Open Access Review

Article DOI: 10.7759/cureus.39407

Thromboelastography in the Perioperative

Period: A Literature Review
Review began 05/12/2023
Vendhan Ramanujam 1 , Stephen DiMaria 1 , Vivek Varma 1
Review ended 05/17/2023
Published 05/23/2023 1. Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University,
© Copyright 2023 Providence, USA
Ramanujam et al. This is an open access
article distributed under the terms of the Corresponding author: Vendhan Ramanujam, vcramanuj@gmail.com
Creative Commons Attribution License CC-
BY 4.0., which permits unrestricted use,
distribution, and reproduction in any
medium, provided the original author and
source are credited. Abstract
Assessing coagulation status is essential for prompt intervention to reduce morbidity and mortality related
to bleeding and thrombotic complications during the perioperative period. Traditional coagulation tests
such as platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), international
normalized ratio (INR), and activated clotting time (ACT) provide only static evaluation. These tests are not
designed for assessment of dynamically changing coagulation conditions during the perioperative time.
However, viscoelastic coagulation testing such as thromboelastography (TEG) produces a rapid numerical
and graphical representation that helps to detect and direct targeted hemostatic therapy. Searching the
literature through PubMed, Medline, Ovid, CINAHL, and ClinicalTrials.gov we retrieved 210 studies, which
represent the use of TEG in the perioperative period. The included studies were categorized under various
settings such as trauma, obstetrics, orthopedics, intensive care unit (ICU), cardiovascular, transplant, and
miscellaneous scenarios. TEG showed promising results in trauma surgeries in predicting mortality,
hypercoagulability, and bleeding even when it was compared to conventional methods. TEG was also useful
in monitoring anticoagulant therapy in orthopedic and obstetric surgeries; however, its role in predicting
thrombotic events, hypercoagulability, or complications was questionable. In ICU patients, it showed
promising results, especially in the prediction or improvement of sepsis, coagulopathy, thrombotic events,
ICU duration, hospital stay, and ventilator duration. TEG parameters effectively predicted hypercoagulation
in transplant surgeries. Regarding cardiovascular surgeries, they were effective in the prediction of the need
for blood products, coagulopathy, thrombotic events, and monitoring anticoagulation therapy. More
randomized clinical trials comparing TEG parameters with standardized tools are needed to produce robust
results to standardize its use in different perioperative settings.

Categories: Anesthesiology, Other

Keywords: outcomes, coagulation, transfusion, perioperative period, teg, thromboelastography

Introduction And Background

Monitoring of blood coagulation status during the perioperative period is crucial for prompt intervention as
bleeding and thrombotic complications related to surgery can significantly affect morbidity and mortality.
Assessing the coagulation status comprehensively is a challenge since the coagulation cascade is dynamic
and depends on the interaction of several factors including primary hemostasis, platelet clot formation,
secondary hemostasis, thrombin generation, and fibrinolysis [1]. Traditional coagulation tests such as
platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), international
normalized ratio (INR), activated clotting time (ACT), and plasma fibrinogen levels provide only static
evaluation of the patient and are not designed for assessment of dynamically changing coagulation
conditions during perioperative time; thus, they lack the ability to direct targeted hemostatic therapy [2].
However, viscoelastic coagulation testing such as thromboelastography (TEG) is devised for a quick global
assessment of hemostasis more like in vivo hemostasis by continuously monitoring the clotting process
from its steps of initiation, amplification, propagation, and termination through fibrinolysis. They produce a
rapid numerical and graphical representation that helps clinicians with the early management of goal-
directed hemostatic resuscitation and anticoagulation effects [3-6]. Our goal is to systemically search and
summarize the existing evidence from studies that have reported the utility of viscoelastic coagulation
testing and its impact on clinical outcomes during the perioperative period.

Thromboelastography (TEG)
TEG is a whole blood-based assay that runs at 37°C to mimic natural blood clotting in vivo [7]. The
instrument consists of a pin immersed into a cup containing whole blood that begins to clot when a
constant rotational force is applied to it. As the viscosity of blood increases, the pin becomes cross-linked to
the cup via fibrin and platelet interactions. Now there is a torque between the cup and the pin, and the
movement of the pin produces an electrical signal that is traced as a curve over time. As the clot breaks down
and torque decreases, the tracing fades. The signals are then interpreted by TEG software where changes in
amplitude are plotted, and different parameters of the curve are measured to assess coagulation status [8].
The parameters include reaction (R) time, coagulation (K) time, alpha (α) angle, maximum amplitude (MA),
and lysis at 30 minutes (LY30). The tracing and results are available in real-time, enabling prompt

How to cite this article

Ramanujam V, DiMaria S, Varma V (May 23, 2023) Thromboelastography in the Perioperative Period: A Literature Review. Cureus 15(5): e39407.
DOI 10.7759/cureus.39407
 interpretation for goal-directed therapy [9]. While TEG is favored in North America, there are other
viscoelastic tests such as rotational thromboelastometry (ROTEM) that are favored in Europe. Both the tests
are equivalent with interchangeable results and interpretations, yet characteristics and nomenclature
differences exist, and they are illustrated in Tables 1-2.

Characteristic TEG ROTEM

Cup motion Moving Fixed

Pin motion Fixed Moving

Pipetting Manual Automated

Detector system Torsion Wire Optical

Samples ran at one time Two Four

TABLE 1: Characteristic differences between TEG and ROTEM

TEG: thromboelastography; ROTEM: rotational thromboelastometry

TEG ROTEM

Reaction time (R-time) Clotting time (CT)

Coagulation time (K-time) Clot formation time (CFT)

Maximum amplitude (MA) Maximum clot firmness (MCF)

Lysis 30 (LY30) Lysis Index 30 (LI30)

TABLE 2: Nomenclature differences between TEG and ROTEM

TEG: thromboelastography; ROTEM: rotational thromboelastometry

Interpretation of parameters
Reaction Time (R-Time)

Reaction time is the first measurement of the coagulation cascade. Its measurement is related to
coagulation factor activation. This value is similar to extrinsic and intrinsic clotting pathway measurements
by PT and aPTT respectively. The R-time largely reflects the adequacy of coagulation factors and is the most
sensitive parameter to measure the effects of heparin therapy including low molecular weight heparin
(LMWH) [10, 11]. An elevated or prolonged R-value (more than eight minutes) can signify a deficiency in
clotting factors, hemodilution, or the presence of heparin. Therefore, indicating a need for transfusion of
fresh frozen plasma. On the other hand, a shortened R-time (less than four minutes) can indicate
hypercoagulopathy requiring the use of anticoagulation.

K-Time

It is a measurement of the time interval between R and time to reach 20 mm clot amplitude. K-time and α
angle are both related to coagulation factor amplification. Therefore, their values correlate, and they both
indicate a deficiency in clot growth kinetics. A low value can indicate a deficiency in fibrinogen and may
reveal a need for cryoprecipitate. A high value is similar to the R-time, which represents a hypercoagulable
state, and an anticoagulant may be required.

α Angle

It is a measurement of the line tangent to the slope of the curve during clot formation. The computer
software calculates the angle based on the slope and time. A number of factors including thrombin
generation and fibrinogen levels determine the angle. It identifies states of hyper- or hypo-coagulopathies.

MA Value

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 It is the maximum amplitude that represents the distance traveled by the cross-linked cup/pin. It is a
measurement of maximum clot strength and provides information on both fibrinogen and platelet function.
A high MA value may indicate hypercoagulation and the need for an anticoagulant. A low MA value indicates
low clot strength, which can be caused by decreased fibrinogen levels, low platelet counts, or decreased
platelet function. If a low MA is combined with a decreased K value, this is an indication of cryoprecipitate
therapy. MA value is very important when paired with a platelet count because a low platelet count and a
normal MA value indicate a patient has a normal platelet function and therefore does not require platelet
transfusion. Conversely, treatment with platelets may be indicated for patients with a low MA value, low
platelet function, and normal platelet count [12].

LY30

It is clot lysis at 30 minutes. It is the last major TEG parameter and measures the percent of the decrease in
area under the curve over 30 minutes. Therefore, it reflects fibrinolysis after maximum amplitude is reached.
This measurement is most useful for patients undergoing thrombolytic therapy or during disseminated
intravascular coagulation (DIC). A high LY30 percentage indicates hyperfibrinolysis and patients may
require antifibrinolytic agents including tranexamic acid, aprotinin, and aminocaproic acid.

Review
Methods
A review of the literature was conducted to identify qualifying publications. The search was conducted in the
following databases: PubMed, Medline, Ovid, CINAHL, and ClinicalTrials.gov. Search criteria were defined
using the string (thromboelastography or TEG) and (perioperative or postoperative or preoperative or
operative) in all search fields. Inclusion criteria for the systematic review included articles that represented
original research including as a focal outcome evaluation of TEG procedures; in one or more perioperative
settings (pre, intra, or postoperative); in a human population; have been published in a peer-reviewed
source and in English. Excluded items included theses or dissertations, conference abstracts, and
proceedings, theoretical papers, comments or letters to the editor, or previous reviews. We abstracted data
from selected studies that include patient samples, perioperative settings where TEG was utilized, TEG
parameters that were assessed, and clinical outcomes that were reported. Because of clinical and
methodologic heterogeneity among studies, we expected to report results qualitatively rather than
conducting a meta-analysis.

The initial database search described in the methods section yielded 8,200 unique articles after duplicates
were removed. Among them, 6,156 reports were included and assessed for eligibility after excluding records
without data (N = 75), not in English (N = 425), that were non-peer-reviewed (e.g., conference abstracts) (N =
1,012), that were reviewed (N = 526) and that were not retrievable (N = 6). After further automated and
manual screening of assessed reports for eligibility, 210 articles were found to be eligible and included in the
review (Figure 1). Reasons for rejection of assessed articles included studies that were ineligible (N = 281),
were reviews (N = 249), in which TEG was mentioned but not evaluated (N = 4,959), did not include patient
outcomes (N=175), studies not in perioperative settings (N = 71). Also, articles in languages other than
English (N = 127), studies with veterinary samples (N = 73), retracted studies (N = 9), and the use of the
abbreviation TEG not referring to thromboelastography (N = 2) were excluded.

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 FIGURE 1: PRISMA flow diagram with included searches of databases
and registers
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

The included 210 studies were categorized under various surgical settings. Studies in the cardiovascular
settings were the maximum with 64 studies while those based in the surgical intensive care unit (ICU)
setting were the least with only one study.

Trauma
TEG finds its clinical application critically useful in trauma; the American College of Surgeons recommends
it to be available at all level I and level II trauma centers. Complications from trauma-related surgery such as
hemorrhage and thrombosis remain the leading causes of preventable death. Hemorrhage exacerbation is
associated with trauma-induced coagulopathy (TIC) and has been shown to be present in more than 25% of
severely injured patients upon arrival to the emergency department. TIC is a lethal, unbalanced, and
abnormal process. Its early stages are characterized by hypercoagulability and bleeding whereas the later
stages are characterized by hypercoagulability with venous thromboembolism and multiple organ failure. In
such a scenario, comprehensive information about coagulation status is essential. TEG by analyzing various
contributors of both hemostasis and clot dissolution provide extensive information that has been shown to
predict mortality as well as positively impact it during TIC [13-15]. TEG parameters such as MA and R-time
detect platelet function and coagulation factor deficiency with a high degree of specificity that guide
individualized therapy for patients [16, 17]. It is accurate in diagnosing hypofibrinogenemia as well [18].
Their ability to reliably detail the hypercoagulable states in cancer patients and the distorted coagulation
status in alcoholic patients during trauma is well demonstrated [19, 20]. Overall, they reflect coagulation
status better than traditional coagulation tests [21].

