ROTEM - An Introduction and overview.pptx

Brief introduction of ROTEM analysis.

1. ROTEM: An introduction and overview

2. What is thromboelastometry or thromboelastograpy ? Method of measuring the viscoelastic properties of a blood clot Demonstrates: Clot formation Clot firmness Clot breakdown ( fibrinolysis ) Global assessment of hemostasis performed in whole blood.

3. Why Use ROTEM? To detect reduced clotting factor activity, poor clot firmness and premature lysis in the bleeding patient to guide transfusion and other therapy. To provide an estimate of hemostatic reserve in patients to avoid transfusion.

4. Why Use ROTEM? Gives information on four critical areas of hemostasis and need for targeted therapy in bleeding patients. Potential Hemostatic Lesion Therapeutic Interventions Fibrinolysis Antifibrinolytic therapy: tranexamic acid (TXA) aminocaproic acid (Amicar) Fibrinogen levels Cryoprecipitate fibrinogen concentrates Clotting factor activity Plasma Prothrombin complex concentrates Platelet activity Platelet transfusion

5. Why not use standard coagulation tests? Standard coagulation tests (PT/INR, PTT, fibrinogen levels) are measured only in plasma. These tests do not have cellular blood elements that contribute to hemostasis. Does not measure clot lysis or fibrin polymerization. Standard testing complements ROTEM, but measures different elements.

6. When to use ROTEM Active Hemorrhage Trauma Massive hemorrhage Obstetric hemorrhage Acquired coagulation disorders Cardiac and vascular surgery

7. When NOT to use ROTEM Monitoring therapeutic effects of anticoagulants. Antiplatelet agents: clopidogrel , aspirin, prasugrel New oral anticoagulants: Dabigatran , rivaroxiban , apixiban ROTEM will not reliably detect the anticoagulant effects of these drugs . ROTEM can be used in patients who are actively bleeding and on warfarin or heparin. HEPTEM can evaluate heparin effect. ROTEM is NOT for therapeutic monitoring of either warfarin or heparin.

8. Basics of Thromboelastometry

9. The ROTEM Instrument

10. Platelet-fibrin strands Viscoelastic clot-based testing Whole blood sample Oscillating cup or pin TEG: thromboelastography ROTEM: rotational thromboelastometry

11. The ROTEM graph Amplitude in (mm) Time (in sec) The graph demonstrates the change in amplitude (clot firmness) over a time period The greater the amplitude the firmer the clot Colors: 0-2mm: green 2-20 mm: pink > 20 mm: blue

12. Hemostasis simplified Platelet surface Fibrinogen Thrombin Fibrin Clot Intrinsic Pathway Clotting factors Extrinsic Pathway Clotting factors PTT PT/INR

13. ROTEM – Assays EXTEM – Extrinsic pathway activation INTEM – Intrinsic pathway activation FIBTEM – adds platelet inhibitor Measures sole contribution of fibrinogen to clot firmness APTEM – adds antifibrinolytic to EXTEM; evaluates fibrinolysis HEPTEM – adds heparinase to INTEM; evaluates heparin effect

14. APTEM –adds aprotinin ( antifibrinolytic ) Hemostasis ROTEM Extrinsic pathway Intrinsic Pathway Fibrinogen activity

15. HEPTEM Extrinsic pathway Intrinsic Pathway Fibrinogen activity HEPTEM: Reverses heparin. Cardiovascular ROTEM

16. ROTEM ® Measured Parameters CT – onset of clot formation (sec) CFT – clot propagation rate (sec) a- angle – tangent to the clotting curve from 2mm (degrees o ) A10 – amplitude 10 minutes after CT (mm) MCF – Maximum Clot Firmness (mm) LI30 – Lysis Index (% of clot remaining 30 minutes after CT) ML – Maximum Lysis (% of lysis at any time)

