Semin Thromb Hemost 2019; 45(05): 449-457
DOI: 10.1055/s-0039-1692210
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Clinical Application of Thromboelastography/Thromboelastometry (TEG/TEM) in the Neonatal Population: A Narrative Review

Aikaterini Konstantinidi*
1   NICU Nikaia General Hospital “Agios Panteleimon”, Piraeus, Greece
,
Rozeta Sokou*
1   NICU Nikaia General Hospital “Agios Panteleimon”, Piraeus, Greece
,
Stavroula Parastatidou
1   NICU Nikaia General Hospital “Agios Panteleimon”, Piraeus, Greece
,
Katerina Lampropoulou
1   NICU Nikaia General Hospital “Agios Panteleimon”, Piraeus, Greece
,
George Katsaras
1   NICU Nikaia General Hospital “Agios Panteleimon”, Piraeus, Greece
,
Theodora Boutsikou
2   Neonatal Department, National and Kapodistrian University of Athens, Aretaeio Hospital, Athens, Greece
,
Antonios K. Gounaris
3   NICU, University Hospital of Larissa, Larissa, Greece
,
Argyrios E. Tsantes
4   Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
,
Nicoletta Iacovidou
2   Neonatal Department, National and Kapodistrian University of Athens, Aretaeio Hospital, Athens, Greece
› Author Affiliations
Further Information

Publication History

Publication Date:
13 June 2019 (online)

Abstract

Hemostasis is a dynamic age-related process, which gradually evolves from fetal life throughout childhood until adulthood. Although at birth there is a hemostatic deficit of most coagulation factors, studies have shown that this “hemostatic immaturity” is functionally counterbalanced in healthy term or preterm newborns. This delicate hemostatic balance is, however, deranged in sick neonates, resulting in an enhanced risk of hemorrhage and/or thrombosis. In critically ill neonates, conventional coagulation tests do not seem to provide reliable information or indications regarding the functional status of platelets or fibrinolysis. In contrast, viscoelastic tests, namely thromboelastography/thromboelastometry (TEG/TEM) hold promise for rapid assessment of the whole hemostatic potential, allowing immediate intervention should this be required. However, neonatal data are limited due to lack of reference values, especially in premature neonates. In this narrative review, we provide some insights around current knowledge regarding TEG/TEM applications in healthy and sick newborns. Overall, the use of viscoelastic tests in diagnosis and management of coagulation disorders in neonates is definitely worth further exploration. Consideration should be made to include these tests in the routine laboratory investigation of neonates and specific transfusion algorithms should also be developed in order to avoid treatment pitfalls.

Informed Consent

For this type of study formal consent is not required.


Authors' Contributions

A.K. and R.S. contributed to the conception and design of the study. All authors contributed to the interpretation of data for the work, drafted the manuscript and critically revised the article for important intellectual content, and approved the final version to be published.


* These authors share equal contribution.


