Thromboelastography: a more accurate assessment of global hemostasis

Abstract

A 47-year-old male with acute myeloid leukemia underwent resection of a paraspinous mass. Preoperative laboratory study results were as follows: white blood cell count, 2.6 ¥ 10 9 /L; hematocrit (Hct), 29%; platelet (PLT) count, 878 ¥ 10 9 /L; prothrombin time, 17.2 seconds (normal, 11.9-14.4 sec); and partial thromboplastin time, 41 seconds (normal, 22-37 sec). Intraoperatively, hemostasis was difficult to achieve. Two units of plasma and one plateletpheresis were transfused. Postoperatively, incisional bleeding continued and Hct decreased to 24%. Bleeding in the setting of thrombocytosis (921 ¥ 10 9 /L), minimally prolonged prothrombin time (16.6 sec), and mildly elevated fibrinogen concentration (420 mg/dL) prompted a transfusion medicine consultation.To assess the coagulation system, thromboelastograph (TEG 5000, Haemonetics, Braintree, MA) was obtained. TEG monitors the mechanical properties of the developing clot and subsequent lysis. Movement of an immersed transducer transmits a signal that generates a hemostasis profile. Initial TEG showed normal thrombin generation (R), but clot lysis indices (LY30 = 9.5% and CI > 1) suggested early secondary fibrinolysis, commonly seen in early disseminated intravascular coagulation (DIC). To prevent development of overt DIC, treatment with low-dose subcutaneous heparin was recommended. Four hours after heparin administration, repeat TEG showed LY30 normalized to 0%, suggesting cessation of the fibrinolytic phase of DIC. However, elevated angle and MA/G indicated higher fibrin(ogen) stabilization and PLT function, suggesting hypercoagulability. The patient received subcutaneous heparin every 12 hours for 48 hours. His bleeding resolved and he was discharged on Postoperative Day 4. This case demonstrates the clinical utility of thromboelastography. Routine laboratory testing did not suggest DIC, and transfusion of plasma and PLTs did not lead to clinical improvement; TEG evaluation allowed a more accurate assessment of all phases of coagulation, which revealed incipient DIC. As a result, more appropriate therapy was instituted with a successful outcome.

Viscoelastic hemostasis assays in septic, critically ill coronavirus disease 2019 patients: a practical guide for clinicians

“…One case report in a patient with post-operative fibrinolysis treatment with low dose unfractionated heparin showed normalization of LY30 and prevention of progression to DIC. 13 However in another report of 33 patients with severe sepsis, of whom 17 were treated with antithrombin in addition to low dose low molecular weight heparin, hypercoagulability was not reversed by this treatment and did not change the outcome in these patients despite significantly supratherapeutic AT levels. 14 The overall quality of evidence on the value of TEG in adults with sepsis remains low, however it remains promising that TEG parameters, especially in the setting of hypo coagulability might be able to identify patient with sepsis induced DIC and predict more severe disease and higher mortality.…”