[HSF] Aprotinin and TEG

[Mark Levinson]

On Nov 21, 2006, at 9:16 PM, Tea Acuff wrote:

> Do others have simiarly strong pro or con TEG biases and why?

We have been using it about 1 year.    Most TEGs are normal  
preop.       By the time
I have the postop results, I usually know that I need factors or  
platelets based on the same
observational methods Donald Ross is using.

However, there are some situations where it has really helped.   One  
is in hypercoagulable states.
I had a recent patient with overactive platelets despite ASA.       
She had clotted 3 prior AFB grafts.
She is now on ASA, Plavix and Coumadin after an Ax-Fem-Fem

We have had a few pulmonary cancer patients who are mildly  
hypercoagulable and I fear they
are prone to DVT.

When a patient is on Lovenox pre-op, the TEG is sensitive to Lovenox  
while the PTT is not, making it
useful to tell if the Lovenox has worn off.     In patients who have  
a bleeding episode on the non-surgical
service, TEG often detects Lovenox effect.

As for Plavix effect, the TEG seems very sensitive and each Plavix  
patient shows a high degree of platelet
inhibition on TEG.    However, not all of these bleed (as confirming  
what Don Ross said).    Just the same, it
does help in some situations.    For example, if it is an elective  
case, I can tell by TEG when the Plavix has
worn off!

The other value for TEG is that it does pick up some cases of ASA  
resistance.      This can be helpful in
situations like vascular grafts where you definately want the ASA  
effect on board.

TEG also is very useful in fibrinolytic states.   However, in the  
surgical arena, most of the time we can
see fibrinolytic states ourselves (with diffuse non-focal  
bleeding).    And the last analysis available after
a long TEG run is the fibrinolytic indices, so it takes time and when  
the patient is bleeding a lot, sometimes
its best to treat in anticipation.    I use a loading dose of 5 gms  
of Amicar and then an Amicar/Protamine drip
until the bleeding stops clinically.

Mark Levinson, MD