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A retrospective comparison on the effectiveness of TEG Ratio versus ACT in providing adequate anticoagulation in ECMO patients : a thesis submitted to the faculty of the Milwaukee School of Engineering in partial fulfillment of the requirements for the degree of Master of Science in Perfusion / by Amber Harmon.

by Harmon, Amber, author., Gerrits, Dr. Ronald, thesis advisor , Fennigkoh, Dr. Larry , Shimek, Gary , Milwaukee School of Engineering

[Milwaukee School of Engineering], [2016]

Extracorporeal membrane oxygenation.

Thromboelastography.

Anticoagulants (Medicine)

70 leaves : illustrations, some of which are in color ; 29 cm

Introduction -- Background -- Methods -- Results -- Discussion -- Conclusion -- Appendix A: ACT versus TEG Ratio -- B: TEG Ratio 2.0 versus TEG Ratio 1.5 -- C: ACT versus TEG Ratio 2.0 versus TEG Ratio 1.5.

Extracorporeal membrane oxygenation (ECMO) is a means of long-term support for patients experiencing acute cardiac and/or respiratory failure. One of the major challenges associated with ECMO treatment is keeping patients appropriately anticoagulated. Proper anticoagulation helps to prevent two major ECMO complications: bleeding and thrombosis. Anticoagulation monitoring can be done via multiple methods including: activated clotting time (ACT), prothrombin time (PT), partial thromboplastin time (PTT), antifactor Xa, Antithrombin III (ATIII), and TEG. To date, little has been published regarding which of these monitoring strategies is the most beneficial for reducing blood product usage and hemorrhagic complications. With no single accepted protocol for managing anticoagulation, clinical sites are left to determine for themselves what might work best for their patients. The goals of this retrospective study were to 1) determine if the use of TEG Ratio of R values results in less chest tube drainage, heparin dosing, and blood product administration than ACT, and 2) determine if a TEG Ratio of R values of 1.5 results in less chest tube drainage, heparin dosing, and blood product administration than a TEG Ratio of R values of 2.0.

Data were collected from patients receiving ECMO treatment at Aurora St. Luke's Hospital between July 2013 and September 2015, and retrieved from their EPIC database. An analysis of 38 patients was performed that looked at the correlation of age, sex, BSA, type of ECMO, cannulation site, length of ECMO, Hct, Hgb, platelet count, ACT, Kaolin TEG R time, Heparinase TEG R time, and anticoagulation protocol with clinical outcomes. The clinical outcomes included were heparin infusion rate, hourly chest tube output, and PRBC and FFP transfusions. Multiple regressions were performed to identify significant predictors of clinical outcomes within three anticoagulation protocol groups: ACT (n=9), TEG Ratio 2.0 (n=12) and TEG Ratio 1.5 (n=17), with post hoc T-tests being performed to compare clinical outcomes between the protocol groups. One-way ANOVA testing of the protocol groups confirmed the results seen in T-testing.

Results showed that heparin infusion rates decreased significantly with the use of TEG Ratio (5.3 ± 4.0) when compared to ACT (13.1 ± 4.7). Chest tube output was higher in the TEG Ratio group (51.5 ± 86.6) compared to the ACT group (38.9 ± 60.4) Final testing for TEG Ratio versus ACT rendered no significant differences in PRBC and FFP transfusions. Comparison between the TEG Ratio groups showed higher heparin infusion rates in the TEG Ratio 1.5 group (5.7 ± 4.0) than the TEG Ratio 2.0 group (4.9 ± 3.9). Chest tube output, as well as PRBC and FFP transfusions, between the TEG Ratio groups showed no significant differences. Analysis comparing ACT, TEG Ratio 2.0 and TEG Ratio 1.5 individually demonstrated significant differences in heparin infusion rates between all groups, but only a significant difference in chest tube output between the ACT and TEG Ratio 2.0 group. This study shows that use of a TEG Ratio is a safe and effective means of managing anticoagulation in ECMO patients when compared to ACT.

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