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Basic Clinician Training. Module 2. Review of the Hemostatic Process Hemostasis Monitoring with the TEG Analyzer How the TEG Analyzer Monitors Hemostasis Parameters Tracings Blood Sample Types and Preparation Test Your Knowledge. TEG ® Technology. Hemostatic Process. Endothelial Cells.

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module 2
Basic Clinician Training

Module 2

Review of the Hemostatic Process

Hemostasis Monitoring with the TEG Analyzer

How the TEG Analyzer Monitors Hemostasis

Parameters

Tracings

Blood Sample Types and Preparation

Test Your Knowledge

TEG® Technology

hemostatic process
Hemostatic Process

Endothelial Cells

Change in Platelet Shape

Area of Injury

Endothelium damaged

Collagen

Platelet

AA

ADP

Platelet plug formed

(white clot)

CoagulationCascade

Thrombin generated on platelet surface

Platelet-fibrin plug formed

(red clot)

tPA

Fibrin Strands

Fibrinolysis

Plasminogen

Plasmin

Degradation Products

Clot lysis

routine coagulation tests pt aptt platelet counts
Routine Coagulation Tests: PT, aPTT, Platelet Counts
  • Based on cascade model of coagulation
    • Measure protein interaction in plasma (thromboplastin)
    • Exclude cellular contributions (platelets, monocytes, etc.)
    • Determine adequacy of coagulation factor levels
  • Use static endpoints
    • Ignore altered thrombin generation
    • Ignore cellular elements
    • Ignore overall clot structure
hemostasis monitoring teg hemostasis system
Hemostasis Monitoring:TEG Hemostasis System
  • Whole blood test
  • Measures hemostasis
    • Clot initiation through clot lysis
    • Net effect of components
  • TEG system
    • Laboratory based
    • Point of care
    • Remote, can be networked
    • Flexible to institution needs
the teg analyzer description
The TEG Analyzer:Description
  • Reflects balance of the hemostatic system
  • Measures the contributions and interactions of hemostatic components during the clotting process
  • Uses activated blood to maximize thrombin generation and platelet activation in an in vitro environment
    • Measures the hemostatic potential of the blood at a given point in time under conditions of maximum thrombin generation
teg technology
TEG Technology

The TEG Analyzer

How It Works

teg technology how it works
TEG Technology:How It Works
  • Cup oscillates
  • Pin is attached to a torsion wire
  • Clot binds pin to cup
  • Degree of pin movement is a function of clot kinetics
  • Magnitude of pin motion is a function of the mechanical properties of the clot
  • System generates a hemostasis profile
    • From initial formation to lysis
utility of teg analysis
Utility of TEG Analysis
  • Demonstrates all phases of hemostasis
    • Initial fibrin formation
    • Fibrin-platelet plug construction
    • Clot lysis
  • Identifies imbalances in the hemostatic system
    • Risk of bleeding
    • Risk of thrombotic event
what teg analysis captures
What TEG Analysis Captures

Amplitude of pin oscillation

Time

thrombin formation clotting time the r parameter identified
Thrombin Formation (Clotting Time)The R Parameter: Identified

Amplitude of

pin oscillation

Time

  • Reaction time
  • Fibrin creates a connection between cup and pin

Initial fibrin

formation

Intrinsic,extrinsic,commonpathways

Pin is engaged

Pin is stationary

Cup oscillates,

pin remains stationary

Pin starts to

oscillate with cup

thrombin formation the r parameter defined
Thrombin FormationThe R Parameter: Defined
  • Time until formation of critical mass of thrombin
  • Expression of enzymatic reaction function (i.e. the ability to generate thrombin and fibrin)

