Running TEGs in Cardiac rooms

[GA8314]

When do your perfusionists run TEGs during your cardiac cases (assuming they do)? At what points?

Currently, we run one for a baseline just after induction. Nice to have a baseline. Then, after bypass. The problem is that it takes so long that depending on how long it takes to close, we don't get numbers back in time for transport to ICU. So we don't have time to really take focused blood product action in the event of a coagulopathy while still in the room..... So, in the event of some residual oozing, we'll often (after addressing ACT with additional protamine) just give platelets.... But, it feels like throwing darts to some extent though I realize that's the most probable disfunction in the absence of any real data from a TEG..... We do run Amicar as standard.

Thoughts? Solutions? Same experiences?

Also, where I trained we did not renal dose the Amicar. Do you guys either not use Amicar or lower the dose in cases of GFR<60?? This seems to be the culture where I'm at, but I usually override it, and maybe just go with a lower bolus and infusion if GFR lower....

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[sethco]

At the one location where we do a large volume of cardiac, we run a baseline TEG with platelet mapping preop and then send a TEG with Heparinase when we send rewarming labs while on CPB. All other places where I do Cardiac don't have TEG capabilities, so rely on baseline and rewarming labs (I.e. H/H, Plt count, Fibrinogen). Coags as needed when off pump post-protamine

 

[deleted171991]

A few thoughts (I don't do cardiac):

If I were you, I would send a TEG once I am done transfusing everything in the OR. That way the ICU will know what else needs correction, by the time the patient is settled in.

Re Amicar: Apparently renal clearance approximates creatinine clearance (116 ml/min) while total body clearance is 169 ml/min. So if the GFR drops to 60 ml/min, total body clearance would drop to about 2/3.

AMICAR® (aminocaproic acid)Injection, Oral Solution, and Tablets

 

[dhb]

We do one baseline and one after protamine but are surgeons our are not so fast as to not have a idea of what the teg looks like.
R is 4-8min K 0-4

 

[spigelian]

Long time lurker. Echo the sentiment to get lab values on pump to be able to have targeted product available as soon as protamine is given. TEG and ROTEM are valuable, but you can also get by with PLT and Fibrinogen values. The earliest I would send labs on pump is 5 or 10 min after cross clamp and the latest would be around the time of rewarming again so that values are back in time.

I also think you need to consider the type of case you are doing (DHCA vs routine CABG) and the practice environment (surgeons favoring empiric transfusion). If you are doing a DHCA case or other case with likely bleeding and plan to empirically transfuse post protamine, then I would probably only send PLT and fibrinogen on pump to get baseline values in the event in the event it led me to order more than 2PLT or 2Cryo. Otherwise I would empirically transfuse and then send ROTEM or TEG as well as PLT and fibrinogen at the end of the case so that values are available to the ICU upon arrival.

 

[AdmiralChz]

Long time lurker. Echo the sentiment to get lab values on pump to be able to have targeted product available as soon as protamine is given. TEG and ROTEM are valuable, but you can also get by with PLT and Fibrinogen values. The earliest I would send labs on pump is 5 or 10 min after cross clamp and the latest would be around the time of rewarming again so that values are back in time.

I also think you need to consider the type of case you are doing (DHCA vs routine CABG) and the practice environment (surgeons favoring empiric transfusion). If you are doing a DHCA case or other case with likely bleeding and plan to empirically transfuse post protamine, then I would probably only send PLT and fibrinogen on pump to get baseline values in the event in the event it led me to order more than 2PLT or 2Cryo. Otherwise I would empirically transfuse and then send ROTEM or TEG as well as PLT and fibrinogen at the end of the case so that values are available to the ICU upon arrival.

Very much agree - TEG and ROTEM are valuable, but by definition they take a significant amount of time to run to get meaningful data. Most surgeons haven’t been interested in waiting that long before clamoring for products, in my limited experience in residency and fellowship.

I think it’s more helpful for targeted transfusion in the ICU.

 

[pgg]

In fellowship we'd routinely send PLT, fibrinogen, and TEG early enough so that the results would be back about the time we came off bypass and gave protamine. The lab would run the TEG and we could remotely view the TEG unfolding in realtime on our monitor in the OR. Usually used TXA except for DHCA cases or patients with seizure disorders (Amicar instead).

Now if I order a TEG I don't get the results until we're in the ICU. I just get a fibrinogen and PLT count in the OR.