 
  • References

  • 1 Andrew M, Paes B, Milner R. , et al. Development of the human coagulation system in the full-term infant. Blood 1987; 70 (01) 165-172
  • 2 Strauss T, Sidlik-Muskatel R, Kenet G. Developmental hemostasis: primary hemostasis and evaluation of platelet function in neonates. Semin Fetal Neonatal Med 2011; 16 (06) 301-304
  • 3 Favaloro EJ, Lippi G. Translational aspects of developmental hemostasis: infants and children are not miniature adults and even adults may be different. Ann Transl Med 2017; 5 (10) 212-212
  • 4 Diaz-Miron J, Miller J, Vogel AM. Neonatal hematology. Semin Pediatr Surg 2013; 22 (04) 199-204
  • 5 Revel-Vilk S. The conundrum of neonatal coagulopathy. Hematology (Am Soc Hematol Educ Program) 2012; 2012: 450-454
  • 6 Motta M, Del Vecchio A, Chirico G. Fresh frozen plasma administration in the neonatal intensive care unit: evidence-based guidelines. Clin Perinatol 2015; 42 (03) 639-650
  • 7 Goel R, Josephson CD. Recent advances in transfusions in neonates/infants. F1000Res 2018; 7 (609) F1000 Faculty Rev-609
  • 8 Kang YG, Martin DJ, Marquez J. , et al. Intraoperative changes in blood coagulation and thrombelastographic monitoring in liver transplantation. Anesth Analg 1985; 64 (09) 888-896
  • 9 Luddington RJ. Thrombelastography/thromboelastometry. Clin Lab Haematol 2005; 27 (02) 81-90
  • 10 Lier H, Vorweg M, Hanke A, Görlinger K. Thromboelastometry guided therapy of severe bleeding. Essener Runde algorithm. Hamostaseologie 2013; 33 (01) 51-61
  • 11 Görlinger K, Iqbal J, Dirkmann D, Tanaka KA. Whole blood assay: thromboelastometry. In: Teruya J. , ed. Management of Bleeding Patients. Cham, Switzerland: Springer International Publishing; 2016: 37-64
  • 12 Görlinger K, Sakai T, Dirkmann D, Planinsic RM, Saner FH. Bleeding related to liver transplant. In: Teruya J. , ed. Management of Bleeding Patients. Cham, Switzerland: Springer International Publishing; 2016: 263-280
  • 13 Radicioni M, Mezzetti D, Del Vecchio A, Motta M. Thromboelastography: might work in neonatology too?. J Matern Fetal Neonatal Med 2012; 25 (Suppl. 04) 18-21
  • 14 Hartert H. Blutgerinnungsstudien mit der Thrombelastographie, einem neuen Untersuchungsverfahren. Klin Wochenschr 1948; 26 (37–38): 577-583
  • 15 Edwards RM, Naik-Mathuria BJ, Gay AN, Olutoye OO, Teruya J. Parameters of thromboelastography in healthy newborns. Am J Clin Pathol 2008; 130 (01) 99-102
  • 16 Sidlik R, Strauss T, Morag I. , et al. Assessment of functional fibrinolysis in cord blood using modified thromboelastography. Pediatr Blood Cancer 2016; 63 (05) 839-843
  • 17 Strauss T, Levy-Shraga Y, Ravid B. , et al. Clot formation of neonates tested by thromboelastography correlates with gestational age. Thromb Haemost 2010; 103 (02) 344-350
  • 18 Mirabella L, Cotoia A, Colacicco G. , et al. Reference values for coagulation assessment in full-term newborns. Minerva Anestesiol 2017; 83 (04) 369-374
  • 19 Cvirn G, Gallistl S, Kutschera J. , et al. Clot strength: a comparison between cord and adult blood by means of thrombelastometry. J Pediatr Hematol Oncol 2008; 30 (03) 210-213
  • 20 Israels SJ, Rand ML, Michelson AD. Neonatal platelet function. Semin Thromb Hemost 2003; 29 (04) 363-372
  • 21 Haley KM, Recht M, McCarty OJ. Neonatal platelets: mediators of primary hemostasis in the developing hemostatic system. Pediatr Res 2014; 76 (03) 230-237
  • 22 Del Vecchio A, Motta M, Romagnoli C. Neonatal platelet function. Clin Perinatol 2015; 42 (03) 625-638
  • 23 Miller BE, Bailey JM, Mancuso TJ. , et al. Functional maturity of the coagulation system in children: an evaluation using thrombelastography. Anesth Analg 1997; 84 (04) 745-748
  • 24 Kettner SC, Pollak A, Zimpfer M. , et al. Heparinase-modified thrombelastography in term and preterm neonates. Anesth Analg 2004; 98 (06) 1650-1652 table of contents
