Possibilities and limitations of thromboelastometry/thromboelastography

T. Lang; von M. Depka

doi:10.1055/s-0037-1617078

Hämostaseologie, Inhaltsverzeichnis

Hamostaseologie 2006; 26(S 02): S21-S29
DOI: 10.1055/s-0037-1617078

Original Article

Schattauer GmbH

Possibilities and limitations of thromboelastometry/thromboelastography

Authors

T. Lang

¹Department of Anaesthetics, Hannover Medical School, Germany

²Werlhof Institute, Hannover, Germany
von M. Depka

²Werlhof Institute, Hannover, Germany

Abstract

Summary

Thromboelastometry/thromboelastography provides information about clot strength and stability. Modified procedures have improved the standardisation and increased the diagnostic power of these test systems. Heparinase- modified thromboelastometry/thromboelastography allows assessment of the heparin effect. The introduction of FIBTEM on the ROTEM® also makes it possible to differentiate between disorders of the plasma and platelet components of clot strength. This may be of interest in the perioperative setting, as our clinical data show that elevated levels of D-dimer have no predictive value for hyperfibrinolysis.

However, disorders of primary haemostasis such as von Willebrand’s disease cannot be determined with thromboelastometry/ thromboelastography, nor do the effects of acetyl salicylic acid and clopidogrel on platelets influence the results. Only platelet aggregation inhibitors which affect the glycoprotein IIb/IIIa receptors, such as ReoPro®, may reduce clot strength at high doses. A similar effect is to be expected with severe Glanzmann’s thrombasthenia. Coagulation times in thromboelastometry/thromboelastography (measured as CT/r value) show poor correlation with conventional coagulation parameters because of the different activators used.

The introduction of rotation thromboelastometry (ROTEM®) provides a stable system suitable for near patient testing.

