Management of High Clotting Rate Time on Thromboelastography

Understanding High CRT on TEG

A high Clotting Rate Time (CRT) on TEG indicates delayed clot initiation, suggesting a deficiency in clotting factors, which can be due to coagulation factor deficiencies or the presence of anticoagulants, according to the World Journal of Emergency Surgery guidelines 3
Normal coagulation requires adequate levels of clotting factors, which may be depleted in trauma, surgery, or critical illness, as stated by Critical Care guidelines 1

The American College of Critical Care recommends administering fibrinogen concentrate (first choice) or cryoprecipitate to restore clotting factor levels, with a target fibrinogen level of at least 1.5-2.0 g/L in bleeding patients 1, 2
Fibrinogen is often the first coagulation factor to reach critically low levels during major bleeding, according to Critical Care guidelines 1

If fibrinogen concentrate or cryoprecipitate is unavailable, the Critical Care guidelines recommend administering FFP, with consideration of a FFP:RBC ratio of at least 1:2 in massive transfusion scenarios 1, 2
Use FFP when PT/aPTT is >1.5 times normal control, as stated by Critical Care guidelines 2
Note that FFP contains only ~70% of normal levels of clotting factors, according to Critical Care guidelines 2

The World Journal of Emergency Surgery guidelines recommend maintaining a platelet count >50,000/mm³ for patients with life-threatening hemorrhage, and considering higher platelet counts for patients requiring neurosurgery or with traumatic brain injury 3, 4, 5
Include platelets in a balanced transfusion approach (RBC:Plasma:Platelets at 1:1:1 ratio) during initial massive transfusion, as stated by Critical Care and World Journal of Emergency Surgery guidelines 1, 4

Continue to monitor TEG parameters to guide ongoing treatment, according to the World Journal of Emergency Surgery guidelines 3
Target a prothrombin time (PT)/activated partial thromboplastin time (aPTT) of <1.5 times normal control, as recommended by the World Journal of Emergency Surgery guidelines 4, 5

In patients with liver disease, TEG may provide more valuable information than standard coagulation tests, according to the Journal of the American College of Cardiology guidelines 6, 7
Patients on anticoagulant medications will require specific management approaches based on the anticoagulant used, as stated by the World Journal of Emergency Surgery and Journal of the American College of Cardiology guidelines 3, 6

Do not rely solely on conventional coagulation tests (PT, aPTT) as they may not correlate well with clinical bleeding or TEG parameters, according to Critical Care guidelines 1
Remember that TEG may be poorly sensitive to fibrinolysis in some cases, so integrate clinical assessment with laboratory findings, as stated by Critical Care guidelines 1
Do not delay treatment while waiting for laboratory results in cases of severe bleeding, according to Critical Care and World Journal of Emergency Surgery guidelines 1, 3