Basic Clinician Training

Module 2
TEG Technology
 Hemostasis monitoring
Routine 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.
Hemostasis monitoring
TEG analysis system

Whole blood test

Measures all phases of hemostasis:
initiation through lysis
Shows the net effect of
hemostatic components on blood
clotting process
The TEG analyzer
Description
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.
TEG technology
How it works
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)
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
 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
Amplitude of
pin rotation

What TEG analysis captures

Time
TEG parameters

Identification
Definition
 Thrombin formation
The R parameter - identified
Amplitude of
pin rotation

Initial fibrin
formation
Time

Intrinsic,
extrinsic,
common
pathways

Pin is Pin is
Pin starts to rotate with cup
stationary engaged

Cup rotates, pin remains stationary

 Fibrinogen
The a (angle) parameter - identified
Fibrin
Amplitude of
pin rotation

increases

Time

Pin is
engaged

Amplitude of pin rotation increases as fibrin is generated

and cross links are formed
 Platelet function
The MA parameter - identified
Maximum amplitude (MA) of pin rotation
Amplitude of
pin rotation

Time

Amplitude of pin rotation

 Platelet function
The 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
Coagulation index
The 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 < -3.0: hypocoagulable
CI > +3.0: hypercoagulable
 Fibrinolysis
The LY30 parameter - identified
Decrease in amplitude of pin rotation
Amplitude of

30 minutes after MA reached

pin rotation

MA
Time

30 min
 Fibrinolysis
The 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
 TEG parameter summary
Definitions
R Latency from the time that the blood was placed in the TEG analyzer
until the initial fibrin formation.

a, K Measures the rapidity (kinetics) of fibrin build-up and cross-linking, that

is, the speed of clot strengthening.

MA Maximum dynamic properties of fibrin and platelet bonding via

GPIIb/IIIa; represents platelet function

G Derived from MA, represents the ultimate strength of the fibrin clot

CI Coagulation Index is linear combination of the above parameters.

LY30 LY30 measures the rate of amplitude reduction 30 minutes after MA.
This measurement gives an indication of the stability of the clot.
Amplitude of
pin rotation

TEG parameter summary

Time
What does TEG report?

Clot strength
Platelet function

Clotting Clot Clot stability

time kinetics Clot breakdown
 Amplitude of
pin rotation
Normal TEG tracing
Time

30 min
Hemorrhagic TEG tracing

30 min
Prothrombotic TEG tracing

30 min
Fibrinolytic TEG tracing

30 min
 Components of the TEG tracing
Example: R
Actual
value

Normal range

Parameter
Units
Value
Normal range
TEG decision tree
Qualitative
 TEG decision tree
Quantitative
US Patent 6,787,363

Hemorrhagic

Fibrinolytic

Thrombotic
TEG tracing
Example: hemorrhagic

* *
*
*
TEG tracing
Example: prothrombotic
*

*
*

*
TEG tracing
Example: fibrinolytic
*
*
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.
 Review exercises

TEG parameters
Hemostasis monitoring

Begin
exercises Skip exercises
Exercise 1: TEG parameters

The R value represents which of the following

phases of hemostasis?
a. Platelet adhesion
b. Activation of coagulation pathways and initial fibrin
formation
c. Buildup of platelet-fibrin interactions
d. Completion of platelet-fibrin buildup
e. Clot lysis

Answer Next
Exercise 2: TEG parameters

Select the TEG parameters that demonstrate

kinetic properties of clot formation. (select all that
apply)
a. R
b. Angle (a)
c. MA
d. LY30
e. CI

Answer Next
Exercise 3: TEG parameters

The rate of clot strength buildup is demonstrated

by which of the following TEG parameters?
a. R
b. Angle (a)
c. MA
d. LY30
e. CI

Answer Next
Exercise 4: TEG parameters

Which of the following TEG parameters will best

demonstrate the need for coagulation factors
(i.e. FFP)?
a. R
b. Angle (a)
c. MA
d. LY30
e. CI

Answer Next
Exercise 5: TEG parameters

Clot strength is dependent on which of the

hemostatic components?
a. 100% platelets
b. 80% platelets, 20% fibrinogen
c. 50% platelets, 50% fibrinogen
d. 20% platelets, 80% fibrinogen
e. 100% fibrinogen

Answer Next
Exercise 6: TEG parameters

Which of the following TEG parameters

demonstrate a structural property of the clot?
(select all that apply)
a. R
b. Angle (a)
c. MA
d. LY30
e. CI