Keywords

Thrombelastometry - thrombelastography - ROTEM - TEG

Volltext

Referenzen

References
1 Spahn DR. Strategies for transfusion therapy. Best Pract Res Clin Anaesthesiol 2004; 18: 661-73.
2 Bux J. Transfusion-related acute lung injury (TRALI): a serious adverse event of blood transfusion. Vox Sang 2005; 89: 1-10.
3 Goodnough LT. Risks of blood transfusion. Anesthesiol Clin North America 2005; 23: 241-252.
4 Stanworth SJ, Brunskill SJ, Hyde CJ. et al. Is fresh frozen plasma clinically effective? A systematic review of randomized controlled trials. Br J Haematol 2004; 126: 139-152.
5 Wandt H, Frank M, Ehninger G. et al. Safety and cost effectiveness of a 10 x 109/L trigger for prophylactic platelet transfusions compared with the traditional 20 x 109/L trigger: a prospective comparative trial in 105 patients with acute myeloid leukemia. Blood 1998; 91: 3601-3606.
6 Koscielny J, Ziemer S, Radtke H. et al. A practical concept for preoperative identification of patients with impaired primary hemostasis. Clin Appl Thromb Hemost 2004; 10: 195-204.
7 Oldenburg J, Ananyeva NM, Saenko EL. Molecular basis of haemophilia A. Haemophilia 2004; 10 (Suppl. 04) 133-139.
8 Michiels JJ, Gadisseur A, Budde U. et al. Characterization, classification, and treatment of von Willebrand diseases: a critical appraisal of the literature and personal experiences. Sem Thromb Hemost 2005; 31: 577-601.
9 Mannucci PM. Management of von Willebrand disease in developing countries. Sem Thromb Hemost 2005; 31: 602-609.
10 Petrini P. Treatment strategies in children with hemophilia. Paediatr Drugs 2002; 4: 427-437.
11 Boldt J, Papsdorf M, Rothe A. et al. Changes of the hemostatic network in critically ill patients – Is there a difference between sepsis, trauma, and neurosurgery patients?. Crit Care Med 2000; 28: 445-450.
12 Ozier Y, Steib A, Ickx B. et al. Haemostatic disorders during liver transplantation. Eur J Anaesthesiol 2001; 18: 208-18.
13 Raja SG, Dreyfus GD. Impact of off-pump coronary artery bypass surgery on postoperative bleeding: current best available evidence. J Cardiol Surg 2006; 21: 35-41.
14 Kestin AS, Valeri CR, Khuri SF. et al. The platelet function defect of cardiopulmonary bypass. Blood 1993; 82: 107-117.
15 Hoffman M, Monroe DM. A cell-based model of haemostasis. Thromb Haemost 2001; 85: 958-65.
16 Hassouna HI. Laboratory evaluation of hemostatic disorders. Hematol Oncol Clin North Am 1993; 7: 1161-1249.
17 Miller BE, Mochizuki T, Levy JH. et al. Predicting and treating coagulopathies after cardiopulmonary bypass in children. Anesth Analg 1997; 85: 1196-1202.
18 Hartert H. Blutgerinnungsstudien mit der Thrombelastographie, einem neuen Untersuchungsverfahren. Klin Wochenschrift 1948; 26: 577-583.
19 Chandler WL. The thromboelastography and the thromboelastograph technique. Sem Thromb Hemost 1995; 21 (Suppl. 04) 1-6.
20 Shore-Lesserson L, Manspeizer HE, DePerio M. et al. Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Anesth Analg 1999; 88: 312-319.
21 Spiess BD, Gillies BS, Chandler W. et al. Changes in transfusion therapy and reexploration rate after institution of a blood management program in cardiac surgical patients. J Cardiothorac Vasc Anesth 1995; 9: 168-173.
22 Spiess BD. Thromboelastography and cardiopulmonary bypass. Sem Thromb Hemost 1995; 21 (Suppl. 04) 27-33.
23 Calatzis A, Fritsche P, Calatzis A. et al. A comparison of the technical principle of the RoTEG coagulation analyser and conventional thrombelastographic systems. Ann Hematol 1996; 76 Suppl P90.
24 Calatzis A, Fritsche P, Kling M. et al. A new technique for fast and specific intraoperative coagulation monitoring. Eur Surg Res 1996; 28 Suppl I 47-48.
25 Calatzis A, Calatzis A, Fritsche P. et al. An analysis of the correlation of the RoTEG coagulation analysser and the Hellige thrombelastograph D. Ann Hematol 1996; 72 Supp I P87.
26 Mallett SV, Cox DJ. Thrombelastography. Br J Anaesth 1992; 69: 307-313.
27 Bowbrick VA, Mikhailidis DP, Stansby G. The use of citrated whole blood in thromboelastography. Anesth Analg 2000; 90: 1086-1088.
28 Camenzind V, Bombeli T, Seifert B. et al. Citrate storage affects thrombelastograph analysis. Anesthesiology 2000; 92: 1242-1249.
29 Koster A, Kukucka M, Fischer T. et al. Evaluation of post-cardiopulmonary bypass coagulation disorders by differential diagnosis with a multichannel modified thromboelastogram: a pilot investigation. J Extra Corpor Technol 2001; 33: 153-158.