Since TIC is associated with uncontrolled bleeding, TEG's ability to provide insight into both depletion
coagulopathy and hyperfibrinolysis allows it to guide massive transfusion protocol (MTP); and predict the
associated mortality [22-25]. TEG-guided resuscitation has demonstrated lower blood product usage, shorter
ICU and hospital stay, and lower overall costs especially when compared to conventional coagulation tests
that come with limitations such as its time-consuming nature, failure to delineate the complex nature of

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 TIC, and unclear value in guiding transfusion [26-29]. This has been shown to improve mortality outcomes,
especially in pelvic fractures, penetrating as well as blunt trauma patients, and burn patients [30-33]. While
the ability of TEG to predict transfusion has been replicated in the general population it was not the case in
the polytrauma population [34]. Using TEG protocols that are directed to reduce blood product usage and
improve survival [35, 36], transfusion has become more patient-specific with an average transfusion ratio of
2.5:1:2.9 (red blood cells: plasma: platelets), different from the current 1:1:1 guideline [37]. TEG has been
shown to be valid during MTP and results in different patterns of blood transfusion based on individual
patient requirements as well as a reduction in overall hemorrhage-related deaths during trauma [38, 39].
When it comes to MTP-related blood product usage, TEG does not differ from conventional testing and
ROTEM [40, 41]. During trauma surgery involving the liver and spleen, interestingly, TEG guidance has
demonstrated less as well as increased blood product usage but shorter surgery time [42, 43]. With the
success of TEG in assessing coagulopathic parameters in trauma patients, TEG has been investigated for
detecting and reversing anticoagulants only with limited success, and conventional tests (e.g., PT, INR, PTT)
that have shown better results comparatively have been recommended [44-47]. TEG finds its utility in the
pediatric trauma population as well where it has been shown to accurately predict MTP requirement,
thromboembolism, and mortality [48, 49, while outcomes such as blood product use, ventilator duration,
and length of ICU stay were found to be worse with TEG use there was no change in mortality [50] (Table 3).

Patient Operative TEG Procedures

Citation Clinical Outcomes Summary of Findings
Sample Setting Assessed

Farrell et 50 US TEG-MA, TEG R-

“Death diamond” combination of TEG parameters is strongly
al., 2021 trauma Intraoperative time, TEG-K, TEG Mortality
predictive of mortality after trauma
[13] patients alpha-angle

rTEG-MA, rTEG R-
98 US rTEG parameters predicted coagulopathy, coagulopathy
Chin et al., time, rTEG-K, rTEG Mortality,
trauma Intraoperative impacted mortality differently among different subsets of
2014 [14] alpha-angle, rTEG- coagulopathy
patients patients
LY30

58 Indian
Intraoperative
Albert et al., trauma TEG R-time, k-time, TEG values including prolonged k-time and shortened alpha
prior to Coagulopathy
2019 [15] patients alpha-angle angle predicted coagulopathy after TBI
transfusion
with TBI

Moore et 58 US
al., 2015 trauma Intraoperative TEG-MA Platelet function TEG-MA was predictive of platelet function
[16] patients

550 US
Chow et al., Coagulation factor TEG R-time predicts coagulation factor deficiency with high
trauma Intraoperative TEG R-time
2020 [17] deficiency specificity but low sensitivity
patients

623 US
Chow et al., TEG-MA, TEG-K, TEG parameters predict hypofibrinogenemia with high
trauma Intraoperative Hypofibrinogenemia
2019 [18] TEG alpha-angle specificity but low sensitivity
patients

157
TEG-MA, TEG R- Hypercoagulability,
Mou et al., Chinese TEG parameters were related to hypercoagulability, but not
Preoperative time, TEG-K, TEG VTE, thrombotic
2019 [19] oncology to VTE or thrombosis
alpha-angle complications
patients

Howard et 415 US TEG-MA, TEG R- Hypocoagulation in

TEG parameters gave inaccurate indications of
al., 2014 trauma Intraoperative time, TEG-K, TEG relation to alcohol
hypocoagubility in patients with alcohol exposure
[20] patients alpha-angle exposure

40
Chinese TEG-MA, TEG R-
Liu et al., TEG parameters predicted coagulopathy more accurately
older adult Preoperative time, TEG-K, TEG Coagulopathy
2016 [21] than traditional lab values
fracture alpha-angle
patients

118 US TEG-MA, TEG R-

Ives et al., Coagulopathy,
trauma Preoperative time, TEG-K, TEG TEG parameters predicted MTP and mortality
2012 [22] MTP, mortality
patients alpha-angle

Coleman et 343 US TEG-MA, TEG R-

Massive transfusion TEG parameters are predictive of the need for massive
al., 2018 trauma Intraoperative time, TEG-K, TEG
status transfusion
[23] patients alpha-angle

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 Moore et 324 US
tPA-TEG parameters efficiently identify patients needing
al., 2017 trauma Intraoperative rTEG tPA–TEG MTP
MTP
[24] patients

Pezold et 80 US TEG-MA, TEG R-

al., 2012 trauma Intraoperative time, TEG-K, TEG Mortality TEG parameters predict early mortality
[25] patients alpha-angle

TEG-guided Blood product

Mohamed 134 US Introduction of TEG-guided resuscitation protocol resulted in
resuscitation usage, ICU length
et al., 2017 trauma Intraoperative lower blood product usage, shorter ICU length of stay, shorter
protocol vs. clinician of stay, hospital
[26] patients hospital length of stay, and lower overall costs
discretion length of stay, costs

Holcomb et 1,974 US TEG-MA, TEG R-

Blood product TEG parameters were superior predictors of blood product
al., 2012 trauma Intraoperative time, TEG-K, TEG
usage usage compared with conventional coagulation tests
[27] patients alpha-angle

69 US
Kaufmann TEG-MA, TEG R-
blunt Hypercoagulability,
et al., 1997 Intraoperative time, TEG-K, TEG TEG parameters were predictive of need for transfusion
trauma transfusion
[28] alpha-angle
patients

681 TEG-guided
Schochl et
Austrian hemostatic therapy Blood product TEG-guided protocol resulted in lower blood product usage
al., 2010 Intraoperative
trauma vs. clinician usage volume
[29]
patients discretion

131 US May vary

Kane et al., pelvic (retrospective
TEG R-time Mortality TEG R-time was predictive of mortality risk
2015 [30] trauma record
patients review)

Mortality, blood
Bostian et 141 US TEG parameters on intake were associated with extent of
loss, transfusion,
al., 2020 trauma Preoperative TEG-LY30 blood loss, volume of blood products transfused, and
hemoglobin
[31] patients mortality risk
changes

TEG-directed
TEG-directed resuscitation had better mortality outcomes for
289 US resuscitation
Tapia et al., Blood product penetrating trauma, and lower blood product usage volume
trauma Intraoperative protocol vs.
2013 [32] volume, mortality for more severe blunt trauma patients compared with
patients standardized MTP
standardized MTP protocol
protocol

May vary TEG-MA, TEG R-

65 US Resuscitation,
Huzar et al., (retrospective time, TEG-K, TEG TEG parameters predicted resuscitation, transfusion
burn transfusion
2018 [33] registry alpha-angle, TEG- volumes, and mortality
patients volumes, mortality
study) LY30

Van
Wessem 135 Dutch TEG-MA, TEG R-
and trauma Intraoperative time, TEG-K, TEG Coagulopathy TEG parameters were not predictive of coagulopathy
Leenen, patients alpha-angle
2017 [34]

TEG-directed MTP
Gonzalez et 111 US
protocol vs. Survival, blood The TEG-directed protocol increased survival and reduced
al., 2016 trauma Intraoperative
conventional MTP product volume blood product usage
[35] patients
protocol (RCT)

TEG-guided
Sumislawski 278 US
resuscitation vs. Mortality, Patients treated with TEG-guided protocols had better
et al., 2018 trauma Intraoperative
conventional assay- coagulopathy survival
[36] patients
guided resuscitation

Mamczak et 40 US
TEG-PM guided Blood product TEG-guided transfusion protocol resulted in different patterns
al., 2016 trauma Intraoperative
transfusion protocol usage of blood product usage from standardized modality
[37] patients

TEG-MA, TEG R-
Stettler et 825 US time, TEG-K, TEG TEG parameters are valid for use in guiding MTP
al., 2018 trauma Intraoperative MTP administration

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 [38] patients alpha-angle, TEG- administration
LY30

182
Johansson TEG-MA, TEG R- Survival,
Danish TEG parameters differed between survivors and non-
et al., 2013 Intraoperative time, TEG-K, TEG transfusion, blood
trauma survivors but did not independently predict survival
[39] alpha-angle product volume
patients

67 US TEG-guided MTP
Unruh et al., Blood product There was no difference in blood product usage between
trauma Intraoperative vs. conventional
2019 [40] usage TEG-guided MTP and conventional testing-guided MTP
patients testing

33
TEG vs. ROTEM
Rizoli et al., Canadian TEG and ROTEM parameters had similar performance for
Intraoperative parameters in Coagulopathy
2016 [41] trauma detecting intraoperative coagulopathy
comparison
patients

Dudek et 258 US TEG-guided Volume of blood

Patients receiving TEG-guided transfusion received more
al., 2021 trauma Intraoperative transfusion vs. product use, time to
blood products and had a shorter time to surgery
[42] patients standardized MTP surgery

Intraoperative TEG-guided blood

166 US Blood product TEG-guided therapy was associated with lower blood
Wang et al., liver or component therapy
trauma usage, hospital product usage volume and shorter average hospital length of
2017 [43] spleen vs. clinician
patients length of stay stay
surgery discretion

May vary
Barton et 824 US TEG parameters can differentiate some but not all common
(retrospective Preoperative
al., 2021 trauma TEG-PM anticoagulants. Authors recommend investigation of other
observational anticoagulation
[44] patients methods detecting need for anticoagulation reversal
study)

Coagulopathy due
Kobayashi 182 US TEG-MA, TEG R-
to novel oral TEG parameters were not effective at detecting coagulopathy
et al., 2018 trauma Preoperative time, TEG-K, TEG
anticoagulant due to NOA therapy
[45] patients alpha-angle
(NOA) therapy

Preoperative TEG did not differentiate patients with preoperative

54 US TEG-MA, TEG R-
Ali et al., anticoagulation, anticoagulation therapy. Authors recommend using
trauma Intraoperative time, TEG-K, TEG
2017 [46] postoperative conventional testing methods to identify patients in need of
patients alpha-angle
coagulopathy anticoagulation reversal

100 US TEG-MA, TEG R-

Myers et al., Anticoagulation TEG parameters correlate with anticoagulation reversal, but
trauma Intraoperative time, TEG-K, TEG
2020 [47] reversal detection conventional tests perform better in clinical settings
patients alpha-angle

