Basic Clinician Training Module 2

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Basic Clinician TrainingModule 2

• TEG Technology

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Hemostasis monitoringRoutine coagulation tests
PT, aPTT

• Based on cascade model of coagulation
• Measure coagulation factors interaction in
  solution (plasma)
• Determine if adequate levels of coagulation
  factors are present for clot formation
• Do not reflect the roles of cells or
  contributions of local vascular and tissue
  conditions
• Plasma-based assays miss the impact of platelets
  and platelet activation on thrombin generation.
• Plasma-based assays use static endpoints (e.g.
  fibrin formation) - miss impact of altered
  thrombin generation on platelet function and clot
  structure.

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Hemostasis monitoringTEG analysis system

• Whole blood test
• Measures all phases of hemostasis
• initiation through lysis
• Shows the net effect of
• hemostatic components on blood
• clotting process

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The TEG analyzerDescription

• TEG point of care (POC) whole blood coagulation
  monitoring device
• Time to initial results 4-8 minutes
• Time to completion (clot lysis) 45-60 minutes
• 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 optimal conditions of
  thrombin generation
• Demonstrates the contributions and interactions
  of hemostatic components during the clotting
  process.

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TEG technologyHow it works
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TEG sample preparation

• Blood samples can be modified by adding agents
  to the sample
• Activator maximizes thrombin generation and
  speeds up clotting time
• Kaolin activates intrinsic pathway, used for
  normal TEG analysis
• Tissue factor specifically activates extrinsic
  pathway
• Heparinase removes heparin from sample, allows
  view of the underlying hemostatic status of a
  patient on heparin.
• Platelet activators allows testing antiplatelet
  agent responsiveness and efficacy. (Module 7)

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TEG sample types

• Kaolin used for normal TEG analysis
• Kaolin with heparinase used for normal TEG
  analysis when patient on heparin
• Compared with Kaolin-only sample (run
  simultaneously) to determine reversal of heparin

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Utility of the TEG

• Demonstrates all phases of hemostasis
• Initial fibrin formation
• Fibrin-platelet plug construction
• Clot lysis
• Identifies a balance or imbalance in the
  hemostatic system between the clot forming and
  clot breakdown pathways
• Identifies likely cause(s) of bleeding
• Identifies likely cause(s) of thrombosis

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What TEG analysis captures
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TEG parameters

• Identification
• Definition

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Thrombin formationThe R parameter - identified
Initial fibrin formation
Intrinsic,extrinsic,commonpathways
Pin is stationary
Pin is engaged
? Pin starts to rotate with cup
Cup rotates, pin remains stationary
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FibrinogenThe a (angle) parameter - identified
Fibrin increases
Pin is engaged
Amplitude of pin rotation increases as fibrin is
generated and cross links are formed
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Platelet functionThe MA parameter - identified
Maximum amplitude (MA) of pin rotation
Amplitude of pin rotation
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Platelet functionThe MA parameter - defined
Maximum amplitude (MA) of pin rotation
Amplitude of pin rotation

• Amplitude of pin rotation depends on clot
  strength
• Clot strength 80 platelets 20 fibrinogen
• Platelet function influences thrombin generation
  and fibrin formation ? relationship between R, a,
  and MA

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Coagulation indexThe CI parameter - defined

• Linear combination of kinetic parameters of clot
  development and clot strength (R, K, angle, MA)
• Provides a global index of hemostatic status
• CI lt -3.0 hypocoagulable
• CI gt 3.0 hypercoagulable

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FibrinolysisThe LY30 parameter - identified
Decrease in amplitude of pin rotation 30 minutes
after MA reached
MA
30 min
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FibrinolysisThe LY30 parameter - defined
Decrease in amplitude of pin rotation 30 minutes
after MA reached
MA
30 min

• Reduction in amplitude of pin rotation depends on
  extent of fibrinolysis

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TEG parameter summaryDefinitions
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TEG parameter summary
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What does TEG report?
Clot strength Platelet function
Clot stability Clot breakdown
Clotting time
Clot kinetics
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Normal TEG tracing
30 min
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Hemorrhagic TEG tracing
30 min
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Prothrombotic TEG tracing
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Fibrinolytic TEG tracing
30 min
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Components of the TEG tracingExample R
Actual value
Normal range
ParameterUnitsValueNormal range
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TEG decision treeQualitative
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TEG decision treeQuantitative
US Patent 6,787,363
Hemorrhagic
Fibrinolytic
Thrombotic
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TEG tracingExample hemorrhagic




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TEG tracingExample prothrombotic




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TEG tracingExample fibrinolytic


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Summary

• 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.

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Review exercises

• TEG parameters
• Hemostasis monitoring

Begin exercises
Skip exercises
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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
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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
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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
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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
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Exercise 5 TEG parameters

• Clot strength is dependent on which of the
• hemostatic components?
• 100 platelets
• 80 platelets, 20 fibrinogen
• 50 platelets, 50 fibrinogen
• 20 platelets, 80 fibrinogen
• 100 fibrinogen

Answer
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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
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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?
• R
• Angle (a)
• LY30
• CI
• None of the above

Answer
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Exercise 8 TEG parameters

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

Answer
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Exercise 9 TEG parameters

• Which of the following conditions will 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
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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
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Exercise 11 Hemostasis monitoring

• 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 influence of thrombin generation on
  platelet function
• Use fibrin formation as an end point

Answer
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Exercise 12 Hemostasis monitoring

• 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
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Exercise1 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

R
Next
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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

Next
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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

Next
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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

Next
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Exercise 5 TEG parameters

• Clot strength is dependent on which of the
• hemostatic components?
• 100 platelets
• 80 platelets, 20 fibrinogen
• 50 platelets, 50 fibrinogen
• 20 platelets, 80 fibrinogen
• 100 fibrinogen

Next
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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)
• e. CI

Next
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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?
• R thrombin generation occurs mainly on the
  surface of platelets, thus a defect in platelet
  function may slow the rate of thrombin and fibrin
  formation.
• Angle (a) a defect in platelet function may
  slow the rate of formation of platelet-fibrin
  interactions, thus slowing the rate of clot
  buildup.
• LY30
• CI
• None of the above

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Exercise 8 TEG parameters

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

Next
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Exercise 9 TEG parameters

• Which of the following conditions will 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

Next
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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)

Next
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Exercise 11 Hemostasis monitoring

• 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 influence of thrombin generation on
  platelet function
• Use fibrin formation as an end point

Next
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Exercise 12 Hemostasis monitoring

• 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 (vascular mediated event that
  occurs in vivo, but not in vitro)
• Clot lysis

Next
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End of Module 2