ROTEM vs TEG

[Airlife91]

My hospital is looking at getting either a ROTEM or TEG system. We do a fair amount of cardiac and have a decent trauma volume, so I’m definitely looking forward to having this resource. I personally do a lot of cardiac and in training and a previous job used ROTEM frequently. I’ve never used TEG (the system they are considering is the TEG6).

Can anyone weigh in on advantages of one over systems over another, or personal preferences? Why one system might be better than another?
Thanks!

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[DrZzZz]

Used TEG in training, we sent the blood to the lab. Lab ran the tests, we could see the results live on the computer.
In my current practice, we recently got the TEG6s. We actually run the TEG ourselves. It's practically stupid proof. Match up the appropriate collection tube and TEG cartridge depending on what you're running (Global, Platelet mapping, Ly30). The machine tells you what to do. You just pipette the blood into the cartridge and let it run. Again, see the results live on the computer (or on the TEG machine itself if you feel like standing there). Super simple. Actually nice to not have to send it off to the lab.

Can't speak on ROTEM, no experience with it. So no comparison, sorry if it's not helpful. But I can vouch for the TEG6s.

 

[Airlife91]

Used TEG in training, we sent the blood to the lab. Lab ran the tests, we could see the results live on the computer.
In my current practice, we recently got the TEG6s. We actually run the TEG ourselves. It's practically stupid proof. Match up the appropriate collection tube and TEG cartridge depending on what you're running (Global, Platelet mapping, Ly30). The machine tells you what to do. You just pipette the blood into the cartridge and let it run. Again, see the results live on the computer (or on the TEG machine itself if you feel like standing there). Super simple. Actually nice to not have to send it off to the lab.

Can't speak on ROTEM, no experience with it. So no comparison, sorry if it's not helpful. But I can vouch for the TEG6s.

Does TEG6 have an assay that neutralizes heparin so that you get an idea of things while on CPB and heavily heparinized?

 

[Ronin786]

As far as clinical relevance, there really isn't a big difference between ROTEM and TEG. It just depends on what you're familiar with.

However, ROTEM will soon have a cartridge system with no pipetting (I.e. ABGs). If you can hold out till that is available it'll make all your lives' a lot easier.

 

[DrZzZz]

Does TEG6 have an assay that neutralizes heparin so that you get an idea of things while on CPB and heavily heparinized?

Yes. The standard/global TEG runs a sample with Heparinase so you can evaluate clotting issues even in the presence of heparinized blood.

 

[dchz]

Does TEG6 have an assay that neutralizes heparin so that you get an idea of things while on CPB and heavily heparinized?

Yes. The standard/global TEG runs a sample with Heparinase so you can evaluate clotting issues even in the presence of heparinized blood.

I don't believe TEG 6 has enough heparinase for CPB. Someone please verify and correct me if I'm wrong, but I seem to remember all the CPB TEG6 shows up as a flat line. (May be things changed since 1.5 years ago when I used it)

 

[DrZzZz]

I don't believe TEG 6 has enough heparinase for CPB. Someone please verify and correct me if I'm wrong, but I seem to remember all the CPB TEG6 shows up as a flat line. (May be things changed since 1.5 years ago when I used it)

You're right (I think). I missed the part in his question about running it WHILE on pump. My bad.

 

[dchz]

Worked fairly extensively with all 3.

TEG 5 vs TEG 6: TEG6 is really easy to use compared to the TEG 5. However, I am not a huge fan of TEG 6. Main reason is that heparinase is not customizable and it does not give you the LY30. Either way, there is no way the blood bank is gonna let you run it point of care given they have to maintain quality control. So I really don't understand why an anesthesiologist would choose TEG 6 over TEG 5. Except that you can make more money for the sales rep.

TEG 5 Vs ROTEM: ROTEM gives a lot more info than a TEG 5 so if you want isolated customizable tests for certain aspects of coagulation cascade, ROTEM is gonna give you a lot of information. However, it is burdened by the fact that everyone that does trauma and cardiac has to understand what the information is telling you. The data is only as good as the user. TEG 5 has the advantage of Plt works, I'm at an institution that has plt works and I've yet to see a report from it that prevented me from transfusing platelets.

One of the authors at Mt.Sinai swore that ROTEM is more sensitive than TEG. But I have been unable to verify this claim.

Lastly, I'm hardly convinced the test even matters. The whole point of the tests is to reduce unnecessary transfusions. In order to do that, you have to have anesthesiologists both be experienced enough to interpret the test correctly and also have the backbone to hold off transfusing products under pressure - something that requires a cultural change rather a fancy test.

 

[DrZzZz]

I am not a huge fan of TEG 6. Main reason is that heparinase is not customizable and it does not give you the LY30. Either way, there is no way the blood bank is gonna let you run it point of care given they have to maintain quality control. So I really don't understand why an anesthesiologist would choose TEG 6 over TEG 5. Except that you can make more money for the sales rep.

Lastly, I'm hardly convinced the test even matters. The whole point of the tests is to reduce unnecessary transfusions. In order to do that, you have to have anesthesiologists both be experienced enough to interpret the test correctly and also have the backbone to hold off transfusing products under pressure - something that requires a cultural change rather a fancy test.

As to the first section there, the TEG6 has specific cartridges if you want an LY30. The blood bank control varies by hospital obviously. Like I said, we run our own TEG in the OR suite (we have machines near the trauma ORs and the cardiac ORs). They take care of the QC periodic tests, but we do get our own machines to run the tests.

