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LETTERS TO THE EDITOR

Thromboelastography: Another Point of View

Department of Anesthesiology, MSB, Houston, TX

To The Editor:

Dr. Samama (1) wrote a well-intentioned but unnecessarily harsh editorial on the future of thromboelastography (1). As clinicians that utilize the TEG^® coagulation analyzer (Haemoscope Corp., Skokie, IL) on a daily basis in patient care, we take issue with many points raised in the editorial.

1. Samama asserts that TEG^® coagulation analysis is not a "conventional hemostasis test." A whole-blood, real-time monitor of global coagulation would seem to be more "conventional" for clinicians than isolated measures of time to fibrin formation performed on platelet-poor plasma with sheep thromboplastin as an activator.

2. In the United States, onerous federal laboratory guidelines for the TEG^® coagulation analyzer (far in excess of the manufacturer’s requirements) have been implemented at most institutions; our technician achieves a >99% compliance rating to ensure more than adequate quality assurance.

3. We agree that the device has not met "the demands of large...comparative biological studies," but ask why it should require validation against discrete measures of thrombin formation and fibrinolysis? The device has clearly impacted perioperative coagulation management and blood product transfusion. Several authors have been instrumental in the implementation of this device in a variety of surgical settings (2,3). Yes, it is quick (with celite activation, initial results are available within 10–20 min); no, it is not expensive (especially compared to a prothrombin time, partial thromboplastin time, fibrinogen, and platelet count); and yes, it is extremely useful for its defined role in prompt identification of causes of bleeding and objective guidance to blood component therapy in the operating room.

4. Collaboration with hematologists could well be considered, but it is neither essential nor mandated for continued use of the device, as suggested by Samama (1). In addition, ongoing international cardiac surgery patient enrollment as well as large institution databases will facilitate further standardization of TEG^® coagulation analysis variables in various subpopulations.

Most anesthesiologists with clinical experience and published research utilizing the TEG^® coagulation analyzer will have a different perspective than that presented by Samama (1), and will attest to both the value and validity of the device in the perioperative management of abnormal coagulation. Samama asserts that it is "expensive and nonvalidated." On the basis of our extensive clinical and research experience, we respectfully disagree.

References

1. Samama CM. Thromboelastography: the next step. Anesth Analg 2001; 92: 563–4.[Free Full Text]
2. Kang YG, Martin DJ, Marquez J, et al. Intraoperative changes in blood coagulation and thrombelastographic monitoring in liver transplantation. Anesth Analg 1985; 64: 888–96.[Abstract/Free Full Text]
3. Spiess BD, Tuman KJ, McCarthy RJ, et al. Thrombelastography as an indicator of post-cardiopulmonary bypass coagulopathies. J Clin Monit 1987; 63: 856–63.

Département d’Anesthésie-Réanimation, Hôpital Avicenne, Bobigny Cedex, France

In Response:

A rapid MEDLINE screening of abstracts may underestimate the investment of a research group on a given topic, TEG^® (Haemoscope, Skokie, IL) coagulation analysis for instance. We have been working as clinicians in the field of perioperative coagulation and TEG^® analysis for many years. A recent article using TEG^® coagulation analysis emphasizes our interest in this type of monitoring (1).

We do believe that the TEG^® coagulation analyzer is still a very promising device. However several points have to be discussed with respect to the above letter.

Until now, TEG^® coagulation analysis has never been recognized as a conventional hemostasis test by the world hemostasis society, the International Society on Thrombosis and Haemostasis (ISTH). No standardization ISTH subcommittee has ever been devoted to this device, and even if we completely agree that a whole blood test could be more relevant than a test performed on platelet-poor plasma, this is not the leading opinion of most of our hemostasis colleagues. A lot of work must be done.

Federal laboratory guidelines cannot replace scientific recommendations based on comparative evaluations. Even if your technician achieves compliance close to 100%, this has nothing to do with sensitivity and specificity. Furthermore, usual laboratory tests have to follow well-defined evaluation procedures. This has never been the case for TEG coagulation analysis. Why?

Indeed, we agree that this device has impacted the North American perioperative management of coagulation and blood transfusion. However, it does not represent the referent coagulation device in Europe and in the world hemostasis scientific literature. In addition, stating that the use of this device is cost-effective is somehow optimistic. No study based on an economic design has ever been built on this topic.

Collaborative studies with hematologic groups and final standardization procedures must be built. We, as anesthetists, belong to the anesthetic community and, until now, we should not perform biological procedures alone.

Finally, we would had been highly interested in Pivalizza and Abramson’s personal references for what they call an extensive clinical and research experience because the articles cited in their letter were published by others many years ago.

References

1. Huraux C, Ankri A, Eyraud D, et al. Hemostatic changes in patients receiving hydroxyethyl starch: the influence of ABO blood group. Anesth Analg 2001; 92: 1396–401.[Abstract/Free Full Text]

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