Initial fibrin

formation

Intrinsic,extrinsic,commonpathways

Pin is engaged

Pin is stationary

Cup oscillates,

pin remains stationary

Pin starts to

oscillate with cup

thrombin formation abnormalities the r parameter elongated r
Thrombin Formation AbnormalitiesThe R Parameter: Elongated R
  • Possible causes of imbalance:
    • Slow enzymatic reaction
  • Possible etiologies:
    • Factor deficiency/

dysfunction

    • Residual heparin
  • Common treatments:
    • FFP
    • Protamine

Initial fibrin

formation

Initial fibrin

formation

Pin is stationary

Pin is engaged

thrombin formation abnormalities the r parameter short r
Thrombin Formation AbnormalitiesThe R Parameter: Short R
  • Possible causes of imbalance:
    • Over-stimulated

enzymatic reaction

    • Fast fibrin

formation

  • Possible etiologies:
    • Enzymatic

hypercoagulability

  • Common treatments:
    • Anticoagulant

Initial fibrin

formation

Pin is engaged

Pin is stationary

fibrinogen the angle parameter identified
FibrinogenThe α (Angle) Parameter: Identified
  • Rate of increase in pin oscillation amplitude as fibrin is generated and cross-links are formed

Fibrin increases

Baseline

Pin is engaged

fibrinogen the angle parameter defined
FibrinogenThe α (Angle) Parameter: Defined
  • Kinetics of clot formation
    • Rate of thrombin

generation

    • Conversion of Fibrinogen  fibrin
    • Interactions among fibrinogen, fibrin, and platelets
    • Cellular contributions

Fibrin increases

Baseline

Pin is engaged

fibrinogen abnormalities the angle parameter low a
Fibrinogen AbnormalitiesThe α (Angle) Parameter: Low a
  • Possible causes of imbalance:
    • Slow rate of fibrin

formation

  • Possible etiologies:
    • Low fibrinogen levels or

function

    • Insufficient rate/amount

of thrombin generation

    • Platelet

deficiency/dysfunction

  • Common treatments:
    • FFP
    • Cryoprecipitate

Fibrin increases

Baseline

Pin is engaged

fibrinogen abnormalities the angle parameter high a
Fibrinogen AbnormalitiesThe α (Angle) Parameter: High a
  • Possible causes of imbalance:
    • Fast rate of fibrin

formation

  • Possible etiologies:
    • Platelet

hypercoagulability

    • Fast rate of thrombin

generation

  • Common treatments:
    • None

Fibrin increases

Baseline

Pin is engaged

platelet function the ma parameter defined
Platelet FunctionThe MA Parameter: Defined
  • Maximum amplitude
  • Clot strength = 80% platelets + 20% fibrinogen
  • Platelet function influences thrombin generation and fibrin formation  relationship between R, α, and MA

Maximum amplitude (MA)

of pin oscillation

Amplitude of

pin oscillation

platelet function abnormalities the ma parameter low ma
Platelet Function AbnormalitiesThe MA Parameter: Low MA

Maximum amplitude (MA)

of pin oscillation

  • Possible causes:
    • Insufficient platelet-

fibrin clot formation

  • Possible etiologies:
    • Poor platelet function
    • Low platelet count
    • Low fibrinogen levels

or function

  • Common treatments:
    • Platelet transfusion

Amplitude of

pin oscillation

platelet function abnormalities the ma parameter high ma
Platelet Function AbnormalitiesThe MA Parameter: High MA

Maximum amplitude (MA)

of pin oscillation

  • Possible causes:
    • Excessive platelet

activity

  • Possible etiologies:
    • Platelet

hypercoagulability

  • Common treatments:
    • Antiplatelet agents
    • Note: Should be

monitored for efficacy and/or resistance (See Module 6: Platelet Mapping)

Amplitude of

pin oscillation

coagulation index the ci parameter defined
Coagulation IndexThe CI Parameter: Defined
  • Global index of hemostatic status
  • Linear combination of kinetic parameters of clot development and strength (R, K, angle, MA)
    • CI > +3.0:

hypercoagulable

    • CI < -3.0:

hypocoagulable

fibrinolysis ly30 and epl ly30 and epl parameters identified
Fibrinolysis: LY30 and EPLLY30 and EPL Parameters: Identified
  • LY30 is the percent decrease in amplitude of pin oscillation 30 minutes after MA is reached
  • Estimated percent lysis (EPL) is the estimated rate of change in amplitude after MA is reached

