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Thromboelastometry
Thromboelastometry (TEM), previously named rotational thromboelastography (ROTEG) or rotational thromboelastometry (ROTEM), is an established viscoelastic method for hemostasis testing in whole blood.〔Calatzis A, Calatzis A, Kling M, Stemberger A, Hipp R. Konzept zum "bedside" - Gerinnungsmonitoring mittels modifizierter Thrombelastographie. Der Anaesthesist 1995;44(2):437〕 It is modification of traditional thromboelastography (TEG). TEM investigates the interaction of coagulation factors, their inhibitors, anticoagulant drugs, blood cells, specifically platelets, during clotting and subsequent fibrinolysis. The rheological conditions mimic the sluggish flow of blood in veins. TEM is performed with the ROTEM whole blood analyzer (Tem Innovations GmbH, Munich) and is an enhancement of thrombelastography, originally described by H. Hartert in 1948.〔Hartert H. Blutgerinnungsstudien mit der Thrombelastographie, einem neuen Untersuchungsvefahren. Klinische Wochenschrift 1948;26:577-583〕
While traditional thromboelastography is a global assay for blood clotting disorders and drug effects, TEM is primarily used in combination with appropriate differential assays. They allow testing in the presence of therapeutic heparin concentrations and provide differential diagnostic information to support decisions in therapy. In numerous publications the validity of the method is shown. Application of TEM at the point of care (POC) or in emergency laboratories is getting more and more popular. TEM detects both hypo- and hyperfunctional stages of the clotting process and is probably the only reliable rapid test for the diagnosis of hyperfibrinolysis. In contrast to standard clotting tests, the fibrin stabilizing effect of factor XIII contributes to the result. The rapid availability of results helps to discriminate surgical bleeding from a true haemostasis disorder and improves the therapy with blood products, factor concentrates, anticoagulants and protamine, hemostyptic and antifibrinolytic drugs.〔Kozek-Langenecker S. Management of massive operative blood loss. Minerva Anesthesiol 2007;73:401-15〕〔Innerhofer P, Streif W, Kuehbacher GP, Fries D. Monitoring of perioperative dilutional coagulopathy using the ROTEM analyzer: basic principles and clinical examples. Transfus Med Hemother 2004;31:244-249〕 Several reports confirm that application of TEM is cost effective by reducing the consumption of blood products.〔Spalding GJ, Hartrumpf M, Sierig T, Oesberg N, Kirschke CG, Albes JM. Cost reduction of perioperative coagulation management in cardiac surgery: value of "bedside" thrombelastography (ROTEM). Eur J Cardiothorac Surg. 2007;31:1052-7〕〔K. Goerlinger, D. Dirkmann, A. Hanke, F. Dusse, M. Hartmann. Reduction of blood transfusion and cost saving by thrombelastometry-based point-of-care coagulation management in visceral and transplantation surgery. Eur J Anaesthesiol 2008;25, Supplement 44〕〔Anderson L, Quasim I, Soutar R, Steven M, Macfie A, Korte W.An audit of red cell and blood product use after the institution of thromboelastometry in a cardiac intensive care unit. Transfus Med. 2006;16:31-9〕
==Method==
Blood (300 µl, anticoagulated with citrate) is placed into the disposable cuvette using an electronic pipette. A disposable pin is attached to a shaft which is connected with a thin spring (the equivalent to Hartert’s torsion wire in thrombelastography) and slowly oscillates back and forth. The signal of the pin suspended in the blood sample is transmitted via an optical detector system. The test is started by adding appropriate reagents. The instrument measures and graphically displays the changes in elasticity at all stages of the developing and resolving clot. The typical test temperature is 37°C, but different temperatures can be selected, e.g. for patients with hypothermia.〔Dirkmann D, Hanke AA, Görlinger K, Peters J. Hypothermia and acidosis synergistically impair coagulation in human whole blood.Anesth Analg. 2008;106:1627-32〕
In contrast to thrombelastography with its pendulum-like principle, the design of the TEM viscoelastic detection system (figure 1) makes it quite robust and insensitive against mechanical shocks or vibrations.
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