133 US Coagulopathy,
Leeper et TEG-MA, TEG R- TEG parameters can be combined with other variables as
pediatric thromboembolism,
al., 2018 Preoperative time, TEG-K, TEG part of a principal components analysis to predict transfusion,
trauma transfusion,
[48] alpha-angle thromboembolism, and mortality
patients mortality

117 US
Phillips et TEG-MA, TEG R-
pediatric MTP
al., 2021 Intraoperative time, TEG-K, TEG TEG parameters accurately identify patients needing MTP
trauma implementation
[49] alpha-angle
patients

125 US rTEG vs. other non- Mortality, blood

Aladegbami Patients with rTEG had worse outcomes on all measures
pediatric TEG assessments product use,
et al., 2018 Intraoperative except mortality (which did not differ). However, rTEG was
trauma (observational ventilator duration,
[50] used primarily for more severely injured patients
patients study) length of ICU stay

TABLE 3: Studies of TEG in trauma perioperative settings

TEG: thromboelastography; TEG-MA: TEG with maximum amplitude; rTEG; rapid thromboelastography; tPA-TEG: tissue plasminogen activator; TEG-PM:
TEG with platelet mapping; TBI: traumatic brain injury; VTE: venous thromboembolism; ROTEM: rotational thromboelastometry; MTP: massive
transfusion protocol

Obstetric

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 Pregnancy is uniquely a hypercoagulable state. This usually results in thromboembolic complications that
can affect the pregnancy, necessitating the need for anticoagulants. Under such circumstances, TEG
parameters have been found to be useful in guiding anticoagulation therapy [51]. But its sensitivity has not
been found to be adequate to monitor the progress of anticoagulation [10]. On the other hand, pregnancy-
related complications such as pre-eclampsia and eclampsia reverse the blood coagulability into the
hypercoagulable state as well as hemolysis that can be exacerbated during surgery. Although TEG relates
such coagulopathic scenarios during pregnancy with the risk profiles preoperatively [52], they have yet been
found to be inferior when compared to conventional coagulation tests in predicting intraoperative
coagulopathy and blood loss [53]. They still have been demonstrated to reduce blood product use, costs, risks
of ICU admission, and the need for emergency hysterectomy [54] (Table 4).

Patient Operative TEG Procedures

Citation Clinical Outcomes Summary of Findings
Sample Setting Assessed

Griffiths et 24 UK TEG-MA, TEG R-

Postoperative TEG parameters do not have the sensitivity to
al., 2017 obstetric time, TEG-K, TEG Anticoagulant detection
Cesarean section accurately monitor anticoagulant therapy progress
[10] patients alpha-angle

19 UK
Boyce et al., Intraoperative Response to heparin TEG parameters were useful for guiding heparin
obstetric TEG R-time
2011 [51] Cesarean section dosage on coagulation dosage
patients

45
Karlsson et TEG-MA, TEG R- TEG parameters were worse predictors of
Swedish
al., 2014 Intraoperative time, TEG-K, TEG Coagulopathy, blood loss coagulopathy and blood loss compared with
obstetric
[52] alpha-angle conventional laboratory tests
patients

Preoperative,
54 UK
Smith et al., postoperative TEG-MA, TEG R- TEG parameters were associated with
obstetric Coagulopathy, risk profiles
2009 [53] Caesarian time postoperative coagulopathy and risk profiles
patients
section

Preoperative TEG-directed Blood loss, blood product

Snegovskikh 86 US Introduction of TEG-directed transfusion protocol
transfusion due to transfusion use, ICU admission,
et al., 2018 obstetric reduced blood product use, costs, and risks of ICU
severe protocol vs. emergency hysterectomy,
[54] patients admission or emergency hysterectomy
hemorrhage clinician discretion costs

TABLE 4: Studies of TEG in obstetric perioperative settings

TEG: thromboelastography; TEG-MA: TEG with maximum amplitude

Orthopedic
Orthopedic surgery in general involves the release of massive tissue factors triggering a coagulation process
that requires anticoagulants for venous thromboembolism prevention and treatment. For joint surgeries,
neuraxial and peripheral nerve blocks are mainstay anesthesia choices that need information on the
patient’s coagulation profile and medications that affect coagulation. So comprehensive information about
coagulation status in orthopedic surgery patients is important. In demographic-specific orthopedic surgery
patients, TEG has been reported to be a better measure of hypercoagulability compared to conventional
measures [55] but has been found not to predict venous thromboembolism risk [56]. In spine surgery, TEG
has predicted clotting factor deficiency such as hypofibrinogenemia and was found to be an inferior
predictor of coagulation status as a whole compared to traditional laboratory measures [57, 58]. However,
their sensitivity to sustained coagulation changes i.e., after seven days is superior compared with traditional
measures [59]. When it comes to anticoagulation, TEG has been established to differentiate anticoagulated
patients as well as monitor their therapy [60-62]. TEG-guided anticoagulation prophylaxis has better safety
and comparable efficacy to conventional prophylaxis strategy [63]. TEG did not find any significance in
detecting specific outcomes related to orthopedic surgery such as bone cement implantation syndrome and
infections [64, 65] (Table 5).

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 Patient Operative TEG Procedures
Citation Clinical Outcomes Summary of Findings
Sample Setting Assessed

Lloyd-Donald 52 Australian Preoperative, TEG-MA, TEG R- TEG parameters were a better measure of
et al., 2021 orthopedic intraoperative, time, TEG-K, TEG Hypercoagulability hypercoagulability in this population than
[55] patients postoperative alpha-angle conventional measures

Parameswaran 101 Indian TEG-MA, TEG R-

et al., 2016 orthopedic Preoperative time, TEG-K, TEG VTE TEG parameters did not predict VTE risk
[56] patients alpha-angle

244 US
TEG-MA, TEG R- TEG parameters were worse predictors of
Horlocker et spinal Intraoperative
time, TEG-K, TEG Coagulopathy coagulation status than traditional laboratory
al., 2001 [57] surgery spinal fusion
alpha-angle measures
patients

39 Chinese
Intraoperative
Chen, Hu, et adolescent
scoliosis TEG-FLEV Hypofibrinogenemia TEG-FLEV predicts hypofibrinogenemia
al., 2020 [58] orthopedic
surgery
patients

Coagulability after TEG R-time and TEG-MA measures were both

228 Chinese
Bai et al., 2021 Pre- and post- TEG R-time, TEG- anticoagulant more sensitive to sustained coagulation changes
orthopedic
[59] operative THA MA prophylaxis (1 and 7 after 7 days compared with traditional laboratory
patients
days post-surgery) measures

24 US TEG-MA, TEG R-
Klein et al., Preoperative, TEG parameters differentiate anticoagulated
orthopedic time, TEG-K, TEG Anticoagulation
2000 [60] postoperative patients
patients alpha-angle

TEG-MA, TEG R-
80 Chinese Intraoperative
Li et al., 2020 time, TEG-K, TEG Anticoagulation TEG parameters are useful for monitoring
orthopedic posterior
[61] alpha-angle, TEG-CI, monitoring anticoagulant therapy
patients lumbar fusion
TEG-PIR

30 Turkish
Tekkesin et al., Preoperative, Anticoagulation TEG parameters are useful for monitoring
orthopedic TEG R-time
2016 [62] postoperative monitoring anticoagulation therapy perioperatively
patients

197 Chinese Intraoperative Blood loss, transfusion TEG-guided risk stratification for anticoagulation
Chen, Ma, et TEG-guided risk
orthopedic total joint rate, transfusion prophylaxis resulted in better safety and equal
al., 2020 [63] stratification
patients arthroplasty volume, DVT efficacy as conventional prophylaxis strategy

250 Chinese TEG-MA, TEG R-

Qiao and Sun, Periprosthetic joint
orthopedic Intraoperative time, TEG-K, TEG TEG parameters predicted PJI
2021 [64] infection (PJI)
patients alpha-angle

32 Italian TEG-MA, TEG R- Bone cement

Morda et al., Preoperative,
orthopedic time, TEG-K, TEG implantation syndrome TEG parameters were not predictive of BCIS
2017 [65] postoperative
patients alpha-angle (BCIS)

TABLE 5: Studies of TEG in orthopedic perioperative settings

TEG: thromboelastography; TEG-PM: TEG with platelet mapping; TEG-MA: TEG with maximum amplitude; VTE: Venous thromboembolism

ICU
Surgical ICU patients commonly have a myriad of coagulation abnormalities such as thrombocytopenia,
prolonged global coagulation times, reduced levels of coagulation inhibitors, or high levels of fibrin split
products. Additionally, they are at increased risk of venous thromboembolism due to immobilization,
pharmacologic paralysis, repeat surgical procedures, sepsis, mechanical ventilation, vasopressor use, and
renal dialysis. Identifying the etiology of these coagulation abnormalities is of utmost importance since
each coagulation disorder necessitates different therapeutic strategies. Since TEG provides a comprehensive
evaluation of the viscoelastic properties of blood compared to standard plasma assays, in surgical ICU
patients TEG has been demonstrated to be predictive of ICU duration, ventilator duration, hospital length of
stay, and risk of thromboembolic events [66]. The detection of coagulation abnormalities is even more
important in sepsis, a well-known comorbidity during ICU admission since consumption of coagulation

2023 Ramanujam et al. Cureus 15(5): e39407. DOI 10.7759/cureus.39407 9 of 32

 factors and subsequent coagulopathy occurs. TEG in this sense has been established to detect coagulopathy
and distinguish it among those with and without sepsis so that appropriate management can ensue (Table 6)
[66].

TEG
Patient Operative
Citation Procedures Clinical Outcomes Summary of Findings
Sample Setting
Assessed

Kashuk
152 US Hypercoagulability, thromboembolic events, TEG-indicated hypercoagulability was predictive of
et al.,
SICU Intraoperative r-TEG G transfusion, ICU length of stay, hospital ICU duration, ventilator duration, hospital duration,
2009
patients length of stay, ventilator days and risk of thromboembolic event
[66]

TABLE 6: Studies of TEG in ICU perioperative settings

Cardiovascular
Blood Product Transfusion

The use of TEG in cardiovascular surgeries significantly reduced blood product transfusion compared to
clinician-guided practice [67-76]. However, it was not associated with any change in ICU stay or mortality
[69, 71, 72]. Redfern et al. 2020 found that TEG-guided protocol significantly reduced blood product use,
costs, and reoperation rates; however, it did not impact mortality compared to clinician discretion in 1098
US cardiac patients [74]. Sun et al. 2014 found that TEG-guided protocol was associated with lower fresh
frozen plasma (FFP) and platelet transfusion volume without any association with plasma transfusion
volume or platelet count in 39 Chinese cardiac patients during ventricular assist device placement [76].

On the other hand, a weak relationship between thromboelastography with platelet mapping (TEG-PM) and
platelet transfusion volume was observed in 44 US pediatric cardiac patients [77]. In addition, Westbrook et
al. 2009 showed no significant difference in blood product usage between the TEG-guided and the clinician-
guided groups in 69 Australian cardiac patients [78].

Bleeding Prediction

The ability of TEG parameters to predict bleeding was questionable in the literature as some studies showed
that the use of TEG-MA, TEG R-time, TEG-K, and TEG α-angle was also predictive of blood loss during the
operation [75, 79-88] and even postoperatively [89-96]. They could also predict short-term bleeding
complications and micro-bleeding [97, 98]. However, they predicted hemostasis only without cyanosis in 63
Italian cardiac patients [99]. Using TEG-MA was useful in predicting long-term ischemic event risk [100],
platelet function [101], and “high on-treatment platelet reactivity” [102].

