Study Proposes TEG 6s-Based Treatment Algorithm for Optimizing Bleeding Management in Cardiac Surgery

Recent study aims to develop a treatment algorithm based on the TEG 6s device for managing bleeding in patients undergoing cardiac surgery, following a rigorous systematic literature review and expert consultation. Cardiac surgeries often lead to significant blood loss and concomitant transfusion requirements, with approximately 50% of patients needing blood products during these procedures. Blood transfusions are associated with adverse effects, making effective management strategies imperative. Current guidelines advocate for transfusion algorithms utilizing point-of-care coagulation monitors to direct interventions in coagulopathic patients. Despite this, transfusion rates have only modestly declined, indicating gaps in implementation.

Literature Review Findings - The literature review identified a total of 304 manuscripts, with only 14 meeting the inclusion criteria relevant to TEG-based algorithms in cardiac surgery. Additionally, two further studies were included based on expert recommendations. The evidence surrounding TEG 6s, particularly in the United States, is limited, as only one study utilizes it for a dedicated treatment algorithm. In contrast, the majority of literature referenced the older TEG 5000 system.

TEG 6s Technology and Its Advantages

TEG 6s technology provides enhanced usability and requires smaller blood samples compared to its predecessor, allowing for quicker adjustments in patient treatment. It operates multiple assays simultaneously to assess various aspects of coagulation status. The necessity for a TEG 6s-based algorithm arises from the need to adapt existing practice to this newer technology and to improve clinical outcomes. An expert advisory board, comprising specialists from various fields, synthesized findings from the literature review with clinical experience to propose a simplified transfusion algorithm. This proposed algorithm emphasizes the need for intraoperative monitoring during cases where coagulopathy is present, guiding clinicians through assessments of residual heparin, fibrinolysis, coagulation factors, and deficiencies in platelets and fibrinogen. Noteworthy is the recommendation to prioritize interventions based on clinical severity, employing a unit-based operational model to enhance adherence.

Proposed Thresholds and Interventions

Several proposed thresholds target different coagulopathy types, such as recommending additional protamine if prolonged reaction times indicate residual heparin effects, and specific interventions based on coagulation factor deficiencies. Also detailed are strategies for recognizing and treating hypofibrinogenemia and assessing platelet functionality.

Clinical Implications of TEG 6s Use

The study outlines potential benefits of utilizing the TEG 6s device in a clinical context, particularly with the introduction of heparin neutralization (HN) cartridges that facilitate assessments in patients undergoing heparinization. Notably, clinical validations for this new cartridge are anticipated, potentially broadening the applications of TEG 6s in evaluating hemostatic functions in patients subjected to complex surgeries.

Sensitivity and Data Considerations

Results from previous studies indicate that while TEG 6s correlates with TEG 5000 results, variable sensitivity may arise, necessitating care in adopting historical references for clinical decision-making. A clear understanding of TEG parameters marked a critical point in developing the transfusion algorithm, with suggestions made for continuous evaluation and adaptation of threshold values as new data emerge.

Conclusion and Future Directions

Ultimately, while evidence for TEG 6s specific algorithms in cardiac surgeries remains sparse, this proposed framework aims to initiate dialogue and provide a basis for clinical standardization and validation efforts in optimizing blood management during cardiac operations. Further research is warranted to establish evidence-based protocols tailored for TEG 6s devices.

Key Points

- A treatment algorithm utilizing the TEG 6s device has been proposed for managing bleeding in cardiac surgery patients to address significant blood loss and transfusion needs, given that approximately 50% of such patients require blood products, which carry risks associated with adverse effects.

- A comprehensive literature review revealed only 14 relevant manuscripts on TEG-based algorithms for cardiac surgery, with additional insights from two expert-recommended studies, highlighting limited evidence on the utilization of TEG 6s, especially in the United States, where prior literature predominantly references the older TEG 5000 system.

- TEG 6s technology offers enhanced usability along with the capability to analyze smaller blood samples more quickly than its predecessor, thus facilitating timely patient treatment adjustments. Its multiple assays provide a comprehensive assessment of coagulation status, warranting the need for a new algorithm to improve clinical outcomes.

- An expert advisory board developed a simplified transfusion algorithm based on existing literature and clinical expertise, emphasizing the importance of intraoperative monitoring for patients with coagulopathy and guiding interventions through assessments of heparin levels, fibrinolysis, and coagulation factor deficiencies.

- Recommended thresholds target various coagulopathy types, such as administering additional protamine for prolonged reaction times indicative of residual heparin effects, and the algorithm includes strategies for identifying and treating hypofibrinogenemia and evaluating platelet function.

- While the TEG 6s has shown correlation with TEG 5000 results, variability in sensitivity necessitates caution in applying historical references for clinical decisions. Continuous evaluation and adaptation of threshold values are suggested as new data emerges, underscoring the need for further research to establish standardized protocols for TEG 6s in optimizing blood management during cardiac surgeries.

Reference –

Courtney Maxey-Jones et al. (2025). TEG® 6s-Guided Algorithm For Optimizing Patient Blood Management In Cardiovascular Surgery: Systematic Literature Review And Expert Opinion.. *Journal Of Cardiothoracic And Vascular Anesthesia*. https://doi.org/10.1053/j.jvca.2025.02.011