 

[GA8314]

Long time lurker. Echo the sentiment to get lab values on pump to be able to have targeted product available as soon as protamine is given. TEG and ROTEM are valuable, but you can also get by with PLT and Fibrinogen values. The earliest I would send labs on pump is 5 or 10 min after cross clamp and the latest would be around the time of rewarming again so that values are back in time.

I also think you need to consider the type of case you are doing (DHCA vs routine CABG) and the practice environment (surgeons favoring empiric transfusion). If you are doing a DHCA case or other case with likely bleeding and plan to empirically transfuse post protamine, then I would probably only send PLT and fibrinogen on pump to get baseline values in the event in the event it led me to order more than 2PLT or 2Cryo. Otherwise I would empirically transfuse and then send ROTEM or TEG as well as PLT and fibrinogen at the end of the case so that values are available to the ICU upon arrival.

So, you think it's worth it to get TEG from drawn sample while on CPB?

 

[spigelian]

So, you think it's worth it to get TEG from drawn sample while on CPB?

If available at a given institution, I do think there is value to having TEG or ROTEM along with PLT and Fibrinogen values while on pump. I think it fills in the overall global picture and confirms how the low PLT or fibrinogen are adversely affecting clot formation and additionally can give you an idea if FFP or PCC's may be indicated. As we commonly give antifibrinolytics, I have never actually seen fibrinolysis, but it could detect that as well. I do think you could get by without TEG/ROTEM using instead PLT and fibrinogen. Continued bleeding after correcting low PLT and fibrinogen would either be factor deficiencies requiring FFP and/or PCC's or would be surgical.

I also think there is value in TEG/ROTEM for demonstrating proper resuscitation as a normal TEG/ROTEM along with PLT >100 and fibrinogen >200 to 250 with persistent bleeding gives reassurance that the patient has been properly transfused and there is a surgical problem.

As far as the accuracy of any of these values on pump, I do think they are reasonably accurate and can help guide transfusion at the time of separation from CPB. In fellowship, we routinely sent each of these labs off during the pump run. Sometimes multiple samples were sent as the initial ones were thought to have been lost (but must have been found as both results showed up), or the pump run was longer than expected and the values did not markedly change from those sent early on in the pump run. PLTs and fibrinogen were a little lower the longer the pump run was, but it was gradual and the initial large drop (if preoperative values were available) were likely from initiation of CBP itself.

 

[dchz]

Those that send a baseline TEG/Rotem, what are you hoping to find? You're really gonna give products before CPB?

At our institution the baseline is optional/discouraged, and i think for good reason. it's a $2k test without much relevance.

Those of you that send a rewarming TEG and plt/fib, why do you do both? What does a plt/fib tell you that a TEG doesn't?

 

[dchz]

In fellowship we'd routinely send PLT, fibrinogen, and TEG early enough so that the results would be back about the time we came off bypass and gave protamine. The lab would run the TEG and we could remotely view the TEG unfolding in realtime on our monitor in the OR. Usually used TXA except for DHCA cases or patients with seizure disorders (Amicar instead).

Now if I order a TEG I don't get the results until we're in the ICU. I just get a fibrinogen and PLT count in the OR.

Is the TXA a institutional preference? i've seen data suggesting it's more expensive and more side effects than aminocaproic acid

also i guess timing is a good reason for plt/fib

 

[dchz]

Long time lurker. Echo the sentiment to get lab values on pump to be able to have targeted product available as soon as protamine is given. TEG and ROTEM are valuable, but you can also get by with PLT and Fibrinogen values. The earliest I would send labs on pump is 5 or 10 min after cross clamp and the latest would be around the time of rewarming again so that values are back in time.

I also think you need to consider the type of case you are doing (DHCA vs routine CABG) and the practice environment (surgeons favoring empiric transfusion). If you are doing a DHCA case or other case with likely bleeding and plan to empirically transfuse post protamine, then I would probably only send PLT and fibrinogen on pump to get baseline values in the event in the event it led me to order more than 2PLT or 2Cryo. Otherwise I would empirically transfuse and then send ROTEM or TEG as well as PLT and fibrinogen at the end of the case so that values are available to the ICU upon arrival.

Congrats on posting! we value your opinion, speak up more

Which of the following tend to bleed more in your experience?

