1. Basic Clinician Training Module 2
TEG® Technology

3. 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.

4. 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

5. 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): 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.

6. TEG technology How it works

7. 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)

8. 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

9. 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

10. What TEG analysis captures
Time
Amplitude of
pin rotation
What TEG analysis captures

11. Identification Definition
TEG parameters
Identification
Definition

12. Thrombin formation The R parameter - identified
Time
Amplitude of
pin rotation
Initial fibrin
formation
Intrinsic, extrinsic, common pathways
Pin is stationary
Pin is engaged
 Pin starts to rotate with cup
Cup rotates, pin remains stationary

16. Fibrinogen The a (angle) parameter - identified
Time
Amplitude of
pin rotation
Fibrin
increases
Pin is
engaged
Amplitude of pin rotation increases as fibrin is generated
and cross links are formed

20. Platelet function The MA parameter - identified
Maximum amplitude (MA) of pin rotation
Time
Amplitude of
pin rotation
Amplitude of pin rotation

21. 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

24. 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

25. Fibrinolysis The LY30 parameter - identified
Decrease in amplitude of pin rotation
30 minutes after MA reached
Time
Amplitude of
pin rotation MA
30 min

26. 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

29. TEG parameter summary Definitions
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.

30. TEG parameter summary
Time
Amplitude of
pin rotation

31. Clot stability Clot breakdown
What does TEG report?
Clot strength
Platelet function
Clotting time
Clot kinetics
Clot stability Clot breakdown

32. “Normal” TEG tracing
Time
Amplitude of
pin rotation
30 min

33. Hemorrhagic TEG tracing
30 min

34. Prothrombotic TEG tracing
30 min

35. Fibrinolytic TEG tracing
30 min

36. Components of the TEG tracing Example: R
Actual value
Normal range
Parameter Units Value Normal range

37. TEG decision tree Qualitative

38. TEG decision tree Quantitative
US Patent 6,787,363
Hemorrhagic
Fibrinolytic
Thrombotic

39. TEG tracing Example: hemorrhagic* * * *

40. TEG tracing Example: prothrombotic* * * *

41. TEG tracing Example: fibrinolytic* *

42. 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.

43. TEG parameters Hemostasis monitoring
Review exercises
TEG parameters
Hemostasis monitoring
Begin
exercises
Skip exercises

44. Exercise 1: TEG parameters
The R value represents which of the following
phases of hemostasis?
Platelet adhesion
Activation of coagulation pathways and initial fibrin formation
Buildup of platelet-fibrin interactions
Completion of platelet-fibrin buildup
Clot lysis
Answer
Next

45. Exercise 2: TEG parameters
Select the TEG parameters that demonstrate
kinetic properties of clot formation. (select all that
apply) R
Angle (a) MA
LY30 CI
Answer
Next

46. Exercise 3: TEG parameters
The rate of clot strength buildup is demonstrated
by which of the following TEG parameters? R
Angle (a) MA
LY30 CI
Answer
Next

47. Exercise 4: TEG parameters
Which of the following TEG parameters will best
demonstrate the need for coagulation factors
(i.e. FFP)? R
Angle (a) MA
LY30 CI
Answer
Next

48. Exercise 5: TEG parameters
Clot strength is dependent on which of the
hemostatic components?
100% platelets
80% platelets, 20% fibrinogen
50% platelets, 50% fibrinogen
20% platelets, 80% fibrinogen
100% fibrinogen
Answer
Next

49. Exercise 6: TEG parameters
Which of the following TEG parameters
demonstrate a structural property of the clot?
(select all that apply) R
Angle (a) MA
LY30 CI
Answer
Next

50. 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? R
Angle (a)
LY30 CI
None of the above
Answer
Next

51. Exercise 8: TEG parameters
Clot stability is determined by which of the following
TEG parameters? R
Angle (a) MA
LY30 CI
Answer
Next

52. 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?
R value: Kaolin with heparinase
R value: Kaolin vs. Kaolin with heparinase
MA value: Kaolin with heparinase
MA value: Kaolin vs. kaolin with heparinase
Answer
Next

53. Exercise 10: TEG parameters
Which of the following parameters provides an indication
of the global coagulation status of a patient? R
Angle (a) MA
LY30 CI
Answer
Next

54. Exercise 11: Hemostasis monitoring
Which of the following statements are true regarding the
PT and aPTT tests? (select all that apply)
Measure coagulation factor interaction in solution
Measure platelet contribution to thrombin generation
Measure influence of thrombin generation on platelet function
Use fibrin formation as an end point
Answer
Next

55. Exercise 12: Hemostasis monitoring
The TEG analyzer can monitor all phases of hemostasis
except which of the following? (select all that apply)
Initial fibrin formation
Fibrin-platelet plug construction
Platelet adhesion
Clot lysis
Answer
Next

56. Exercise1: TEG parameters
The R value represents which of the following
phases of hemostasis?
Platelet adhesion
Activation of coagulation pathways and initial fibrin formation
Buildup of platelet-fibrin interactions
Completion of platelet-fibrin buildup
Clot lysis R
Next

57. Exercise 2: TEG parameters
Select the TEG parameters that demonstrate
kinetic properties of clot formation. (select all that
apply) R
Angle (a) MA
LY30 CI
Next

58. Exercise 3: TEG parameters
The rate of clot strength buildup is demonstrated
by which of the following TEG parameters? R
Angle (a) MA
LY30 CI
Next

59. Exercise 4: TEG parameters
Which of the following TEG parameters will best
demonstrate the need for coagulation factors
(i.e. FFP)? R
Angle (a) MA
LY30 CI
Next

60. Exercise 5: TEG parameters
Clot strength is dependent on which of the
hemostatic components?
100% platelets
80% platelets, 20% fibrinogen
50% platelets, 50% fibrinogen
20% platelets, 80% fibrinogen
100% fibrinogen
Next

61. Exercise 6: TEG parameters
Which of the following TEG parameters
demonstrate a structural property of the clot?
(select all that apply) R
Angle (a)
MA (demonstrates maximum clot strength)
LY30 (demonstrates clot breakdown or the structural
stability of the clot)
e. CI
Next

62. 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?
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.
Angle (a) – a defect in platelet function may slow the rate of formation of platelet-fibrin interactions, thus slowing the rate of clot buildup.
LY30 CI
None of the above
Next

63. Exercise 8: TEG parameters
Clot stability is determined by which of the following
TEG parameters? R
Angle (a) MA
LY30 CI
Next

64. 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?
R value: Kaolin with heparinase
R value: Kaolin vs. Kaolin with heparinase
MA value: Kaolin with heparinase
MA value: Kaolin vs. kaolin with heparinase
Next

65. Exercise 10: TEG parameters
Which of the following parameters provides an indication
of the global coagulation status of a patient? R
Angle (a) MA
LY30
CI (Coagulation index: a linear combination of the R, K, angle, and MA)
Next

66. Exercise 11: Hemostasis monitoring
Which of the following statements are true regarding the
PT and aPTT tests? (select all that apply)
Measure coagulation factor interaction in solution
Measure platelet contribution to thrombin generation
Measure influence of thrombin generation on platelet function
Use fibrin formation as an end point
Next

67. Exercise 12: Hemostasis monitoring
The TEG analyzer can monitor all phases of hemostasis
except which of the following? (select all that apply)
Initial fibrin formation
Fibrin-platelet plug construction
Platelet adhesion (vascular mediated event that occurs in vivo, but not in vitro)
Clot lysis
Next

68. End of Module 2