To the second part, I agree, but again, varies by institution. Outside of a small handful of outliers, most of our surgeons respect us enough that if we tell them product isn't indicated (ESPECIALLY if there's TEG data to back that up), they won't fight us on that. So all depends on the relationship you have with the surgeons at your joint. But yes, there are surgeons that don't care what the data says - if the patient is bleeding, there's no way it's a vicryl deficiency, so the patient needs product. Usually not worth the fight in those instances.

 

[Airlife91]

Great info, thank you. Looks like I'll be relatively happy with either. In our discussions, I have been adamant that we must have easy access to start the sample immediately after it is drawn, and have easy access to real-time results.

The cartridge aspect is very nice. I'm inquiring with ROTEM to see if/when that will be available.

Now my experience is only with ROTEM...but I do have some of their propaganda that touts a much faster turnaround time to actionable results when compared to TEG6. Also advantages in Heparin neutralization (4 in Fibtem and 7 in heptem, vs 1 in TEG6).

Also 100% agree with the sentiments above regarding this only being worthwhile if people know when/how to use the results. And we have a great relationship with most surgeons, so I'm hoping that won't be a big problem. Change is always a little hard though. We'll see.

Thanks again for the input.

 

[dchz]

As to the first section there, the TEG6 has specific cartridges if you want an LY30. The blood bank control varies by hospital obviously. Like I said, we run our own TEG in the OR suite (we have machines near the trauma ORs and the cardiac ORs). They take care of the QC periodic tests, but we do get our own machines to run the tests.

That's really interesting! I would like more detail on how you use your TEG6 in cardiac and trauma cases:

When do you run the TEG for your cardiac case?

Does the separate LY30 cartridge give you a normal TEG6 as well? If so why not just run that all the time? What is the point of the separate cartridge?

Why do you run a TEG for your trauma cases? What does it tell you than to give whole blood? I fail to see how the information it gives you affects how you transfuse during true emergent trauma - if the bleeding is controlled, no need for TEG, if the bleeding isn't controlled, give whole blood or RBC, FFP, and Plt per MTP.

 

[DrZzZz]

That's really interesting! I would like more detail on how you use your TEG6 in cardiac and trauma cases:

When do you run the TEG for your cardiac case?

Does the separate LY30 cartridge give you a normal TEG6 as well? If so why not just run that all the time? What is the point of the separate cartridge?

Why do you run a TEG for your trauma cases? What does it tell you than to give whole blood? I fail to see how the information it gives you affects how you transfuse during true emergent trauma - if the bleeding is controlled, no need for TEG, if the bleeding isn't controlled, give whole blood or RBC, FFP, and Plt per MTP.

We run TEGs in cardiac if there's been a long pump run and we are expecting coagulopathy, or for any case where the surgeon whines about oozing. Generally run it after heparin reversal. There's some surgeons that want one for every case, but most are fine using it situationally.

The Ly30 cartridge does not a run a TEG with Heparinase like the standard/global cartridge does. As far as I know, that's all you lose by using the Ly30 cartridge.

As for traumas, yes, of course you're just running MTP until the bleeding is controlled on the surgical field and the patient somewhat stabilizes. I don't know about your blood bank, but we never get product sent to us in a ratio we actually want during MTP. The first cooler might be good, but after that, you give the patient whatever you were lucky enough to receive. So in that case where your transfused ratio is off, or even if it wasn't, you can then run the TEG to see if anything else is needed to normalize the cascade if the patient is still oozy.

 

[deleted697535]

we use rotem.
ive heard its better cause if you bump the teg machine it fails.
tbh the tech does it, so all i know is they bring me the printout and i give a bunch of stuff that i was gonna give anyway

 

[abolt18]

We have TEG here, but it has to go to the lab and can take 20+ minutes before they start it, so we have definitely sent a TEG w heparinase when on a long pump run to anticipate correctable coagulopathies. Because it takes so long, you almost HAVE to send it while on bypass to have any worthwhile results.

 

[woopedazz]

Does TEG6 have an assay that neutralizes heparin so that you get an idea of things while on CPB and heavily heparinized?

They all do

 

[dchz]

we use rotem.
ive heard its better cause if you bump the teg machine it fails.
tbh the tech does it, so all i know is they bring me the printout and i give a bunch of stuff that i was gonna give anyway

Agree with the products, which is why I'm convinced the test hardly matters. We have a teg for every bypass case and some partners literally don't look at it. I had TEG available during fellowship but I never ran one because the surgeon thinks plt is the magic bullet and 1 FFP is going to volume overload a pt that has 20g of mannitol...

If one bumps the TEG machine, you see the MA all of a sudden decrease but it still works well enough to give you the info you need 95% of the time.

 

[DrN2O]

I doubt there is that much difference between the different systems themselves. The more important issues are:
1. Who runs the samples: Lab medicine or OR staff? The transport time and the delay at night/weekends will be more significant than the actual time for the test to yield results.
2. Who maintains the machines, and whose responsibility is to perform QC? I hate to be the one on the hook to perform daily QC and troubleshoot.

If you can get your way with these first two (ideally, someone other than me runs the test in the OR 24/7 and does the QR), then you can evaluate next:
3. The ease of use. You can tell me it's idiot-proof, but we all know better. But my ROTEM DOES take a lot of pipetting.

Finally, but may be should be the first
4. How are you, and the surgeons, going to use the result to change management? If you can't get come up with an algorithm that everyone agrees on, it's pointless, and makes the first three issues that much more painful.