On the other hand, Terada et al. 2019 found that intraoperative use of TEG-MA, TEG R-time, TEG-K, and
TEG α-angle was not predictive of blood loss volume in 50 Japanese cardiac patients [103]. Moreover,
another five studies showed that these TEG parameters were not predictive of postoperative bleeding [104-
108] or even intraoperative bleeding [109, 110].

While other TEG parameters like TEG-PM, rapid thromboelastography maximal amplitude (rTEG-MAf), and
rapid thromboelastography fibrinogen level (rTEG-FLEV) were predictive of blood loss volume in cardiac
patients [111, 112].

Coagulopathy and Thrombotic Events

Mostly TEG parameters could predict both coagulopathy and thrombotic events. The use of TEG-MA, TEG R-
time, TEG-K, and TEG α-angle in cardiac patients was predictive of both coagulopathy [84, 85, 113-120] and
even intracranial hemorrhage [120]. Also, they could predict thrombotic events [97, 121] and even pump
thrombosis risk [122]. They detected also the P2Y12 inhibition nonresponse, allowing earlier intervention
for patients receiving preoperative inhibition therapy in 453 US vascular patients [123]. In comparison to
conventional indicators, TEG parameters were better at predicting bleeding and clotting complications
[124]. Heparinase modification allowed TEG parameters to diagnose covert coagulopathy [125, 126]. Only
Brothers et al. 1993 found that these parameters were not reliably corresponded to clinical coagulopathy in
10 US cardiac patients [127].

Bhardwaj et al. 2017 found that TEG-MA predicted postoperative thrombocytopenia in 35 Indian cardiac
patients [128]. In addition, TEG-MA predicted platelet count in cardiac patients [105, 129, 130]. On the other

2023 Ramanujam et al. Cureus 15(5): e39407. DOI 10.7759/cureus.39407 10 of 32

 hand, it did not predict adverse events in 233 Danish vascular patients [131].

Other parameters like rTEG-MAf, rTEG-FLEV, TEG-LY60, and TEG-LY150 were also predictive of
coagulopathy events in cardiovascular surgeries [132, 133].

Anticoagulant Efficacy Prediction

Intraoperative use of TEG-MA, TEG R-time, TEG-K, and TEG α-angle was effective for monitoring
anticoagulant therapy [134-136]. Postoperatively too they were effective for assessing anticoagulation status
[137]. TEG-K was found to be effective in monitoring heparin efficacy intraoperatively in 31 US cardiac
patients [138]. They also were useful in monitoring anticoagulation reversal in 40 Singaporean vascular
patients [106].

TEG-guided intraoperative anticoagulant therapy was effective in 31 US intracranial aneurysm patients

[139]; however, when it was compared to traditional methods, no difference was observed in terms of
protamine usage or heparin reversal efficacy [140]. TEG-MA was comparable to ROTEM-EXTEM in terms of
guiding anticoagulation reversal in 52 UK cardiac patients [141] (Table 7).

Operative TEG Procedures

Citation Patient Sample Clinical Outcomes Summary of Findings
Setting Assessed

TEG-based algorithm Significantly lower volume of transfusion was

Ak et al., 2009 224 Turkish Intraoperative Volume of blood
vs. clinician-guided required for patients in the TEG-guided
[67] CABG patient CABG products transfused
practice (RCT) condition

Use of TEG-guided Patients in the TEG-guided protocol group

100 Japanese Platelet transfusion,
Aoki et al., 2012 protocol vs. standard used less platelet transfusion, but had more
vascular surgery Intraoperative bleeding
[68] of care for transfusion bleeding complications, compared with the
patients complications
determination (RCT) clinician-guided group

TEG-guided
Transfusion TEG-guided transfusion resulted in use of
Datta and De, 3000 Indian transfusion vs.
Intraoperative volume, ICU length lower volume of blood product and no change
2020 [69] cardiac patients clinician-guided
of stay, mortality in ICU stay or mortality
transfusion policy

Use of TEG-directed Introduction of TEG-directed transfusion

Fleming et al., 681 US cardiac Blood product
Intraoperative transfusion vs. procedures reduced volume of blood product
2017 [70] patients usage
clinician discretion used

Intraoperative blood
TEG-guided TEG-guided transfusion reduced
698 US product usage,
Hasan et al., transfusion protocol intraoperative blood product use, but did not
cardiopulmonary Intraoperative postoperative
2022 [71] vs. conventional reduce postoperative transfusion or mortality
bypass patients transfusion,
testing rate
mortality

TEG-guided Blood product

Introduction of TEG-guided transfusion
Kane et al., 150 US pediatric transfusion vs. usage,
Intraoperative protocol resulted in reduction in blood product
2016 [72] cardiac patients clinician-guided postoperative
usage with no increase in complications
transfusion complications

TEG-guided
Introduction of a TEG-guided transfusion
Mendeloff et al., 112 US neonatal transfusion protocol Blood product
Intraoperative protocol resulted in reduced usage of blood
2009 [73] cardiac patients vs. clinician-guided usage
product volume
approach

Blood product Introduction of TEG-guided transfusion

TEG-guided
Redfern et al., 1,098 US usage, costs, protocol reduced blood product usage,
Intraoperative transfusion protocol
2020 [74] cardiac patients reoperation rate, reduced costs, reduced reoperation rates,
vs. clinician discretion
mortality and did not impact mortality

TEG-guided
Shore- TEG-guided transfusion protocol was
105 US cardiac transfusion protocol Blood product
Lesserson et al., Intraoperative associated with lower blood product usage
patients vs. conventional usage
1999 [75] volume
protocol

Coagulopathy, TEG-directed transfusion was associated

TEG-directed platelet count, with lower FFP and platelet transfusion
Sun et al., 2014 39 Chinese Intraoperative
transfusion protocol blood product volume, but there was no difference in plasma
[76] cardiac patients VAD placement
vs. clinician discretion

2023 Ramanujam et al. Cureus 15(5): e39407. DOI 10.7759/cureus.39407 11 of 32

 usage transfusion volume or platelet count

Intraoperative
Barker et al., 44 US pediatric Mortality, platelet Weak relationship between TEG-PM and
and TEG-PM
2019 [77] cardiac patients transfusion volume platelet transfusion volume
postoperative

TEG-guided
There was a no significant difference in blood
Westbrook et 69 Australian transfusion protocol Blood product
Intraoperative product usage between the TEG-guided and
al., 2009 [78] cardiac patients vs. clinician discretion usage
clinician discretion groups
(RCT)

Perioperative TEG-MA was predictive of bleeding volume.

Emani et al., 703 US pediatric
Intraoperative TEG-MA bleeding, TEG-MA guidance had utility for reducing
2021 [79] cardiac patients
transfusion volume transfusion volume

Emani et al., 511 US pediatric Intraoperative TEG-MA predicts intraoperative bleeding

Intraoperative TEG-MA
2018 [80] cardiac patients bleeding volume

36 US TEG-MA, TEG R-time,

Essell et al., Intraoperative TEG parameters were predictive of
cardiopulmonary Intraoperative TEG-K, TEG alpha-
1993 [81] bleeding hemorrhage risk
bypass patients angle

Sivapalan et al., 199 Danish Intraoperative

TEG-MA Transfusion volume TEG-MA was predictive of transfusion volume
2017 [82] cardiac patients CABG

398 Chinese TEG-MA, TEG R-time, Blood loss,

Liu et al., 2021 Preoperative, TEG parameters were predictive of blood
vascular TEG-K, TEG alpha- hemorrhage,
[83] intraoperative loss volume, hemorrhage, and transfusion
patients angle transfusion

TEG-MA, TEG R-time,

Sharma et al., 50 Indian Coagulopathy, TEG parameters predicted coagulopathy and
Intraoperative TEG-K, TEG alpha-
2018 [84] cardiac patients blood loss volume blood loss volume
angle

Intraoperative TEG-MA, TEG R-time, Bleeding,

Tuman et al., 42 US cardiac TEG parameters were predictive of bleeding
cardiopulmonary TEG-K, TEG alpha- hemorrhage,
1989 [85] patients volume, hemorrhage, and coagulopathy
bypass angle coagulopathy

TEG-MA, TEG R-time,

Moganasundram 50 UK pediatric
Intraoperative TEG-K, TEG alpha- Bleeding TEG parameters predicted bleeding
et al., 2010 [86] cardiac patients
angle

Preoperative,
TEG-MA, TEG R-time,
Nuttall et al., 82 US cardiac intraoperative Intraoperative TEG parameters predicted subjective
TEG-K, TEG alpha-
1997 [87] patients cardiopulmonary bleeding clinician judgment of excessive bleeding
angle
bypass

Singh et al., 55 Indian Intraoperative

TEG-MA Blood loss TEG-MA was predictive of blood loss volume
2015 [88] cardiac patients coronary bypass

Platelet function,
Cammerer et al., 255 German Preoperative, surgical bleeding, TEG alpha-angle is a strong predictor of
TEG alpha-angle
2003 [89] cardiac patients intraoperative postoperative postoperative bleeding
bleeding

TEG-MA, TEG R-time,

Martin et. al., 22 UK pediatric Preoperative, Postoperative TEG parameters predicted postoperative
TEG-K, TEG alpha-
1991 [90] cardiac patients postoperative bleeding bleeding
angle

TEG-MA, TEG R-time,

Muller et al., 9 German Postoperative TEG parameters predicted postoperative
Intraoperative TEG-K, TEG alpha-
1975 [91] cardiac patients bleeding bleeding
angle

Preoperative,
TEG-MA, TEG R-time,
Niebler et al., 60 US cardiac intraoperative Postoperative TEG parameters are predictive of
TEG-K, TEG alpha-
2012 [92] patients cardiopulmonary bleeding postoperative bleeding
angle
bypass

59 Israeli TEG-MA, TEG R-time,

Preisman et al., Excessive blood TEG parameters predicted excessive
vascular Preoperative TEG-K, TEG alpha-
2010 [93] loss postoperative blood loss
patients angle

Intraoperative TEG-MA, TEG R-time,

2023 Ramanujam et al. Cureus 15(5): e39407. DOI 10.7759/cureus.39407 12 of 32

 Shih et al., 1997 43 Chinese cardiopulmonary TEG-K, TEG alpha- Postoperative TEG parameters are predictive of
[94] cardiac patients bypass angle bleeding postoperative bleeding

Intraoperative TEG-MA, TEG R-time,

Smith et al., 120 US cardiac Postoperative TEG parameters are associated with
cardiopulmonary TEG-K, TEG alpha-
2020 [95] patients bleeding postoperative bleeding
bypass angle

Intraoperative TEG-MA, TEG R-time,

Williams et al., 494 US pediatric Postoperative TEG parameters predicted postoperative
cardiopulmonary TEG-K, TEG alpha-
1999 [96] cardiac patients bleeding bleeding
bypass angle

54 Polish Preoperative, TEG-MA, TEG R-time,

Rymuza et al., Bleeding TEG parameters predicted short-term
vascular intraoperative TEG-K, TEG alpha-
2018 [97] complications bleeding complications
patients TAVI angle