  • 25 Ravn HB, Andreasen JB, Hvas AM. Does whole blood coagulation analysis reflect developmental haemostasis?. Blood Coagul Fibrinolysis 2017; 28 (03) 218-223
  • 26 Oswald E, Stalzer B, Heitz E. , et al. Thromboelastometry (ROTEM) in children: age-related reference ranges and correlations with standard coagulation tests. Br J Anaesth 2010; 105 (06) 827-835
  • 27 Sewell EK, Forman KR, Wong EC, Gallagher M, Luban NL, Massaro AN. Thromboelastography in term neonates: an alternative approach to evaluating coagulopathy. Arch Dis Child Fetal Neonatal Ed 2017; 102 (01) F79-F84
  • 28 Sokou R, Foudoulaki-Paparizos L, Lytras T. , et al. Reference ranges of thromboelastometry in healthy full-term and pre-term neonates. Clin Chem Lab Med 2017; 55 (10) 1592-1597
  • 29 Saxonhouse MA, Manco-Johnson MJ. The evaluation and management of neonatal coagulation disorders. Semin Perinatol 2009; 33 (01) 52-65
  • 30 Parmar N, Albisetti M, Berry LR, Chan AK. The fibrinolytic system in newborns and children. Clin Lab 2006; 52 (3–4): 115-124
  • 31 Goldenberg NA, Hathaway WE, Jacobson L, Manco-Johnson MJ. A new global assay of coagulation and fibrinolysis. Thromb Res 2005; 116 (04) 345-356
  • 32 Motta M, Guaragni B, Pezzotti E, Rodriguez-Perez C, Chirico G. Reference intervals of citrated-native whole blood thromboelastography in premature neonates. Early Hum Dev 2017; 115: 60-63
  • 33 Schott NJ, Emery SP, Garbee C, Waters J. Thromboelastography in term neonates. J Matern Fetal Neonatal Med 2018; 31 (19) 2599-2604
  • 34 Sokou R, Konstantinidi A, Stefanaki C. , et al. Thromboelastometry: studying hemostatic profile in small for gestational age neonates-a pilot observational study. Eur J Pediatr 2019; 178 (04) 551-557
  • 35 Nakayama Y, Nakajima Y, Tanaka KA. , et al. Thromboelastometry-guided intraoperative haemostatic management reduces bleeding and red cell transfusion after paediatric cardiac surgery. Br J Anaesth 2015; 114 (01) 91-102
  • 36 Faraoni D, Willems A, Romlin BS, Belisle S, Van der Linden P. Development of a specific algorithm to guide haemostatic therapy in children undergoing cardiac surgery: a single-centre retrospective study. Eur J Anaesthesiol 2015; 32 (05) 320-329
  • 37 Karkouti K, Callum J, Wijeysundera DN. , et al; TACS Investigators. Point-of-care hemostatic testing in cardiac surgery: a stepped-wedge clustered randomized controlled trial. Circulation 2016; 134 (16) 1152-1162
  • 38 Scott JP, Niebler RA, Stuth EAE. , et al. Rotational thromboelastometry rapidly predicts thrombocytopenia and hypofibrinogenemia during neonatal cardiopulmonary bypass. World J Pediatr Congenit Heart Surg 2018; 9 (04) 424-433
  • 39 Straub A, Schiebold D, Wendel HP. , et al. Using reagent-supported thromboelastometry (ROTEM) to monitor haemostatic changes in congenital heart surgery employing deep hypothermic circulatory arrest. Eur J Cardiothorac Surg 2008; 34 (03) 641-647
  • 40 Grant HW, Hadley GP. Prediction of neonatal sepsis by thromboelastography. Pediatr Surg Int 1997; 12 (04) 289-292
  • 41 Sokou R, Giallouros G, Konstantinidi A. , et al. Thromboelastometry for diagnosis of neonatal sepsis-associated coagulopathy: an observational study. Eur J Pediatr 2018; 177 (03) 355-362
  • 42 Konstantinidi A, Sokou R, Tsantes A. , et al. Thromboelastography and coagulation profile in neonates with perinatal hypoxia-asphyxia. J Neonatal Perinatal Med 2017; 10: 209-231
  • 43 Van Poucke S, Stevens K, Marcus AE, Lancé M. Hypothermia: effects on platelet function and hemostasis. Thromb J 2014; 12 (01) 31
  • 44 Forman KR, Wong E, Gallagher M, McCarter R, Luban NLC, Massaro AN. Effect of temperature on thromboelastography and implications for clinical use in newborns undergoing therapeutic hypothermia. Pediatr Res 2014; 75 (05) 663-669
  • 45 Radicioni M, Bruni A, Bini V, Villa A, Ferri C. Thromboelastographic profiles of the premature infants with and without intracranial hemorrhage at birth: a pilot study. J Matern Fetal Neonatal Med 2015; 28 (15) 1779-1783