Answer Next
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?
a. R
b. Angle (a)
c. LY30
d. CI
e. None of the above

Answer Next
Exercise 8: TEG parameters

Clot stability is determined by which of the following

TEG parameters?

a. R
b. Angle (a)
c. MA
d. LY30
e. CI

Answer Next
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?

a. R value: Kaolin with heparinase

b. R value: Kaolin vs. Kaolin with heparinase
c. MA value: Kaolin with heparinase
d. MA value: Kaolin vs. kaolin with heparinase

Answer Next
Exercise 10: TEG parameters

Which of the following parameters provides an indication

of the global coagulation status of a patient?

a. R
b. Angle (a)
c. MA
d. LY30
e. CI

Answer Next
Exercise 11: Hemostasis monitoring

Which of the following statements are true regarding the

PT and aPTT tests? (select all that apply)

a. Measure coagulation factor interaction in solution

b. Measure platelet contribution to thrombin generation
c. Measure influence of thrombin generation on
platelet function
d. Use fibrin formation as an end point

Answer Next
Exercise 12: Hemostasis monitoring

The TEG analyzer can monitor all phases of hemostasis

except which of the following? (select all that apply)

a. Initial fibrin formation

b. Fibrin-platelet plug construction
c. Platelet adhesion
d. Clot lysis

Answer Next
Exercise1: TEG parameters

The R value represents which of the following

phases of hemostasis?
a. Platelet adhesion
b. Activation of coagulation pathways and initial fibrin formation
c. Buildup of platelet-fibrin interactions
d. Completion of platelet-fibrin buildup
e. Clot lysis

Next
Exercise 2: TEG parameters

Select the TEG parameters that demonstrate

kinetic properties of clot formation. (select all that
apply)
a. R
b. Angle (a)
c. MA
d. LY30
e. CI

Next
Exercise 3: TEG parameters

The rate of clot strength buildup is demonstrated

by which of the following TEG parameters?
a. R
b. Angle (a)
c. MA
d. LY30
e. CI

Next
Exercise 4: TEG parameters

Which of the following TEG parameters will best

demonstrate the need for coagulation factors
(i.e. FFP)?
a. R
b. Angle (a)
c. MA
d. LY30
e. CI

Next
Exercise 5: TEG parameters

Clot strength is dependent on which of the

hemostatic components?
a. 100% platelets
b. 80% platelets, 20% fibrinogen
c. 50% platelets, 50% fibrinogen
d. 20% platelets, 80% fibrinogen
e. 100% fibrinogen

Next
Exercise 6: TEG parameters

Which of the following TEG parameters

demonstrate a structural property of the clot?
(select all that apply)
a. R
b. Angle (a)
c. MA (demonstrates maximum clot strength)
d. LY30 (demonstrates clot breakdown or the structural
stability of the clot)
e. CI

Next
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?
a. 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.
b. Angle (a) a defect in platelet function may slow the rate of
formation of platelet-fibrin interactions, thus slowing the rate of clot
buildup.
c. LY30
d. CI
e. None of the above
Next
Exercise 8: TEG parameters

Clot stability is determined by which of the following

TEG parameters?

a. R
b. Angle (a)
c. MA
d. LY30
e. CI

Next
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?

a. R value: Kaolin with heparinase

b. R value: Kaolin vs. Kaolin with heparinase
c. MA value: Kaolin with heparinase
d. MA value: Kaolin vs. kaolin with heparinase

Next
Exercise 10: TEG parameters

Which of the following parameters provides an indication

of the global coagulation status of a patient?

a. R
b. Angle (a)
c. MA
d. LY30
e. CI (Coagulation index: a linear combination of the R,
K, angle, and MA)

Next
Exercise 11: Hemostasis monitoring

Which of the following statements are true regarding the

PT and aPTT tests? (select all that apply)

a. Measure coagulation factor interaction in solution

b. Measure platelet contribution to thrombin generation
c. Measure influence of thrombin generation on
platelet function
d. Use fibrin formation as an end point

Next
Exercise 12: Hemostasis monitoring

The TEG analyzer can monitor all phases of hemostasis

except which of the following? (select all that apply)

a. Initial fibrin formation

b. Fibrin-platelet plug construction
c. Platelet adhesion (vascular mediated event that
occurs in vivo, but not in vitro)
d. Clot lysis

Next
End of Module 2