261 Chinese Intraoperative TEG-MA, TEG R-time,

Xu et al., 2016 Microbleeding
vascular SAC TEG-K, TEG alpha- TEG parameters predicted microbleeding
[98] complications
patients embolization angle

Intraoperative TEG-MA, TEG R-time,

Rizza et al., 63 Italian Cyanosis, TEG parameters were predictive of
cardiopulmonary TEG-K, TEG alpha-
2017 [99] cardiac patients hemostasis hemostasis but not cyanosis
bypass angle

759 Chinese TEG-MA, TEG R-time, Platelet function,

Hou et al., 2017 Intraoperative TEG-MA predicted long-term ischemic event
vascular TEG-K, TEG alpha- long-term ischemic
[100] PCI risk
patients angle events

Kirmani et al., 50 UK cardiac

Preoperative TEG-MA Platelet function TEG-MA is predictive of platelet function
2017 [101] patients

Identification of
110 Chinese
Cheng et al., Intraoperative high-on treatment TEG parameters were effective for predicting
vascular TEG R-time, TEG-MA
2020 [102] PCI platelet reactivity HTPR complications
patients
(HTPR)

TEG-MA, TEG R-time,

Terada et al., 50 Japanese TEG parameters were not predictive of blood
Intraoperative TEG-K, TEG alpha- Blood loss
2019 [103] cardiac patients loss volume
angle

TEG-MA, TEG R-time,

Carroll et al., 19 US cardiac Postoperative TEG parameters were not related to
Intraoperative TEG-K, TEG alpha-
2006 [104] patients bleeding postoperative bleeding
angle

Postoperative TEG-MA, TEG R-time, Postoperative TEG-MA is associated with platelet count, but
Pekelharing et 107 UK pediatric
cardiopulmonary TEG-K, TEG alpha- bleeding, platelet TEG parameters are not predictive of
al., 2013 [105] cardiac patients
bypass angle count postoperative bleeding

40 Singaporean TEG-MA, TEG R-time, Anticoagulation TEG parameters were not predictive of
Ti et al., 2002 Preoperative
vascular TEG-K, TEG alpha- reversal monitoring, postoperative bleeding but were useful for
[106] CABG
patients angle bleeding monitoring anticoagulation reversal

Intraoperative TEG-MA, TEG R-time, Postoperative TEG parameters did not predict postoperative
Welsh et al., 76 US cardiac
cardiopulmonary TEG-K, TEG alpha- bleeding, cause of blood loss, and did not distinguish causes of
2014 [107] patients
bypass angle bleeding bleeding

Post-bypass
Coronary artery
platelet function; TEG-PM post-operative was not related to
Agarwal et al., 54 UK cardiac bypass surgery, TEG-PM post-
blood loss at 4 any outcomes; authors recommend using
2006 [108] patients preoperative and operative
hours; blood loss at pre-operative measures to predict outcomes
postoperative
12 hours

TEG-MA, TEG R-time,

Dorman et al., 60 US vascular
Intraoperative TEG-K, TEG alpha- Blood loss TEG parameters did not predict blood loss
1993 [109] patients
angle

Sharma et al., 439 US cardiac TEG-MA, TEG alpha- TEG parameters did not improve prediction of
Intraoperative Bleeding volume
2014 [110] patients angle bleeding volume

Weitzel et al., 40 US cardiac Postoperative blood TEG parameters predicted postoperative

Intraoperative TEG-PM
2012 [111] patients loss blood loss volume

2023 Ramanujam et al. Cureus 15(5): e39407. DOI 10.7759/cureus.39407 13 of 32

 Miao et al., 2014 100 Chinese rTEG-MAf, rTEG- Blood loss, rTEG parameters were related to
Intraoperative
[112] pediatric cardiac FLEV transfusion volume postoperative blood loss volume
patients
19 German TEG-MA, TEG R-time, TEG parameters predicted coagulopathy and
Koster et al.,
cardiopulmonary Intraoperative TEG-K, TEG alpha- Coagulopathy were useful in guiding intraoperative
2001 [113]
bypass patients angle treatment

TEG-MA, TEG R-time,

Miller et al., 85 US pediatric
Intraoperative TEG-K, TEG alpha- Coagulopathy TEG parameters predicted coagulopathy
2000 [114] cardiac patients
angle

TEG-MA, TEG R-time,

Spiess et al., 38 US cardiac Preoperative,
TEG-K, TEG alpha- Coagulopathy TEG parameters predicted coagulopathy
1987 [115] patients intraoperative
angle

TEG-MA, TEG R-time,

Vlot et al., 2021 89 Dutch TEG parameters were associated with
Intraoperative TEG-K, TEG alpha- Coagulopathy
[116] cardiac patients coagulopathy
angle

Yamamoto et 40 Japanese
Intraoperative TEG-MA Coagulopathy TEG-MA was predictive of coagulopathy
al., 2021 [117] cardiac patients

Yan et al., 2021 521 Chinese TEG-MA values predicted hypercoagulable

Intraoperative TEG-MA Hypercoagulability
[118] cardiac patients states

TEG-MA, TEG R-time,

Zisman et al., 62 Israeli TEG parameters predicted postoperative
Intraoperative TEG-K, TEG alpha- Coagulopathy
2009 [119] cardiac patients coagulopathy
angle

240 Chinese TEG-MA, TEG R-time, Coagulopathy,

Liang et al., TEG parameters were predictive of
ischemic stroke Preoperative TEG-K, TEG alpha- intracranial
2020 [120] coagulopathy and intracranial hemorrhage
patients angle hemorrhage

TEG-MA, TEG R-time,

Tuman et al., 80 US vascular Thrombotic events,
Intraoperative TEG-K, TEG alpha- TEG parameters predicted thrombotic events
1991 [121] patients coagulopathy
angle

Intraoperative,
TEG-MA, TEG R-time, Differences in the rate of change in TEG
Xia et al., 2020 90 US cardiac postoperative
TEG-K, TEG alpha- Pump thrombosis parameters over time in the postoperative
[122] patients LVAD
angle period predicted risk of pump thrombosis
placement

TEG parameters detected P2Y12 inhibition

TEG-MA, TEG R-time,
Rogers et al., 453 US vascular Intraoperative Detection of P2Y12 nonresponse, allowing earlier intervention for
TEG-K, TEG alpha-
2021 [123] patients CABG inhibition patients receiving preoperative inhibition
angle
therapy

TEG parameters provided more accurate

TEG-MA, TEG R-time, Bleeding, platelet
Mack et al., 25 US vascular Preoperative, indication of bleeding and clotting
TEG-K, TEG alpha- count, clotting
2021 [124] patients intraoperative complications compared with conventional
angle complications
indicators

Heparinase modification can be combined

TEG-MA, TEG R-time,
Tuman et al., 51 US cardiac Anticoagulation with TEG parameters to enable monitoring of
Intraoperative TEG-K, TEG alpha-
1994 [125] patients monitoring coagulation status in the presence of
angle
anticoagulants

100 US pediatric TEG-MA, TEG R-time,

Yabrodi et al., Heparinase modification may allow TEG
cardiac ECMO Intraoperative TEG-K, TEG alpha- Coagulopathy
2022 [126] parameters to diagnose covert coagulopathy
patients angle

Intraoperative
TEG-MA, TEG R-time, TEG parameters did not reliably correspond
Brothers et al., 10 US cardiac abdominal aortic
TEG-K, TEG alpha- Coagulopathy to clinical coagulopathy. Authors suggest the
1993 [127] patients aneurysm
angle clinical value of TEG is not supported
surgery

TEG-MA predicts postoperative

Bhardwaj et al., 35 Indian Intraoperative TEG-MA, ROTEM- Coagulopathy,
thrombocytopenia, ROTEM-FIBTEM predicts
2017 [128] cardiac patients cardiac bypass FIBTEM chest drain output
postoperative hyperfibrinogenemia

4 German TEG-MA, TEG R-time, TEG-MA is a strong predictor of platelet

2023 Ramanujam et al. Cureus 15(5): e39407. DOI 10.7759/cureus.39407 14 of 32

 Bhatia et al., pediatric cardiac Postoperative TEG-K, TEG alpha- Platelet count count. Authors recommend using r-TEG in
2017 [129] patients VAD placement angle preference to traditional laboratory measures

Gautam et al., 105 US pediatric

Intraoperative FFTEG Platelet count FFTEG values are predictive of platelet count
2017 [130] cardiac patients

Intraoperative
233 Danish percutaneous
Dridi et al., 2014
vascular coronary TEG-MA Adverse events TEG-MA did not predict adverse events
[131]
patients intervention
(PCI)

80 Chinese
Miao et al., 2015 rTEG-MAf, rTEG- rTEG parameters were predictive of
pediatric cardiac Intraoperative Coagulopathy
[132] FLEV coagulopathy
patients

65 Czech
Vanek et al., TEG-LY60, TEG- TEG parameters were associated with
vascular Postoperative Coagulopathy
2007 [133] LY150 coagulopathy
patients

15 German TEG-MA, TEG R-time, TEG parameters are effective for

Koster et al., Bivalirudin
cardiopulmonary Intraoperative TEG-K, TEG alpha- intraoperative monitoring of anticoagulation
2008 [134] anticoagulation
bypass patients angle therapy

TEG-MA, TEG R-time, TEG parameters are more useful for

Martin et al., 15 UK vascular Preoperative, Anticoagulation
TEG-K, TEG alpha- intraoperative anticoagulation monitoring than
1994 [135] patients intraoperative monitoring
angle conventional tests

TEG-MA, TEG R-time, TEG parameters were more effective than

Wasowicz et al., 38 Canadian Anticoagulation
Intraoperative TEG-K, TEG alpha- conventional laboratory measures at
2009 [136] cardiac patients monitoring
angle monitoring intraoperative anticoagulation

TEG-MA, TEG R-time,

Murray et al., 36 US vascular Anticoagulation TEG was effective at assessing postoperative
Intraoperative TEG-K, TEG alpha-
1997 [137] patients detection anticoagulation status
angle

Intraoperative Heparin
Chavez et al., 31 US cardiac TEG parameters were effective for monitoring
cardiopulmonary TEG TF/K anticoagulation
2004 [138] patients heparin efficacy intraoperatively
bypass efficacy

31 US
McTaggart et intracranial TEG-guided Platelet function, TEG-guided intraoperative anticoagulant
Intraoperative
al., 2015 [139] aneurysm anticoagulant therapy complications therapy was effective
patients

Use of TEG-guided
82 South African TEG-guided anticoagulation methods did not
Levin et al., anticoagulation Protamine dosage,
coronary bypass Intraoperative differ from traditional methods in terms of
2014 [140] compared with heparin reversal
patients protamine usage or heparin reversal efficacy
conventional methods

TEG and ROTEM parameters were

Ortmann et al., 52 UK cardiac TEG-MA, ROTEM- Anticoagulation
Intraoperative comparable in terms of guiding
2015 [141] patients EXTEM reversal detection
anticoagulation reversal

TABLE 7: Studies of perioperative TEG in cardiovascular perioperative settings

CABG: coronary artery bypass graft; TEG: thromboelastography; VAD: ventricular assist device; TEG-PM: TEG with platelet mapping; TEG-MA: TEG
with maximum amplitude; ROTEM: rotational thromboelastometry; FFP: fresh frozen plasma

Transplant
Perioperative TEG is used in organ transplantation surgeries such as liver, kidney, pancreas-kidney, or bowel
because of their abilities in the prediction of coagulopathy and thrombotic events. While Abuelkasem et al.
found that TEG-R could not predict coagulopathy in liver transplant surgeries as effectively as ROTEM [142],
other studies have demonstrated that TEG parameters like TEG-MA, TEG R-Time, TEG-K, and TEG α-angle
could predict or be related to coagulopathy [143-149]. Despite the relation of TEG parameters to
coagulopathy, they were not related to bleeding time [144] which was supported by Sujka et al. who
compared TEG-directed transfusion protocol and the clinician-directed transfusion system and found no

2023 Ramanujam et al. Cureus 15(5): e39407. DOI 10.7759/cureus.39407 15 of 32

 difference between both methods in decreasing the blood loss amount [150].