MA

30 min

fibrinolysis ly30 and epl ly30 and epl parameters defined
Fibrinolysis: LY30 and EPLLY30 and EPL Parameters: Defined
  • Reduction in amplitude of pin oscillation is a function of clot strength, which depends on extent of fibrinolysis

MA

30 min

slide25
Fibrinolytic AbnormalitiesLY30 Parameter: Primary Fibrinolysis
  • Possible causes:
    • Excessive rate of fibrinolysis
  • Possible etiologies:
    • High levels of tPA
  • Common treatments:
    • Antifibrinolytic agent
slide26
Fibrinolytic AbnormalitiesLY30 Parameter: Secondary Fibrinolysis
  • Possible causes:
    • Rapid rate of clot

formation/break-

down

  • Possible etiologies:
    • Microvascular

hypercoagulability

(i.e. DIC)

DIC = disseminated intravascular coagulation

slide27
Fibrinolytic AbnormalitiesLY30 Parameter: Secondary Fibrinolysis
  • Possible causes:
    • Rapid rate of clot

formation/break-

down

  • Possible etiologies:
    • Microvascular

hypercoagulability

(i.e. DIC)

  • Common treatments:
    • Anticoagulant

DIC = disseminated intravascular coagulation

clot strength the g parameter
Clot Strength:The G Parameter
  • Representation of clot strength and overall platelet function
    • G = shear elastic modulus strength (dyn/cm2)
    • G = (5000*MA)/(100-MA)
  • Relationship between clot strength and platelet function
    • MA = linear relationship between clot strength and platelet function
    • G = exponential relationship between clot strength and platelet function
      • More sensitive to changes in platelet function
ma vs g kaolin activated sample
MA vs. G(Kaolin Activated Sample)

Normal MA range

(Kaolin activated)

Hyperactive platelet function

G(dynes/cm2) x 1000

Normal platelet function

Hypoactive platelet function

slide31
TEG Parameter Summary

Platelet function

Clot strength (G)

Clotting time

Clot kinetics

Clot stability Clot breakdown

teg results
Basic Clinician Training

TEG Results

Tracings

Data

Decision Tree

slide33
Components of the TEG TracingExample: R

Amplitude of

pin oscillation

Time

Actual value

Normal range

ParameterUnitsValueNormal range

slide39
TEG Decision TreeQuantitative

Hemorrhagic

Fibrinolytic

Thrombotic

US Patent 6,787,363

teg blood sampling1
TEG Blood Sampling
  • Blood samples
    • Arterial or venous
    • Samples should be consistent
teg blood sampling native
TEG Blood SamplingNative
  • Non-modified blood samples
    • Assayed 4 minutes
    • TEG software based upon assay at 4 minutes
teg blood sampling modified
TEG Blood Sampling Modified
  • Activator
    • Reduces variability
    • Reduces running time
    • Maximizes thrombin generation
  • Kaolin
    • Activates intrinsic pathway
    • Used for normal TEG analysis
  • Tissue factor
    • Specifically activates extrinsic pathway
teg blood sampling heparin
TEG Blood SamplingHeparin
  • Heparinase
    • Neutralizes heparin
    • Embedded in specialized (blue) cups and pins
teg blood sampling citrated
TEG Blood SamplingCitrated
  • Citrated tubes are used
  • Recalcified before analysis
  • Standardize time between blood draw and running test
  • Specific platelet activators are required to demonstrate effect of antiplatelet agents
sample type designations
Sample Type Designations

Whole blood + kaolin

slide50
Summary
  • The 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.
slide51
Basic Clinician Training

Test your knowledge of TEG parameters and hemostasis monitoring by answering the questions on the slides that follow.