17. ROTEM Thromboelastometry - Parameters CT (clotting time) – Measured in seconds Reflects the clotting factor activity (similar to PT/INR and PTT) CFT ( clot formation time) - measured in seconds - fibrin polymerization, stabilization of the clot with thrombocytes and FXIII MCF (maximum clot firmness) – Measured in amplitude (mm) Reflects the firmness and stability of a clot Due to interaction of platelets, fibrin and factor 13 ML (maximum lysis ) – Measured in (%) - Reflects the presence of premature clot lysis (hyperfibrinolysis)

18. Clotting Time Represents: PT ( Extem ) PTT ( Intem ) If prolonged: Low clotting factor activity Maximum Clot Firmness Represents: Greatest amplitude If decreased: Low fibrinogen or platelets Maximum Lysis : Represents fibrinolysis ROTEM Parameters A10: Clot amplitude 10 minutes after CT. Predicts MCF

19. ROTEM ® Thromboelastometry - Parameters A10 – Amplitude(mm) 10 minutes after CT Provides an early and highly predictive assessment of clot firmness (MCF). IMPORTANT FOR RAPID ASSESSMENT AND THERAPEUTIC DECISIONS

20. ROTEM Parameters MCF – Maximum Clot Firmness (mm) Easy to remember: “A10 plus 10 mm” MCF Ref Value: 51 - 72 mm MCF Ref Value: 50 - 70 mm

21. ROTEM – graph information The shape of the graph indicates whether a clot is: firm and stable has premature lysis weak or fragile. Firm & Stable Unstable (early Lysis) Relatively Weak

22. Normal ROTEM tracings Note: Normal HEPTEM = INTEM Normal APTEM = EXTEM

23. In your bleeding patient, ROTEM demonstrates: CT INTEM Prolonged Suggests Heparin influence or enzymatic factor deficiency A corrected CT HEPTEM provides clarity in this case: 210 vs 350 sec Suggests Heparin effect

24. In your bleeding patient, ROTEM demonstrates: A10 EXTEM Reduced Suggests inadequate clot firmness due to either decreased platelets and/or fibrinogen A10 = 27 mm A10 FIBTEM Reduced A10 = 4 mm Suggests inadequate fibrin contribution to clot firmness: low fibrinogen

25. In your bleeding patient, ROTEM demonstrates: A10 EX Reduced Suggests inadequate clot firmness as a result of decreased platelets and/or fibrinogen A10 = 27 A10 FIB Normal A10 = 9mm Suggests adequate fibrinogen Platelets are the cause for low A10 on EXTEM

26. In your bleeding patient, ROTEM demonstrates: ML EX = 100 % Suggests hyperfibrinolysis The APTEM is then run & lysis is corrected in APTEM vs EXTEM Confirms hyperfibrinolysis and shows efficacy of antifibrinolytic therapy > 15% @ 23min 4% @ 20min 30% @ 23min

27. Case examples

28. 62 year old woman presenting with subdural hematoma

29. 62 year old woman presenting with subdural hematoma Low A10 and MCF on EXTEM and INTEM Normal FIBTEM Suggests low platelet activity; recommend platelet transfusion.

30. 60 year old man bleeding - CABG

31. 60 year old man bleeding – CABG Prolonged CT INTEM which corrects on CT HEPTEM Suggests heparin effect; protamine recommended FIBTEM MCF slightly below normal, suggests below normal fibrinogen May require cryoprecipitate if bleeding not corrected with protamine

32. 10 year old with gunshot wound to the head

33. Elevated MCF on the FIBTEM suggestive of hyperfibrinogenemia . No intervention necessary. Secondary to acute phase response 10 year old with gunshot wound to the head

34. combined haemostasis disorder. hyperfibrinolysis (lysis of the clot in EXTEM and INTEM), a prolonged CT in INTEM. a strongly reduced clot firmness in APTEM (indicates a disturbance of clot formation exceeding fibrinolysis) a zero line (no clotting) in FIBTEM (reduced fibrinogen and / or polymerisation disorder). Need rapid combined treatment: an antifibrinolytic drug for the treatment of the hyperfibrinolysis, fibrinogen or FFP (large doses) for improvement of the clot formation. In cases of such an insufficient clot formation, a simultaneous platelet administration is also recommended (it would however also be possible to give fibrinogen or FFP first and then check the clot formation).