Also, TEG parameters predicted hypercoagulable status and thrombotic events [149, 151-153] even in
comparison to the conditional laboratory tests [154] while Krzanicki et al. found that they could predict
hypercoagulable status only without thrombotic events in liver transplant patients [155]. On the other hand,
Sujka et al. found that TEG-directed blood transfusion increased the thromboembolic events compared to
the clinician-directed protocol in liver transplant patients [150].

Regarding the use of blood products, the studies revealed different results. TEG parameters reduced the
usage of blood products [156-158]; however, in comparison to other conventional tests or clinician-directed
transfusion system, no differences were observed except for Sujka et al. who found TEG-directed transfusion
system reduced only FFP use between other blood products [150, 159, 160]. Coakley et al. investigated both
TEG and ROTEM parameters and found that ROTEM improved clinicians’ decisions compared to TEG usage
[161].

In postoperative outcomes like survival, graft function, and hospital stay, controversial results were
observed in the studies. Sam et al. found that TEG did not relate to renal graft function while Walker et al.
found that it is an indicator of graft function [146, 162]. This controversy was seen also in the prediction of
liver cirrhosis [148, 163]. TEG’s usage was not associated with mortality or survival rates [156, 160]. On the
other hand, it decreased hospital stay length and reoperation needs [147, 160] (Table 8).

Operative TEG Procedures Clinical

Citation Patient Sample Summary of Findings
Setting Assessed Outcomes

TEG R-time;
Abuelkasem Intraoperative INTEM-CT and EXTEM-CT were effective
36 US liver transplant ROTEM CT
et al., 2016 liver Coagulopathy predictors of coagulopathy, but TEG-R was
patients (INTEM-CT and
[142] transplant not
EXTEM-CT)

85 US diabetic simultaneous Intraoperative

pancreas-kidney (SPK) during SPK TEG-MA, TEG R- TEG parameters were useful for guiding
Burke et al.,
transplant patients and 54 or kidney time, TEG-K, TEG Coagulopathy transplant surgery and were validated in SPK
2004 [143]
non-diabetic kidney transplant alpha-angle for diabetic patients
transplant patients surgery

Davis &
120 US kidney transplant Intraoperative TEG-K, TEG Bleeding time, TEG parameters were related to
Chandler,
patients renal biopsy alpha-angle coagulopathy coagulopathy but not to bleeding time
1995 [144]

Kettner et TEG-MA, TEG R-

72 Austrian liver transplant TEG parameters can distinguish between
al., 1998 Intraoperative time, TEG-K, TEG Coagulopathy
patients some causes of bleeding complications
[145] alpha-angle

Sam et al., 25 Indian kidney transplant TEG R-time, TEG- Coagulopathy, TEG parameters were related to
Intraoperative
2021 [146] patients CI, TEG-MA graft function coagulopathy but not graft function

Schulick et TEG-MA, TEG R- Coagulopathy, re- TEG parameters were predictive of

40 US liver transplant
al., 2020 Intraoperative time, TEG-K, TEG operation, length coagulopathy, re-operation, and length of
patients
[147] alpha-angle of stay hospital stay

Tanner et TEG-MA, TEG R- TEG parameters predict coagulopathy but do

33 US liver transplant Coagulopathy,
al., 2018 Intraoperative time, TEG-K, TEG not differentiate between patients with and
patients cirrhosis
[148] alpha-angle without postoperative cirrhosis

Thrombotic
Raveh et TEG-MA, TEG R-
48 US visceral transplant complications, TEG parameters were predictive of
al., 2018 Intraoperative time, TEG-K, TEG
patients hemorrhagic thrombotic and hemorrhagic complications
[149] alpha-angle
complications

Blood loss, blood Introduction of TEG-directed transfusion

TEG-directed
product usage, protocol was associated with decreased FFP
Sujka et al., 38 US pediatric liver transfusion
Intraoperative FFP use, usage, but no overall change in blood product
2018 [150] transplant patients protocol vs.
thromboembolic usage or blood loss. Thromboembolic
clinician discretion
complications complications increased

TEG-MA, TEG R-
Portal vein
De Pietri et Intraoperative time, TEG-K, TEG
27 Italian liver transplant thrombosis (PVT), TEG-G and TEG-LY60 were predictive of PVT
al., 2020 and alpha-angle, TEG-
patients hepatic artery and HAT events
[151] postoperative G, TEG-LY30,

2023 Ramanujam et al. Cureus 15(5): e39407. DOI 10.7759/cureus.39407 16 of 32

 TEG-LY60 thrombosis (HAT)

Eldeen et TEG-MA, TEG R- Early hepatic

828 UK liver transplant
al., 2016 Preoperative time, TEG-K, TEG artery thrombosis TEG parameters predict E-HAT
patients
[152] alpha-angle (E-HAT)

TEG-MA, TEG R-
Pivalizza et
19 Italian bowel transplant time, TEG-K, TEG
al., 1998 Intraoperative Hypocoagulation TEG-MA was related to hypocoagulation
patients alpha-angle, TEG-
[153]
CL50

TEG-MA, TEG R- TEG parameters were better predictors of

Garg et al., Preoperative, Postoperative
50 Indian kidney donors time, TEG-K, TEG postoperative hypercoagulability compared
2021 [154] postoperative hypercoagulability
alpha-angle with traditional lab tests

Krzaniki et TEG-MA, TEG R- Hypercoagulability, TEG parameters were predictive of

124 UK liver transplant
al., 2013 Intraoperative time, TEG-K, TEG thrombotic hypercoagulability but not thrombotic
patients
[155] alpha-angle complications complications

Improved algorithm employing additional TEG

Comparison of two
De Pietri et measures of functional fibrinogen and
386 Italian liver transplant alternate TEG- Blood product
al., 2015 Intraoperative maximum amplitude of functional fibrinogen
patients based transfusion volume, mortality
[156] resulted in reduced blood product usage with
algorithms
no change in mortality

TEG-guided transfusion protocol was

Kang et al., 66 US liver transplant TEG-guided Blood product
Intraoperative associated with reduction in blood product
1985 [157] patients transfusion usage
usage

TEG-guided
Zamper et Intraoperative
237 Brazilian liver transplant transfusion Blood product Introduction of TEG-guided transfusion
al., 2018 liver
patients protocol vs. usage protocol reduced blood product usage volume
[158] transplant
clinician discretion

TEG-guided vs.
conventional After propensity matching, there was no
Gaspari et
226 Italian liver transplant coagulation test Blood product difference between blood product usage
al., 2021 Intraoperative
patients (CCT)-guided usage between TEG and CCT-guided transfusion
[159]
transfusion techniques
strategies

TEG-directed vs. Blood product The TEG-directed anticoagulation protocol

Gopal et al., 68 UK pancreas-kidney conventional usage, hospital resulted in reduced blood product usage and
Intraoperative
2020 [160] transplant patients anticoagulation length of stay, 1 shorter length of stay, with no difference in
protocol year survival survival

Kaolin TEG, kaolin

Coakley et TEG and ROTEM parameters differed on
20 UK liver transplant heparinase TEG, Time to administer
al., 2006 Intraoperative transfusion guidance, with ROTEM judged to
patients ROTEM-NITEM, blood transfusion
[161] have made better clinical decisions
ROTEM-FIBTEM

Walker et
71 US kidney transplant Preoperative, TEG-LY30 was predictive of good graft
al., 2020 TEG-LY30 Graft function
patients postoperative function
[162]

TEG-MA, TEG R-
Kohli et al., 164 US liver transplant
Preoperative time, TEG-K, TEG Cirrhosis severity TEG parameters identified cirrhosis severity
2019 [163] patients
alpha-angle

TABLE 8: Studies of TEG in transplant perioperative settings

TEG: thromboelastography; TEG-PM: TEG with platelet mapping; TEG-MA: TEG with maximum amplitude; ROTEM: rotational thromboelastometry; TEG-
CI: TEG with coagulation index; FFP: fresh frozen plasma

Miscellaneous
TEG is used in many other sites involving neurological, gastrointestinal, general, cardiopulmonary, plastic,
urological, and oncological procedures.

2023 Ramanujam et al. Cureus 15(5): e39407. DOI 10.7759/cureus.39407 17 of 32

 Neurological

TEG parameters showed an evitable role in improving hematological outcomes in people who underwent
neurosurgeries whether they were adults [164-168] or children [169]. TEG parameters like TEG-R, TEG-MA,
TEG-K, and TEG α-angle could predict hypercoagulation or thrombotic complications [164, 166, 168, 169];
however, compared to control treatment, no difference was observed [170]. In addition, these parameters
predicted bleeding and hypo-coagulation status whether intraoperative or postoperative [166, 169, 171, 172]
besides using them could decrease bleeding complications risk compared to other conventional labs [170].
TEG-guided transfusion was effective to decrease the transfusion of blood products compared to the
clinician-guided protocol [172]. Also, TEG-guided use of intraoperative antiplatelet therapy succeeded to
prevent major complications [167] while only TEG-R was rare to be associated with postoperative
complications [164].

Only TEG-PM could not predict thrombotic events or even bleeding complications through neurosurgical
procedures [173]; however, it showed good ability in the prediction of platelet inhibition in comparison to
other modalities [165].

Gastrointestinal

TEG parameters showed promising results in gastroenterology surgeries [174]. Using TEG in bariatric
surgeries could predict hypercoagulability conditions [175-177] and this ability especially increased in
females and older patients [175]. However, in liver-related surgeries, TEG efficacy was controversial as Oo
2020 et al. and Vieira da Rocha 2009 et al. showed that the essential TEG parameters were not predictive of
ulcerative bleeding risk or hemostasis variation [178, 179]. On the other hand, Okida 1991 et al. and Zanetto
2021 et al. showed the efficacy of these parameters in the prediction of coagulopathy and perioperative
bleeding [180, 181]. Moreover, compared to clinician-guided transfusion, TEG-guided transfusion decreased
the usage of blood products; however, it was not different to reduce the complications rate [182]. TEG usage
could not predict postoperative sepsis in oesophagectomy surgeries [183]. In patients with obstructive
jaundice, TEG parameters also could not predict coagulopathy or platelet function during their surgeries for
drainage of obstructive jaundice [184] while they predicted bleeding and coagulopathy in cystectomy
operations [185, 186]. Also, they could predict deep venous thrombosis risk in gastric cancer patients
comorbid with portal hypertension [187].

