We present the case of a 65-year-old male with an open ankle injury undergoing vascular repair after receiving 5000 units of heparin four hours prior. Despite transfusion with three units of packed red blood cells (PRBCs), bleeding persisted, and surgical teams hesitated to administer plasma products due to thrombosis risk. TEG revealed residual heparin effect, fibrinogen deficiency, and impaired clot strength. Guided by these findings, a stepwise hemostatic approach involving partial protamine reversal, cryoprecipitate, and platelet support was planned.
This case highlights the role of TEG in differentiating surgical from coagulopathic bleeding, the importance of fibrinogen as an early limiting factor, and strategies for balancing hemostasis with thrombotic risk in vascular surgery.
Bleeding in vascular trauma surgery is a multifactorial problem. The challenge for anesthesiologists lies in differentiating surgical bleeding, which requires correction by the surgeon, from coagulopathic bleeding, which demands targeted hemostatic support. Traditional coagulation tests such as prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) provide static, delayed, and incomplete information.
In contrast, viscoelastic testing (thromboelastography [TEG] and rotational thromboelastometry [ROTEM]) assesses the dynamics of clot initiation, formation, strength, and breakdown at the bedside in real time. These tools have transformed perioperative hemostatic management in trauma, cardiac, and liver transplantation anesthesia [1–3].
A critical consideration in vascular repair is the risk of thrombosis at the repair site. Empiric correction with plasma or cryoprecipitate may reduce bleeding but simultaneously predispose to vessel occlusion. Here, TEG offers precision: guiding therapy based on identified deficits rather than empiric transfusion.
This article presents a case-based discussion integrating basic sciences of coagulation, heparin pharmacology, and TEG principles into perioperative decision-making, with practical lessons for anesthesia residents and practitioners.
A 65-year-old male with no available comorbid history was taken for emergency vascular repair following an open ankle injury.
Preoperative: Received 5000 units of intravenous unfractionated heparin (UFH) four hours earlier.
Intraoperative course: Persistent bleeding despite adequate surgical hemostasis and transfusion of 3 units PRBCs.
Hemodynamics: HR 96 bpm, BP 110/78 mmHg, PPV 17% (suggesting preload responsiveness).
Laboratory: Arterial blood gas (ABG) revealed hemoglobin 7.5 g/dL. Other coagulation parameters were not available due to emergency.
Surgical concern: Plastic surgeons feared graft thrombosis if fresh frozen plasma (FFP) or cryoprecipitate was administered indiscriminately.
The anesthesiology team obtained a citrated TEG 6s with four channels:
CK (Citrated Kaolin): Prolonged R (37.9 min), prolonged K (4.2 min), low angle (48.8°), low MA (47.5 mm).
CKH (Citrated Kaolin with Heparinase): R shortened to 11.9 min, angle 62.7°, MA 52.6 mm.
CRT (Rapid TEG): Normal R (0.7 min), angle 67°, MA 56.9 mm.
CFF (Functional Fibrinogen): A10 16.7 mm, indicating reduced fibrinogen contribution.
LY30: 0%, suggesting no fibrinolysis.
Interpretation: Residual heparin effect + hypofibrinogenemia + dilutional...
