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Thromboelastography in clinical decision-making in the critically ill patient in a district general hospital ICU

Introduction

Thromboelastography (TEG) is a point-of-care monitoring tool that could help in managing coagulopathy in the critically ill. This may be beneficial in reducing the length of stay in the ICU, guide blood product transfusion and improve patient outcome.

Methods

We conducted a retrospective analysis of the use of TEG in a busy district general hospital ICU. We included all 100 patients in whom TEG was performed over 1 year. They required >4 units blood intraoperatively or >2 units blood on the ICU, abdominal aortic aneurysm repair or had sepsis. TEG was performed on 212 occasions, in parallel with routine coagulation studies.

Results

We transfused 656 units of packed RBCs, 27 units of cryoprecipitate, 180 units of FFP and 130 units of platelets, incurring an expenditure of £722,682. The cost of running TEG for that year was £1,845. Two hundred and twelve clinical decisions were made following TEG along with clotting results. We identified 174 (82.08%) abnormal TEG results, of which 88 (50.57%) were accompanied by abnormal clotting. One hundred and eighty-seven (88.21%) clinical decisions were influenced by the TEG result. In this group, 171 (91.44%) were related to guiding transfusion of blood products. Fifteen (8.02%) resulted in a change of medical management, guiding activated protein C administration, renal replacement therapy, invasive procedures and starting secondary anticoagulation prophylaxis.

Conclusion

Standard coagulation assays do not provide any information on platelet function or fibrinolysis [1]. TEG can replace clotting studies and the assessment of platelet function [2]. TEG can guide blood product transfusion in cardiac surgery [1]. TEG can be done with a fraction of the total costs of transfusion and provides confidence during the management of coagulopathy.

Ongoing research should focus on establishing clear guidelines for the appropriate use of the thromboelastograph.

References

  1. 1.

    Avidan MS, et al.: Comparison of structured use of routine laboratory tests or near patient assessment with clinical judgment in the management of bleeding after cardiac surgery. Br J Anaesthesia 2004, 92: 178-186. 10.1093/bja/aeh037

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  2. 2.

    The clinical and cost effectiveness of thromboelastography/thromboelastometry Health Technology Assessment Report, NHS Quality Improvement Scotland; December 2007

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Louw, J., Veenith, T. & Moondi, P. Thromboelastography in clinical decision-making in the critically ill patient in a district general hospital ICU. Crit Care 12, P212 (2008). https://doi.org/10.1186/cc6433

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Keywords

  • Renal Replacement Therapy
  • Aortic Aneurysm
  • Platelet Function
  • Abdominal Aortic Aneurysm
  • Abnormal Clotting