General

Few studies investigated the role of TEG among pediatric patients undergoing general surgical procedures
and they found that applying TEG or ROTEM in pediatric patients increased coagulopathy risk and blood
products use [188] while in neonates, TEG parameters predicted sepsis early [189]. Also, TEG-guided
transfusion decreased blood products use compared to clinician-guided transfusion while in mortality and
morbidity risks, no differences were detected [190]. The use of TEG among adults undergoing general
surgical procedures was better described in the literature. They were effective in the prediction of bleeding
[191]. Using TEG-PM in monitoring platelet inhibition in patients on clopidogrel was useful in decreasing
unneeded treatment cancellations besides the patient risk [192]. However, comparing the conventional
transfusion protocol to TEG-guided transfusion revealed no significant difference in detecting bleeding
[193]. The conventional TEG parameters with the celite-activated ones were predictive or associated with
hypercoagulability or thrombotic events [194-196]. Coagulopathy prediction was achieved also by TEG-
guided transfusion compared to the use of conventional methods [193]. Also, they showed better prediction
values of survival rates compared to other conventional methods [197]. On the other hand, TEG-guided
transfusion was not different to the conventional protocol in the prediction of mortality [193]. They could
predict the blood products use [191] and using TEG-guided transfusion was effective in reducing the need
for blood products [193]. Moreover, they resembled a good option to guide the optimal treatment, especially
in patients comorbid with Gaucher disease who undergoing general surgeries [198]. In flap operations, the
TEG parameters could not predict the flap loss risks [199]; however, they were predictive of coagulopathy
and thrombotic events [200]. Also, in maxillary surgeries, they could predict both bleeding and platelet
count [201].

Extracorporeal Membrane Oxygenation (ECMO)

Applying TEG in surgical procedures in patients on ECMO was controversial in the literature in both adults
and pediatric patients. In pediatric patients, TEG-guided anticoagulation protocol significantly reduced
blood products usage, decreased complications, and increased ECMO circuit life compared to the clinician-
guided system [202, 203] which was supported by Moynihan 2017 et al. who found that they were useful in
monitoring intraoperative anticoagulation [204]. Moreover, TEG-R significantly predicted thrombotic events
[205]. On the other hand, the bleeding complications predictive value of conventional TEG parameters was
controversial as Saini et al. showed that they could not predict bleeding [206] while Sleeper et al. found that
these parameters predicted bleeding [207]. Also, TEG kaolin and heparinase had a poor indication ability of
aPTT and an acceptable indication of platelet count which recommended the usage of conventional
laboratory tests [208]. Regarding their use in adult patients on ECMO, TEG-R, ROTEM-INTEM, and

2023 Ramanujam et al. Cureus 15(5): e39407. DOI 10.7759/cureus.39407 18 of 32

 conventional methods had the same efficacy in anticoagulation monitoring [209]. Also, the TEG flat line
reading had no relation to the perioperative bleeding [210]. However, other studies showed that the
conventional TEG parameters were effective to monitor anticoagulation [211] and to predict coagulopathy
in adults on ECMO patients [212].

Others

TEG was also used in monitoring hematological outcomes in urological procedures such as prostatectomy
[213, 214] and renal biopsy [215] or even in nephrotic syndrome patients [216]. However, its efficacy was
questionable as in prostatectomy procedures, TEG clot lysis correlated with bleeding [214] while other
parameters like TEG-LY30 and TEG-LY40 were not able to predict postoperative coagulopathy [213]. Also,
during the renal biopsy, TEG-MA was not effective to predict bleeding time [215]. However, TEG parameters
like TEG-MA, TEG-R, TEG-K, and TEG α-angle were associated with coagulopathy complications and could
distinguish different renal pathologies in 713 Chinese nephrotic syndrome patients [216]. TEG parameters
were predictive in oncology patients regarding platelet count, hypercoagulability, tumor type, resection
success, and postoperative complications [217-219]. Also, they were useful in monitoring the
anticoagulation status in patients who underwent thoracic surgeries [220] and patients on mechanical
circulatory support devices [221] (Table 9).

TEG
Clinical
Citation Patient Sample Operative Setting Procedures Summary of Findings
Outcomes
Assessed

TEG was useful for predicting hypercoagulability

46 US
Abrahams et al., Intraoperative Hypercoagulability, throughout procedure; post-operative adverse
neurosurgery TEG R-time
2002 [164] craniotomy DVT, hematoma outcomes were too rare to be statistically
patients
associated with TEG parameters

23 US
Corliss et al., TEG-PM provides a better indicator of platelet
neurosurgery Intraoperative TEG-PM Platelet inhibition
2017 [165] inhibition compared with other methodologies
patients

118 US TEG-MA, TEG

Javed et al., intracranial R-time, TEG-K, TEG parameters were predictive of hemorrhagic
Intraoperative Complications
2021 [166] aneurysm TEG alpha- and ischemic complications
patients angle

TEG-guided
183 Chinese Intraoperative TEG-guided therapy was effective at avoiding
Wu et al., 2019 intraoperative Major
neurosurgery cerebrovascular major complications in the context of
[167] antiplatelet complications
patients stent placement intraoperative antiplatelet therapy
therapy

TEG-MA, TEG
39 UK head and
Parker et al., Preoperative free R-time, TEG-K, Thrombotic TEG parameters are predictive of thrombotic
neck surgery
2012 [168] tissue transfer TEG alpha- complications complications
patients
angle

40 Egyptian TEG-MA, TEG

Preoperative,
El Kady et al., pediatric R-time, TEG-K,
intraoperative, Hypocoagulation TEG parameters predicted hypocoagulation
2009 [169] neurosurgery TEG alpha-
postoperative
patients angle

TEG-guided
Li et al., 2021 188 Chinese Bleeding, TEG-guided treatment resulted in less bleeding
Intraoperative treatment vs.
[170] cranial patients complications and no difference in thrombotic complications
control

TEG-MA, TEG
181 Chinese
Zhang et al., R-time, TEG-K, Intraoperative TEG parameters predicted intraoperative blood
neurosurgery Intraoperative
2017 [171] TEG alpha- blood loss loss
patients
angle

TEG-guided
82 Chinese
transfusion Transfusion TEG-guided transfusion resulted in reduced
Zhou et al., intracerebral
Intraoperative protocol vs. volume, bleeding intraoperative and postoperative bleeding and in
2019 [172] hemorrhage
clinician outcomes lower transfusion volumes
patients
discretion

191 US Hemorrhagic
Corliss et al., complications, TEG-PM parameters are not predictive of

2023 Ramanujam et al. Cureus 15(5): e39407. DOI 10.7759/cureus.39407 19 of 32

 2020 [173] neurosurgery Intraoperative TEG-PM thrombotic hemorrhagic or thrombotic complications
patients complications

TEG-MA, TEG
20 Austrian TEG parameters detect postoperative
Mahla et al., Preoperative, R-time, TEG-K, Postoperative
abdominal hypercoagulability up to a week after surgery that
2001 [174] postoperative TEG alpha- hypercoagulability
surgery patients conventional diagnostics do not detect
angle

Duman Guven TEG-MA is predictive of hypercoagulability in

54 Turkish Preoperative,
et al., 2020 TEG-MA Hypercoagulability morbidly obese patients, and is more predictive
bariatric patients postoperative
[175] among female patients and older patients

TEG-MA, TEG
Kupcinskiene et 60 Lithuanian Preoperative, R-time, TEG-K, TEG parameters were useful for perioperative
Hypercoagulability
al., 2017 [176] bariatric patients postoperative TEG alpha- monitoring of coagulability
angle

TEG-MA, TEG
Preoperative TEG parameters predict
Cowling et al., 422 US bariatric R-time, TEG-K,
Preoperative Coagulopathy postoperative coagulopathy in morbidly obese
2021 [177] surgery patients TEG alpha-
patients
angle

TEG-MA, TEG
41 Australian
Oo et al., 2020 R-time, TEG-K, TEG parameters did not accurately indicate
liver surgery Intraoperative Hemostasis
[178] TEG alpha- variations from hemostasis
patients
angle

TEG-MA, TEG
Intraoperative
de Rocha et al., 150 Brazilian R-time, TEG-K, Ulcerative TEG parameters were unrelated to risk of
variceal band
2009 [179] hepatic patients TEG alpha- bleeding ulcerative bleeding
ligation
angle

TEG-MA, TEG
16 Japanese
Okida et al., Preoperative, R-time, TEG-K,
liver surgery Coagulopathy TEG parameters predict coagulopathy
1991 [180] intraoperative TEG alpha-
patients
angle

TEG-MA, TEG
Zanetto et al., 80 US cirrhosis R-time, TEG-K, Perioperative
Intraoperative TEG parameters predicted perioperative bleeding
2021 [181] patients TEG alpha- bleeding
angle

TEG-guided
transfusion Blood product The TEG-guided transfusion protocol resulted in
Vuyyuru et al., 58 Indian liver
Intraoperative protocol vs. usage, lower blood product usage volume with no
2020 [182] disease patients
clinician complications difference in complications
discretion (RCT)

TEG-MA, TEG
43 Czech
Durila et al., Preoperative, R-time, TEG-K, Postoperative
oesophagectomy TEG parameters did not predict sepsis
2012 [183] postoperative TEG alpha- sepsis
patients
angle

Intraoperative
TEG-MA, TEG
23 obstructive during surgery for
Cakir et al., R-time, TEG-K, Coagulopathy,
jaundice Turkish drainage of No effects detected
2009 [184] TEG alpha- platelet function
patients obstructive
angle
jaundice

TEG-MA, TEG
40 Danish Hemorrhage,
Rasmussen et R-time, TEG-K, TEG parameters were predictive of blood loss and
cystectomy Intraoperative coagulation
al., 2015 [185] TEG alpha- coagulopathy
patients competence
angle

39 Danish
Rasmussen et
cystectomy Intraoperative TEG-MA Blood loss TEG-MA was related to blood loss volume
al., 2016 [186]
patients

172 Chinese
TEG-MA, TEG
gastric cancer
Gong et al., Preoperative, R-time, TEG-K, Occurrence of
patients with TEG parameters were predictive of DVT risk

2023 Ramanujam et al. Cureus 15(5): e39407. DOI 10.7759/cureus.39407 20 of 32

 2021 [187] portal postoperative TEG alpha- DVT

hypertension angle

TEG or ROTEM
265 US pediatric May vary Patients receiving TEG or ROTEM had more
Burton et al., vs. no use of Coagulopathy,
general surgery (retrospective coagulopathy and used more blood products than
2021 [188] viscoelastic blood product use
patients registry study) other patients
testing

103 South TEG-MA, TEG

Differentiation of
Grant & Hadley, African neonatal R-time, TEG-K, TEG parameters were effective at early
Postoperative patients with and
1997 [189] general surgery TEG alpha- identification of neonatal sepsis
without sepsis
patients angle

TEG-guided
139 Italian transfusion Blood product Introduction of a TEG-guided transfusion protocol
Raffaeli et al.,
neonatal general Intraoperative protocol vs. usage, mortality, decreased blood product usage volume and did
2022 [190]
surgery patients clinician morbidity not impact mortality or morbidity
discretion

TEG-MA, TEG
55 Chinese Postoperative
Zhang et al., R-time, TEG-K, TEG parameters predicted postoperative bleeding
general surgery Intraoperative bleeding, blood
2014 [191] TEG alpha- and blood product usage
patients product usage
angle

