Transfusion Recommendations Based on Thromboelastography (TEG)
TEG-guided transfusion strategy leads to significantly lower use of blood products compared to standard coagulation test-guided transfusion without compromising patient outcomes, and should be implemented for patients with coagulopathy.
Understanding TEG/ROTEM Parameters
Thromboelastography (TEG) and Rotational Thromboelastometry (ROTEM) provide comprehensive assessment of the entire coagulation process, offering several advantages over conventional coagulation tests:
- Faster results (available within minutes vs. hours)
- Evaluation of all phases of coagulation (initiation, amplification, propagation, and fibrinolysis)
- Detection of hypercoagulability, hyperfibrinolysis, and platelet dysfunction not assessed by routine tests 1
Key Parameters and Interpretation
| Parameter | Measurement | Clinical Significance |
|---|---|---|
| Clotting Time (CT/R) | Time to 2mm amplitude | Reflects initiation of clotting |
| Clot Formation Time (CFT/K) | Time from 2mm to 20mm amplitude | Speed of clot formation |
| Maximum Clot Firmness (MCF/MA) | Maximum amplitude | Maximum clot strength |
| Clot Amplitude at 5/10 min (CA5, CA10) | Amplitude at specific timepoints | Early indicators of clot formation |
| Lysis Index at 30 min (LI30) | % of clot remaining at 30 min | Detects hyperfibrinolysis |
Specific Transfusion Recommendations
1. Fibrinogen Replacement
- Indication: FIBTEM CA5 < 10 mm or FIBTEM MCF < 7 mm 1
- Product: Cryoprecipitate (3 pools) or fibrinogen concentrate (4g) 2, 3
- Target: FIBTEM CA5 ≥ 10 mm or FIBTEM MCF ≥ 7 mm
2. Platelet Transfusion
- Indication: EXTEM CA5 - FIBTEM CA5 < 30 mm or EXTEM MCF - FIBTEM MCF < 45 mm 1
- Product: 1 pool of platelets 2
- Target: EXTEM CA5 - FIBTEM CA5 ≥ 30 mm or EXTEM MCF - FIBTEM MCF ≥ 45 mm
3. Fresh Frozen Plasma (FFP)
- Indication: EXTEM CA5 > 40 mm plus EXTEM CT > 80 s or EXTEM MCF > 45 mm plus prolonged CT 1
- Product: FFP 10-15 mL/kg
- Target: Normalization of EXTEM CT
4. Tranexamic Acid
- Indication: EXTEM LI30 < 85% or visible hyperfibrinolysis on EXTEM 1
- Product: Tranexamic acid 1g IV
- Caution: Not recommended in variceal bleeding 2
Clinical Applications
Trauma Patients
- TEG/ROTEM-guided therapy has been shown to reduce mortality at 24h (13% vs. 5%) and 30 days (25% vs. 11%) 1
- The European guideline on management of major bleeding and coagulopathy following trauma recommends early and repeated monitoring of haemostasis using either traditional laboratory tests or viscoelastic methods 2
- Particularly beneficial in traumatic brain injury patients, with significant reduction in progressive hemorrhagic injury 1
Liver Disease and Variceal Bleeding
- In patients with cirrhosis and active variceal bleeding, if hemostasis is achieved with portal hypertension-lowering drugs and endoscopic treatment, correction of haemostatic abnormalities is not indicated 2
- TEG-guided transfusion strategy in variceal bleeding leads to significantly lower use of blood products (13.3% vs. 100%) without compromising hemostasis 4
- TEG-guided strategy also shows reduced rebleeding at 42 days (10% vs. 36.7%) 4
Cardiac Surgery
- TEG/ROTEM is useful in cardiac surgery and other major surgical procedures with high bleeding risk 1
- Reduces unnecessary transfusions and guides targeted therapy 1, 5
Practical Algorithm for TEG-Guided Transfusion
- Obtain baseline TEG/ROTEM upon admission of patient with suspected coagulopathy
- Assess clot formation parameters:
- If R/CT prolonged > 40 min → FFP transfusion
- If MA/MCF < 30 mm with normal FIBTEM → Platelet transfusion
- If FIBTEM CA5 < 10 mm → Fibrinogen replacement
- If LY30 > 3% or LI30 < 85% → Consider tranexamic acid (except in variceal bleeding)
- Repeat TEG/ROTEM after intervention to assess response
- Continue monitoring at regular intervals during ongoing bleeding
Benefits of TEG/ROTEM-Guided Transfusion
- Reduced overall mortality (3.9% vs. 7.4%) 5
- Decreased use of blood products: red blood cells (14%), fresh frozen plasma (43%), and platelets (27%) 5
- Cost savings through reduced blood product wastage 1
- Fewer additional invasive hemostatic interventions 1
Limitations and Considerations
- TEG/ROTEM requires trained users for proper interpretation 1
- May be insensitive to mild fibrinolytic activation 1
- Quality of evidence remains low based on high risk of bias in studies, heterogeneity, and imprecision 5
- Most studies have been conducted in elective cardiac surgery settings 5
Conclusion
TEG/ROTEM-guided transfusion provides significant advantages over conventional coagulation test-guided strategies by allowing targeted blood component therapy, reducing unnecessary transfusions, and potentially improving patient outcomes. The evidence strongly supports implementation of TEG/ROTEM-guided protocols in patients with coagulopathy, particularly in trauma, liver disease, and cardiac surgery settings.