-Pt with DHCA for aortic repair with CPB of 1.5 hours
-Pt with double valve with CPB run of 4 hours

 

[GA8314]

If available at a given institution, I do think there is value to having TEG or ROTEM along with PLT and Fibrinogen values while on pump. I think it fills in the overall global picture and confirms how the low PLT or fibrinogen are adversely affecting clot formation and additionally can give you an idea if FFP or PCC's may be indicated. As we commonly give antifibrinolytics, I have never actually seen fibrinolysis, but it could detect that as well. I do think you could get by without TEG/ROTEM using instead PLT and fibrinogen. Continued bleeding after correcting low PLT and fibrinogen would either be factor deficiencies requiring FFP and/or PCC's or would be surgical.

I also think there is value in TEG/ROTEM for demonstrating proper resuscitation as a normal TEG/ROTEM along with PLT >100 and fibrinogen >200 to 250 with persistent bleeding gives reassurance that the patient has been properly transfused and there is a surgical problem.

As far as the accuracy of any of these values on pump, I do think they are reasonably accurate and can help guide transfusion at the time of separation from CPB. In fellowship, we routinely sent each of these labs off during the pump run. Sometimes multiple samples were sent as the initial ones were thought to have been lost (but must have been found as both results showed up), or the pump run was longer than expected and the values did not markedly change from those sent early on in the pump run. PLTs and fibrinogen were a little lower the longer the pump run was, but it was gradual and the initial large drop (if preoperative values were available) were likely from initiation of CBP itself.

Thanks very much to all contributors. I've always sort of thought that a CPB value wouldn't be useful, but your suggestion that it can be valuable has me rethinking this and seeing the logic as to how it can be used. The other value is that you'll get something back in time to actually do something about it.

I do also agree with having one drawn for ICU management as well, as FPP suggests.

 

[pgg]

Is the TXA a institutional preference? i've seen data suggesting it's more expensive and more side effects than aminocaproic acid

also i guess timing is a good reason for plt/fib

I actually don’t know the cost. I don’t think either are that expensive, especially in the overall context of cardiac surgery. Both are pretty low side effect / risk profile. I got here, they said Amicar was in the default cardiac tray, I said OK.

 

[DrBeaker]

We have ROTEM at my institution. I send a sample while still on CPB during rewarming (bladder temp 35-36). I only send Extem and Fibtem on CPB. Tells me if I need FFP, PLT, Cryo. Takes about 10 minutes for data, plenty of time for the test to cool while we separate and give protamine. Ill send another maybe 10 minutes after protamine if we continue to have bleeding issues.

 

[pjl]

You don't need numbers to evaluate the early TEG post bypass. Just look at the picture, you can generally get an idea. Results are pretty fast if you get to see it in real time. We have a dedicated 60 inch TV. No idea why that is necessary, but our surgeon gets ANYTHING he wants.

 

[OB1🤙]

I think baseline TEG/ROTEM is a colossal waste of money on soon-to-be-irrelevant information. I don't think they're $2k tests though. A couple hundred maybe.

I also think that there's no point in using POC clot testing if you aren't seeing results at the POC.

We have ROTEM and it runs in the anesthesia techs' room next door. I peek at it after 10 minutes or less of run time, which is long enough for it to show you what you need. It's extremely useful I think. I run it while we start to warm, and you can target what needs to be targeted, if anything. Yellow stuff then is ready to go once protamine goes in.

I don't run it on routine cases. Just longer pump runs/high risk stuff.

 

[ScarfTheVerb]

TEG is <$20 at my facility

 

[caligas]

Our Rotem is run in the lab. By the time they:

1) find the sample, assuming not lost in slow transit 2) find someone to run it, 3) get the machine "warmed up" (this sounds like bull$hit to me, can anybody confirm this is bull$hit?), 4) run the test, and 5)post the results, the patient is in the step down unit using his incentive spirometer and munching on Salisbury steak.

 

[partydoc]

Our Rotem is run in the lab. By the time they:

3) get the machine "warmed up" (this sounds like bull$hit to me, can anybody confirm this is bull$hit?)

Yes, this was a huge barrier at my residency. Machine needs to be calibrated too I think. I thought it was bull#hit when it wasn't warmed up as we're always supposed to have a baseline TEG for when traumas rolled in.

 

[dhb]

We have the TEG in the room and the perfusionist runs the samples. It doesn't cost more than the little tube you put the blood in (not counting the mrice of the machine).
HB you cooling patients.
If it's low cost then it's a great tool and just the ability to tell the surgeon to stfu and concentrate on hemostasis is gold.