182 UK general
Kasivisvanathan surgery patients Stratification of
Detection of
et al., 2014 taking Intraoperative bleeding risk by TEG-PM was effective at minimizing patient risk
platelet inhibition
[192] clopidogrel TEG-PM
therapy

TEG-guided
Coagulopathy, TEG-guided transfusion reduced blood product
74 Chinese transfusion
Shi et al., 2019 blood product usage, and TEG estimated coagulopathy better,
general surgery Intraoperative protocol vs.
[193] usage, blood loss, but there was no difference between groups in
patients conventional
bleeding, mortality bleeding outcomes or mortality
protocol

TEG-MA, TEG
106 Chinese
Mao et al., 2021 R-time, TEG-K, DVT, TEG parameters were associated with DVT status
general surgery Preoperative
[194] TEG alpha- hypercoagulability and hypercoagulability
patients
angle

McCrath et al., 240 US general TEG-MA was predictive of thrombotic

Postoperative TEG-MA Complications
2005 [195] surgery patients complications and myocardial infarction

30 Japanese
Yamakage et Celite-activated TEG parameters are predictive of
general surgery Intraoperative TEGc Coagulopathy
al., 1998 [196] coagulopathy
patients

TEG-MA, TEG
Bhattacharyya 50 critically ill TEG parameters immediately postoperative were
R-time, TEG-K, Survival time,
et al., 2021 Indian general Postoperative better predictors of survival than alternative
TEG alpha- mortality
[197] surgery patients measures
angle

22 Israeli general TEG-MA, TEG

Ioscovich et al., surgery patients R-time, TEG-K, TEG parameters may be useful in guiding
Preoperative Hemostasis
2016 [198] with Gaucher TEG alpha- treatment in this population
disease angle

Preoperative, TEG-MA, TEG

77 Turkish
Ekin et al., 2019 intraoperative, R-time, TEG-K, TEG parameters were not predictive of free flap
reconstructive Free flap loss
[199] postoperative free TEG alpha- loss
surgery patients
flap reconstruction angle

TEG-MA, TEG
100 US Preoperative,
Zavlin et al., R-time, TEG-K, Coagulopathy, TEG parameters predicted coagulopathy and
reconstructive intraoperative,
2019 [200] TEG alpha- thrombosis thrombosis
surgery patients postoperative
angle

TEG-MA, TEG
Madsen et al., 21 Danish R-time, TEG-K, Blood loss, platelet TEG parameters predicted blood loss and platelet
maxillary Intraoperative

2023 Ramanujam et al. Cureus 15(5): e39407. DOI 10.7759/cureus.39407 21 of 32

 2012 [201] patients TEG alpha- count count
angle

Intraoperative TEG-guided
Phillips et al., 46 US neonatal congenital anticoagulation Blood product Introduction of TEG-guided anticoagulation
2020 [202] ECMO patients diaphragmatic vs. clinician usage protocol resulted in reduced blood product usage
hernia surgery discretion

TEG-guided Blood product

Introduction of TEG-guided anticoagulation
anticoagulation usage,
Northrop et al., 366 US pediatric protocol resulted in reduced blood product usage,
Intraoperative protocol vs. hemorrhagic
2015 [203] ECMO patients decreased complications and increased ECMO
clinician complications,
circuit life
discretion ECMO circuit life

TEG-MA, TEG
31 Australian
Moynihan et al., R-time, TEG-K, Anticoagulation TEG parameters are useful for intraoperative
pediatric ECMO Intraoperative
2017 [204] TEG alpha- monitoring anticoagulation monitoring
patients
angle

Hypocoagulation,
Henderson et 49 US pediatric TEG R-time was a predictor of thrombotic
Intraoperative TEG R-time thrombotic
al., 2018 [205] ECMO patients complication
complications

TEG-MA, TEG
Saini et al., 46 US pediatric R-time, TEG-K, Bleeding TEG parameters did not predict bleeding
Intraoperative
2016 [206] ECMO patients TEG alpha- complications complications
angle

TEG-MA, TEG
Sleeper et al., 40 US pediatric R-time, TEG-K,
Intraoperative Bleeding events TEG parameters are predictive of bleeding events
2021 [207] ECMO patients TEG alpha-
angle

TEG was a poor indicator of aPTT and an

27 Australian
Alexander et al., TEG kaolin and aPTT, platelet acceptable indicator of platelet count. Authors
pediatric ECLS Intraoperative
2010 [208] heperinase count recommend using conventional laboratory tests in
patients
this population

TEG R-time, ROTEM-INTEM, and conventional

Giani et al., 25 Italian ECMO TEG R-time, Anticoagulation
Intraoperative diagnostics had similar utility for monitoring
2021 [209] patients ROTEM-INTEM monitoring
anticoagulation status in ECMO

Panigada et al., 32 Italian ECMO TEG “flat line” Perioperative TEG “flat line” was not related to bleeding
Intraoperative
2016 [210] patients reading bleeding outcomes

Ranucci et al., 31 Italian ECMO TEG-MA, TEG Anticoagulation TEG parameters are effective for intraoperative
Intraoperative
2016 [211] patients R-time monitoring anticoagulation monitoring

TEG-MA, TEG
Stammers et al., 17 US ECMO R-time, TEG-K,
Intraoperative Coagulopathy TEG parameters predicted coagulopathy
1995 [212] patients TEG alpha-
angle

49 Italian
Ziegler et al., Intraoperative, TEG-LY30, TEG parameters did not predict postoperative
prostatectomy Coagulopathy
2008 [213] postoperative TEG-LY40 coagulopathy
patients

Intraoperative and
postoperative Postoperative
Bell et al., 1996 30 UK urology
transurethral TEG clot lysis coagulation, blood TEG clot lysis correlates with blood loss
[214] patients
prostatectomy loss
(TURP)

Gal-Oz et al., 417 Israeli renal

Intraoperative TEG-MA Bleeding time TEG-MA did not predict bleeding time
2020 [215] biopsy patients

TEG-MA, TEG
TEG parameters were associated with
Lu et al., 2020 713 Chinese R-time, TEG-K, Coagulopathy,
Intraoperative coagulopathy and VTE and distinguished between
[216] renal patients TEG alpha- VTE
patients with different renal diagnoses
angle

2023 Ramanujam et al. Cureus 15(5): e39407. DOI 10.7759/cureus.39407 22 of 32

 24 Maltese Preoperative and TEG-MA, TEG
Gatt et al., 2014 Platelet count,
oncology postoperative R-time, TEG-K, TEG parameters were predictive of platelet count
[217] coagulation
patients transfusion TEG alpha-
angle
TEG-MA, TEG
Coagulopathy, TEG parameters were associated with
Moore et al., 100 US oncology R-time, TEG
Preoperative tumor type, hypercoagulability, tumor type, and resection
2018 [218] patients alpha-angle,
resection success success
TEG-LY30

Intraoperative TEG-MA, TEG

80 Chinese
Wang et al., prostate R-time, TEG-K, Postoperative TEG parameters were predictive of postoperative
oncology
2018 [219] malignancy TEG alpha- bleeding bleeding
patients
resection angle

TEG-guided
43 Chinese
Lin et al., 2020 Preoperative, monitoring of TEG procedures were useful for monitoring
thoracic surgery Coagulopathy
[220] intraoperative intraoperative anticoagulation status during surgery
patients
anticoagulation

98 US
TEG-MA, TEG
mechanical
Volod et al., R-time, TEG-K, Anticoagulation TEG parameters are useful for monitoring
circulatory Intraoperative
2017 [221] TEG alpha- monitoring anticoagulation status
support device
angle
patients

TABLE 9: Studies of TEG in miscellaneous perioperative settings

TEG: thromboelastography; TEG-PM: TEG with platelet mapping; TEG-MA: TEG with maximum amplitude; ROTEM: rotational thromboelastometry;
aPTT: activated partial thromboplastin time

Strengths and limitations

To our knowledge, this is one of the reviews that addressed the application of TEG usage in monitoring the
hematological outcomes in the perioperative periods including nearly all surgical procedures. Therefore, this
review opens the doors for clinicians to reach out to recent evidence about TEG applications on patients
having any surgery or procedure to enhance transfusion and coagulation-related management. In addition,
we searched many databases and screened the relevant records in detail to include all relevant studies,
which provide the recent updates in TEG applications in multiple surgeries.

The limitation is that this is only a literature review that summarizes existing research on TEG. It does not
include other viscoelastic tests such as ROTEM. Most of the studies lacked comparison groups. While
comparing with standardized laboratory tests, a controversy was observed between the related studies in the
literature. In addition, lacking direct statistical analysis including all related studies made it difficult to solve
the controversy about the efficacy of TEG usage in some surgeries.

Summary
TEG showed promising results in detecting and improving hematological outcomes in patients who
underwent major surgeries and procedures or who were critically ill; however, more comparative studies are
needed to establish this efficacy. These promising results were observed in trauma surgeries regarding
predicting mortality, hypercoagulability, and bleeding even when it was compared to conventional methods;
however, its role to guide blood product transfusion was questionable.

TEG was useful in monitoring anticoagulant therapy in orthopedics operations; however, its roles in
predicting thrombotic events, hypercoagulability, or complications were questionable among the studies.
The same controversy was observed in obstetric operations; however, it showed promising results in ICU
patients, especially in the prediction or improvement of sepsis, coagulopathy, thrombotic events, ICU
duration, hospital stay, and ventilator duration.

In transplant surgeries, they effectively predicted hypercoagulation; however, their roles in predicting
bleeding, blood product needs, and thrombotic events were still questionable. Regarding cardiovascular
surgeries, they were effective in the prediction of the need for blood products, coagulopathy, and thrombotic
events and they were effective in monitoring anticoagulation therapy.

TEG parameters were useful in predicting coagulation and bleeding, preventing complications, and
decreasing blood product transfusion in neurological surgeries; however, compared to the conventional

2023 Ramanujam et al. Cureus 15(5): e39407. DOI 10.7759/cureus.39407 23 of 32

 tools, they were better in all these outcomes except for hypercoagulation, which had the same results. In
abdominal surgeries, TEG was effective in bariatric, cystectomy, and gastric cancer surgeries; however, their
results were controversial in hepatic, esophagectomy, and obstructive jaundice surgeries. The efficacy of
TEG usage was also controversial in patients on ECMO whether they were adults or pediatrics. However, in
general surgeries, a controversy was observed in pediatric patients while a promising efficacy was observed
in adults regarding predicting hypercoagulation, thrombotic events, and blood product transfusion.

Conclusions
Based on the evidence reviewed here we conclude that TEG can be used in a wide range of perioperative
settings to guide transfusion and coagulation management and thereby influence certain outcomes. Because
of some limitations addressed in this review, we recommend performing more randomized clinical trials
comparing TEG parameters with standardized tools and performing meta-analyses to pool all related
studies’ data to solve the controversy between studies. More clinical trials also are needed to investigate the
usage of TEG in critically ill patients, especially in cardiothoracic, obstetric and oncology surgeries as well as
patients on ECMO; geriatric and pediatric patients, and patients with renal disease.

Additional Information
Disclosures
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared that they have
no financial relationships at present or within the previous three years with any organizations that might
have an interest in the submitted work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.

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