  • TEG Parameters
  • Hemostasis Monitoring
slide52
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: page 64

exercise 2 teg parameters
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: page 65

slide54
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: page 66

slide55
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: page 67

slide56
Exercise 5: TEG Parameters
  • Clot strength is dependent upon which of these
  • hemostatic components?
  • 100% platelets
  • 80% platelets, 20% fibrin
  • 50% platelets, 50% fibrin
  • 20% platelets, 80% fibrin
  • 100% fibrin

Answer: page 68

slide57
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: page 69

slide58
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?
  • (Select all that apply)
  • R
  • Angle (a)
  • LY30
  • CI
  • None of the above

Answer: page 70

slide59
Exercise 8: TEG Parameters
  • Clot stability is determined by which of the following
  • TEG parameters?
  • R
  • Angle (a)
  • MA
  • LY30
  • CI

Answer: page 71

slide60
Exercise 9: TEG Parameters
  • Which of the following reagents should be used to provide
  • the information necessary to determine if heparin is the
  • cause of bleeding in a patient?
  • R value: Kaolin with heparinase
  • R value: Kaolin vs. Kaolin with heparinase
  • MA value: Kaolin with heparinase
  • MA value: Kaolin vs. kaolin with heparinase

Answer: page 72

slide61
Exercise 10: TEG Parameters
  • Which of the following parameters provides an indication
  • of the global coagulation status of a patient?
  • R
  • Angle (a)
  • MA
  • LY30
  • CI

Answer: page 73

slide62
Exercise 11: TEG Parameters
  • Which of the following statements are true regarding the
  • PT and aPTT tests? (select all that apply)
  • Measure coagulation factor interaction in solution
  • Measure platelet contribution to thrombin generation
  • Measure the influence of thrombin generation on platelet function
  • Use fibrin formation as an end point

Answer: page 74

slide63
Exercise 12: TEG Parameters
  • The TEG analyzer can monitor all phases of hemostasis
  • except which of the following? (select all that apply)
  • Initial fibrin formation
  • Fibrin-platelet plug construction
  • Platelet adhesion
  • Clot lysis

Answer: page 75

slide64
Answers to 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
slide65
Answers to 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
slide66
Answers to 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
slide67
Answers to 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
slide68
Answers to Exercise 5: TEG Parameters
  • Clot strength is dependent upon which of these
  • hemostatic components?
  • 100% platelets
  • 80% platelets, 20% fibrin
  • 50% platelets, 50% fibrin
  • 20% platelets, 80% fibrin
  • 100% fibrin
slide69
Answers to 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 (demonstrates maximum clot strength)
  • LY30 (demonstrates clot breakdown or the structural stability of the clot)
  • CI
slide70
Answers to 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? (select all that apply)
  • R – Thrombin generation occurs mainly on the surface of platelets; therefore, a defect in platelet function may slow the rate of thrombin generation and fibrin formation.
  • Angle (a) – A defect in platelet function may slow the rate of formation of platelet-fibrin interactions, thereby slowing the rate of clot buildup.
  • LY30
  • CI
  • None of the above
slide71
Answers to Exercise 8: TEG Parameters
  • Clot stability is determined by which of the following
  • TEG parameters?
  • R
  • Angle (a)
  • MA
  • LY30
  • CI
slide72
Answers to Exercise 9: TEG Parameters
  • Which of the following reagents should be used to provide
  • the information necessary to determine if heparin is the
  • cause of bleeding in a patient?
  • R value: Kaolin with heparinase
  • R value: Kaolin vs. Kaolin with heparinase
  • MA value: Kaolin with heparinase
  • MA value: Kaolin vs. kaolin with heparinase
slide73
Answers to Exercise 10: TEG Parameters
  • Which of the following parameters provides an indication
  • of the global coagulation status of a patient?
  • R
  • Angle (a)
  • MA
  • LY30
  • CI (Coagulation Index — a linear combination of the R, K, angle, and MA)
slide74
Answers to Exercise 11: TEG Parameters
  • Which of the following statements are true regarding the
  • PT and aPTT tests? (select all that apply)
  • Measure coagulation factor interaction in solution
  • Measure platelet contribution to thrombin generation
  • Measure the influence of thrombin generation on platelet function
  • Use fibrin formation as an end point
slide75
Answers to Exercise 12: TEG Parameters
  • The TEG analyzer can monitor all phases of hemostasis
  • except which of the following? (select all that apply)
  • Initial fibrin formation
  • Fibrin-platelet plug construction
  • Platelet adhesion— this is a vascular mediated event that occurs in vivo, but not in vitro
  • Clot lysis
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