringTEG analysis system • Whole blood test • Measures all phases of hemostasis: • initiation through lysis • Shows the net effect of • hemostatic components on blood • clotting process

  4. The TEG analyzerDescription • TEG: point of care (POC) whole blood coagulation monitoring device • Time to initial results: 4-8 minutes • Time to completion (clot lysis): 45-60 minutes • Uses activated blood to maximize thrombin generation and platelet activation in an in vitro environment • Measures thehemostatic potential of the blood at a given point in time under optimal conditions of thrombin generation • Demonstrates the contributions and interactions of hemostatic components during the clotting process.

  5. TEG technologyHow it works

  6. TEG sample preparation • Blood samples can be “modified” by adding agents to the sample • Activator – maximizes thrombin generation and speeds up clotting time • Kaolin – activates intrinsic pathway, used for normal TEG analysis • Tissue factor – specifically activates extrinsic pathway • Heparinase – removes heparin from sample, allows view of the underlying hemostatic status of a patient on heparin. • Platelet activators – allows testing antiplatelet agent responsiveness and efficacy. (Module 7)

  7. TEG sample types • Kaolin – used for normal TEG analysis • Kaolin with heparinase – used for normal TEG analysis when patient on heparin • Compared with Kaolin-only sample (run simultaneously) to determine reversal of heparin

  8. Utility of the TEG • Demonstrates all phases of hemostasis • Initial fibrin formation • Fibrin-platelet plug construction • Clot lysis • Identifies a balance or imbalance in the hemostatic system – between the clot forming and clot breakdown pathways • Identifies likely cause(s) of bleeding • Identifies likely cause(s) of thrombosis

  9. What TEG analysis captures Amplitude of pin rotation Time

  10. TEG parameters Identification Definition

  11. Thrombin formationThe R parameter - identified Amplitude of pin rotation Time Initial fibrin formation Intrinsic,extrinsic,commonpathways Pin is stationary Pin is engaged  Pin starts to rotate with cup Cup rotates, pin remains stationary

  12. FibrinogenThe a (angle) parameter - identified Amplitude of pin rotation Time Fibrin increases Pin is engaged Amplitude of pin rotation increases as fibrin is generated and cross links are formed

  13. Platelet functionThe MA parameter - identified Amplitude of pin rotation Time Maximum amplitude (MA) of pin rotation Amplitude of pin rotation

  14. Platelet functionThe MA parameter - defined Maximum amplitude (MA) of pin rotation Amplitude of pin rotation • Amplitude of pin rotation depends on clot strength • Clot strength = 80% platelets + 20% fibrinogen • Platelet function influences thrombin generation and fibrin formation  relationship between R, a, and MA

  15. Coagulation indexThe CI parameter - defined • Linear combination of kinetic parameters of clot development and clot strength (R, K, angle, MA) • Provides a global index of hemostatic status • CI < -3.0: hypocoagulable • CI > +3.0: hypercoagulable

  16. FibrinolysisThe LY30 parameter - identified Amplitude of pin rotation Time Decrease in amplitude of pin rotation 30 minutes after MA reached MA 30 min

  17. FibrinolysisThe LY30 parameter - defined Decrease in amplitude of pin rotation 30 minutes after MA reached MA 30 min • Reduction in amplitude of pin rotation depends on extent of fibrinolysis

  18. TEG parameter summaryDefinitions

  19. TEG parameter summary Amplitude of pin rotation Time

  20. What does TEG report? Clot strength Platelet function Clot stability Clot breakdown Clot kinetics Clotting time

  21. “Normal” TEG tracing Amplitude of pin rotation Time 30 min

  22. Hemorrhagic TEG tracing 30 min

  23. Prothrombotic TEG tracing 30 min

  24. Fibrinolytic TEG tracing 30 min

  25. Components of the TEG tracingExample: R Actual value Normal range ParameterUnitsValueNormal range

  26. TEG decision treeQualitative

  27. TEG decision treeQuantitative US Patent 6,787,363 Hemorrhagic Fibrinolytic Thrombotic

  28. TEG tracingExample: hemorrhagic * * * *

  29. TEG tracingExample: prothrombotic * * * *

  30. TEG tracingExample: fibrinolytic * *

  31. Summary • TEG technology measures the complex balance between hemorrhagic and thrombotic systems. • The decision tree is a tool to identify coagulopathies and guide therapy in a standardized way.

  32. Review exercises TEG parameters Hemostasis monitoring Begin exercises Skip exercises

  33. Exercise 1: TEG parameters The R value represents which of the following phases of hemostasis? • Platelet adhesion • Activation of coagulation pathways and initial fibrin formation • Buildup of platelet-fibrin interactions • Completion of platelet-fibrin buildup • Clot lysis Answer Next

  34. Exercise 2: TEG parameters Select the TEG parameters that demonstrate kinetic properties of clot formation. (select all that apply) • R • Angle (a) • MA • LY30 • CI Answer Next

  35. Exercise 3: TEG parameters The rate of clot strength buildup is demonstrated by which of the following TEG parameters? • R • Angle (a) • MA • LY30 • CI Answer Next

  36. Exercise 4: TEG parameters Which of the following TEG parameters will best demonstrate the need for coagulation factors (i.e. FFP)? • R • Angle (a) • MA • LY30 • CI Answer Next

  37. Exercise 5: TEG parameters Clot strength is dependent on which of the hemostatic components? • 100% platelets • 80% platelets, 20% fibrinogen • 50% platelets, 50% fibrinogen • 20% platelets, 80% fibrinogen • 100% fibrinogen Answer Next

  38. Exercise 6: TEG parameters Which of the following TEG parameters demonstrate a structural property of the clot? (select all that apply) • R • Angle (a) • MA • LY30 • CI Answer Next

  39. Exercise 7: TEG parameters Because the TEG is a whole blood hemostasis monitor, a low MA demonstrating low platelet function may also influence which of the following TEG parameters? • R • Angle (a) • LY30 • CI • None of the above Answer Next

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