August Journal Club

[katevaughn]

Thromboelastography or TEG has become more of a popular measurement tool for monitoring hemostasis in the surgical patient. It provides a more cohesive picture of coagulation status and helps to guide better transfusion resuscitation. It has practically become a standard of care for the severe trauma patient, cardiac surgical patient and liver transplant patient. But if you don’t have the opportunity to be involved in these cases very often, it can be a hard tool to comprehend and use. Attached you will find an interesting article from the AANA Journal explaining the interpretation of the TEG and how to use this important tool in caring for our complex patients. Please address these two questions in your response to help stimulate discussion with your colleagues:



1. What other surgeries/patient populations would TEG be useful for?


2. Do you think we would guide more accurate transfusion resuscitation if we had a TEG with the potential to avoid “wasting” blood products or exposing our patients to hazardous side effects?


Please click on the link to read the attached article. link

[Shannon]

1) Kabeish Spines

2) Maaaaaybe……. I think TEGs speak more to quality of clot formation and not necessarily the quantity of blood volume. If a patient is actively bleeding then I do not deem TEG assessments more useful, however if one is in a case and feel they are adequately resuscitating a patient and the patient continues to bleed; then a TEG may guide and justify product choice. As an example; if one wants to give cryoprecipitate; a TEG may validate such administration. It has been my experience that a quality surgeon is the better judge of the quality of clotting. Plenty of times they may ask for coags. This may be a time that we run a TEG instead of coags. Just my two cents……for free. 

3) My question is what is the cost of running TEGs at Hopkins vs. getting coags? If it is cheaper; it may most effectively guide culture change, and then one can win tickets to a Ravens game.

[mscotth2]

How fun!

Kate and Jen, thank you for doing this.

TEG is something that is used "across town" with some regularity and is quite effective at directing transfusion requirements/goals.

1. I up Shannon's Kabeish spine to a pediatric spine with a large degree of curvature; fairly similar case scenarios to traumatic blood loss. We care for children with a wide range of oncologic processes and genetic blood dyscrasias, I can't help but wonder if it might be useful for these patients who undergo all types of procedures.

2. I think the answer to the question of accurate transfusion resuscitation is a yes. That has been well established, even if not widely implemented.

3. Shannon brings up whether or not it would be cheaper.........the system is so fragmented that if it costs the lab more, they may say no, don't do it..........even if it saves money in unnecessary transfusions or transfusion related complications as those costs are associated with the blood bank or increased hospital stay..........so, overall cost savings (though I was unable to find any hard $$$$) may be significant as suggested in the literature, but if the specific department does not see the savings, that's a hurdle. Think about IV Tylenol reducing pain, adjunct meds and hospital stay--but it costs more so we are restricted in its use from the pharmacy.

[abenson]

This online journal club is Awesome! Thank you Kate for suggesting and implementing the idea. Strong work.

1. I agree with Shannon and Mary. I would also add those cases that the surgeon unintentionally hits a large vessel and we move into transfusion resuscitation. Perhaps not initially but after things get stabilized, and a conversation with the surgeon about hemostasis and clotting, a TEG could be sent to help further guide resuscitation. In addition, how many times do CRNAs take over an all day case at 5pm, 7pm or even 9pm, and several units of blood has been transfused and there is still some issues? This would be a great tool to have in your pocket to send. CRNAs end up in all kinds of cases that this would be helpful. It might not be a frequent occurrence, but this is useful knowledge to have and use when appropriate.

2. This analysis definitely helps guide transfusion and care of the patient. Is it part of our culture that we don't send a TEG when it could really be beneficial? It could be that our team isn't familiar with the test or confident with interpreting the results. I rarely send it but this discussion is a great reminder to use a TEG when appropriate. Coincidently, several weeks ago, a CRNA suggested that Dr. Rizkalla give a lecture to our CRNA team about this exact topic. Details are coming soon, but it is tentatively planned for a Thursday morning in November.

3. I would be interested to know the financial considerations of this test.

[nanci]

Hi
1) I'd agree with using it for trauma cases and to remember that ANY case that runs into excessive bleeding can also be classified as a trauma case. For instance some Whipple procedures or other abdominal cases where large vessels are.....negatively encountered........and transfusion is initiated or even the massive transfusion protocol initiated turn into traumas. Even planned cases like C-section for placenta accrete--maybe a TEG would be useful if bleeding encountered.

2) I'd like to think that overall with our change in transfusion parameters and the number of staff in-service's our institution has provided on blood, blood products, blood transfusion (Thank you Dr. Frank and all his efforts)that we as a group do a good job of accurate transfusion resuscitation and with that minimize the associated amount of hazardous side effects (just by not transfusing at 10 g/dL or higher automatically unless profuse bleeding and hemodynamic instability). Transfusion medicine education has come a long way in recent years and awareness is heightened helping providers to make more informed choices.

3) Agree with Andy about the financial considerations of the test. The cost to implement and maintain all of the Point of Care (POC) regulatory issues would definitely cost the department-- spanning from data capture to document regulatory compliance. Despite the cost of licensure, training, procedures documentation, monitoring and testing compliance, quality control, data management, (among other considerations as well) it will also cost to verify operator competency (and getting providers updated and show competency on a regular basis per institution protocols) and to jump through and follow any and all accreditation issues that come with a POC testing program. Is this why we do not do POCT for Glucose in the OR's and send our samples to the lab? If with our increased awareness and decreased amount of transfusions that we provide to our patients- is it cost effective to initiate a POC testing for TEG's? Interesting.

[Katya]

If this TEG test was developed in 1947, why it is not used widely in the hospitals? I worked in ICU for over 15 years and never heard about this test until I got into anesthesia school. I think it is a great way to cut down on general transfusion blood products and use this test to tailor specific blood products. It can be used for any active bleeding or coagulopathic patients. May be it requires a more detailed understanding of coagulation process for providers and it is easier to deal with PT, INR, PTT numbers (low or high). I agree with Nancy it will require additional training of people.

[belinda]

Great discussion points!

So, 1. Other than the obvious cardiac surgery, our big spine and trauma cases already mentioned; the patient population we regularly see here that may benefit from the more regular use of the TEG to guide appropriate transfusion needs both pre as well as perioperative would be patients with chronic liver and pancreatic disease. Knowing how each patient's defects in coagulation in this population may help us more specifically manage their transfusion requirements (are they hyper or hypocoagulable?)

2.  For our information from our lab:

TEG- $129.98  

PT/PTT/INR- $34.64

For the reasons already mentioned, there are times it would be appropriate to order the TEG if we feel it will more accurately manage our patients in the OR.   I have ordered TEGs in the OR and not difficult to do.  The turn around time for TEG results seemed slow and at least for a trauma cases where you are loosing blood quickly may not help guide our practice as quickly as we would like.  In these cases it is usually a case of hemodilution and subsequently a dilutional coagulopathy the is the biggest culprit. So, giving Platelets along with the other blood products per MTP should help.