30 Lang T, Toller W, Gutl M. et al. Different effects of abciximab and cytochalasin D on clot strength in thrombelastography. J Thromb Haemost 2004; 2: 147-153.
31 Lang T, Bauters A, Braun SL. et al. Multi-centre investigation on reference ranges for ROTEM thromboelastometry. Blood Coagul Fibrinol 2005; 16: 301-310.
32 Chuang J, Sadler MA, Witt DM. Impact of evacuated collection tube fill volume and mixing on routine coagulation testing using 2.5-ml (Pediatric) tubes. Chest 2004; 126: 1262-1266.
33 Nielsen VG, Geary BT, Baird MS. Evaluation of the contribution of platelets to clot strength by thromboelastography in rabbits: the role of tissue factor and cytochalasin D. Anesth Analg 2000; 91: 35-39.
34 Abramson DC, Abouleish EI, Pivalizza EG. et al. Heparinase-guided thrombelastography in an anticoagulated patient. Br J Anaesth 1996; 77: 556-558.
35 Spiess BD, Wall MH, Gillies BS. et al. A comparison of thromboelastography with heparinase or protamine sulfate added in vitro during heparinized cardiopulmonary bypass. Thromb Haemost 1997; 78: 820-826.
36 Mittermayr M, Margreiter J, Velik-Salchner C. et al. Effects of protamine and heparin can be detected and easily differentiated by modified thrombelastography (Rotem): an in vitro study. Br J Anaesth 2005; 95: 310-316.
37 Mann KG, Butenas S, Brummel K. The dynamics of thrombin formation. Arterioscler Thromb Vas Biol 2003; 23: 17-25.
38 Phillips DR, Charo IF, Parise LV. et al. The platelet membrane glycoprotein IIb-IIIa complex. Blood 1988; 71: 831-843.
39 Siebenlist KR, Meh DA, Mosesson MW. Protransglutaminase (factor XIII) mediated crosslinking of fibrinogen and fibrin. Thromb Haemost 2001; 86: 1221-1228.
40 Sorensen B, Johansen P, Christiansen K. et al. Whole blood coagulation thrombelastographic profiles employing minimal tissue factor activation. J Thromb Haemost 2003; 1: 551-558.
41 Sorensen B, Ingerslev J. Whole blood clot formation phenotypes in hemophilia A and rare coagulation disorders. Patterns of response to recombinant factor VIIa. J Thromb Haemost 2004; 2: 102-110.
42 Sorensen B, Ingerslev J. Thromboelastography and recombinant factor VIIa-hemophilia and beyond. Sem Hematol 2004; 41 1 Suppl 1 140-144.
43 Mahla E, Lang T, Vicenzi MN. et al. Thromboelastography for monitoring prolonged hypercoagulability after major abdominal surgery. Anesth. Analg 2001; 92: 572-577.
44 Kettner SC, Panzer OP, Kozek SA. et al. Use of abciximab- modified thrombelastography in patients undergoing cardiac surgery. Anesth Analg 1999; 89: 580-584.
45 Caprini JA, Arcelus JI, Goldshteyn S. et al. Thromboelastography: measuring statistical probabilities. Sem Thromb Hemost 1995; 21 (Suppl. 04) 14-20.
46 Luddington RJ. Thrombelastography/thromboelastometry. Clin Lab Haematol 2005; 27: 81-90.
47 Salooja N, Perry DJ. Thrombelastography. Blood Coagul Fibrinol 2001; 12: 327-337.
48 Samama CM. Thromboelastography: the next step. Anesth Analg 2001; 92: 563-564.
49 Goh KY, Tsoi WC, Feng CS. et al. Haemostatic changes during surgery for primary brain tumours. J Neurol Neurosurg Psychiatry 1997; 63: 334-338.
50 Steer PL. Anaesthetic management of a parturient with thrombocytopenia using thrombelastography and sonoclot analysis. Can J Anaesth 1993; 40: 84-85.
51 Viana JS, Pereira MG, Lozano L. et al. Thrombelastographic evidence of hyperfibrinolysis during liver transplantation for familial amyloidotic polyneuropathy ATTR Met 30. Transplant Proc 2000; 32: 2645-2646.
52 Whitta RK, Cox DJ, Mallett SV. Thrombelastography reveals two causes of haemorrhage in HELLP syndrome. Br J Anaesth 1995; 74: 464-468.
53 Ni H, Denis CV, Subbarao S. et al. Persistence of platelet thrombus formation in arterioles of mice lacking both von Willebrand factor and fibrinogen. J Clin Invest 2000; 106: 385-392.
54 Greilich PE, Alving BM, O’Neill KL. et al. A modified thromboelastographic method for monitoring C7E3 Fab in heparinized patients. Anesth Analg 1997; 84: 31-38.
55 Mousa SA, Khurana S, Forsythe MS. Comparative in vitro efficacy of different platelet glycoprotein IIb/IIIa antagonists on platelet-mediated clot strength induced by tissue factor with use of thromboelastography: differentiation among glycoprotein IIb/IIIa antagonists. Arterioscler Thromb Vasc Biol 2000; 20: 1162-1167.
56 Mousa SA, Forsythe MS. Comparison of the effect of different platelet GPIIb/IIa antagonists on the dynamics of platelet/fibrin-mediated clot strength induced using thromboelastography. Thromb Res 2001; 104: 49-56.