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Basic Clinician Training Module 5

Basic Clinician Training Module 5. Hypercoagulable states. Introduction. A prothrombotic or hypercoagulable state can be the result of: Hyperactive platelet function and/or Hyperactive coagulation cascade function

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Basic Clinician Training Module 5

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  1. Basic Clinician TrainingModule 5 Hypercoagulable states

  2. Introduction • A prothrombotic or hypercoagulable state can be the result of: • Hyperactive platelet function and/or • Hyperactive coagulation cascade function • Proper assessment of the factor(s) contributing to a hypercoagulable state is necessary to determine proper pharmacological intervention to prevent the development of a thrombotic event.

  3. Importance of assessing the hypercoagulable state % with Thrombotic complication MA range Percentage of Patients with a Thrombotic Complication By Quartiles of MA Value McGrath DJ et al. Anesth Analg 96: SCA1-141, 2003

  4. Insert graph from Sinai study

  5. Assessing hypercoagulability with the TEG • TEG analysis can demonstrate hypercoagulable as well as hypocoagulable states • TEG analysis can differentiate between platelet hypercoagulability and enzymatic hypercoagulability.

  6. Hypercoagulable statesPlatelet vs. enzymatic • Hyperactive platelet function is characterized by rapid clot development and abnormally high clot strength. • Hyper enzymatic pathway activity is characterized by rapid fibrin formation with subsequent clot formation.

  7. Platelet hypercoagulability • Characterized by rapid clot development with higher than normal clot strength due to hyperactive platelet function. • Probable causes: • Diminished endogenous platelet inhibitory mechanisms • High platelet numbers • Abnormal generation of platelet activators • Inflammatory mediators

  8. Platelet hypercoagulabilityCommon conditions • Antithrombin III deficiency • Thrombomodulin-Protein C dysfunction or APC resistance • Diminished nitric oxide synthesis/release • Dysplasminogenemia • High plasminogen activator inhibitor • Hyperhomocysteinemia • Malignancy • DIC

  9. Platelet hypercoagulabilityAs shown by TEG Patient status: high risk for thrombotic event Probable cause: Rapid clot formation and strong clot development Common treatment: Platelet inhibitor

  10. Platelet hypercoagulabilityTreatment considerations • Step 1: Identify and quantify prothrombotic state • Step 2: Determine therapeutic response of anti-platelet therapies • WHY?: Patient resistance to aspirin and clopidogrel has been documented in the literature • HOW?: TEG analysis combined with PlateletMapping assay (Module 6). • Assesses platelet inhibition against total platelet function • Provides personalized treatment regimen

  11. Platelet hypercoagulabilityCommon therapy algorithm

  12. Enzymatic hypercoagulability • Characterized by rapid fibrin generation with subsequent clot formation • Probable cause(s): • Loss of antithrombotic protective mechanisms • APC resistance (Factor V Leiden) • ATIII deficiency • Dysfibrinogenemia

  13. Enzymatic hypercoagulabilityAs shown by TEG analysis Patient status: high risk for thrombotic event Probable cause: Rapid thrombin generation and subsequent clot formation Common treatment: Anticoagulation

  14. Enzymatic hypercoagulabilitySpecial considerations • Treatment ultimately depends on clinical situation • Goal is to prevent clot formation • Common inpatient treatment: heparin, LMWH, APC (activate protein C) • Common outpatient treatment: LMWH or Coumadin to maintain INR > 2.0 • If clots have already formed - may require fibrinolytic agent before anticoagulation

  15. Platelet & enzymatic hypercoagulabilityCommon conditions • Heart assist device • Lupus anticoagulant • Cancer • Orthopedic surgery • Pregnancy • Trauma • Burns • Sepsis

  16. Platelet & enzymatic hypercoagulabilityAs shown by TEG analysis Patient status: high risk for thrombotic event • Probable cause(s): • Rapid thrombin generation • Excessive platelet function • Common treatment(s): • Anticoagulation and/or • Platelet inhibitor

  17. Interpretation Exercises Prothrombotic states

  18. Exercise 1 • Using the TEG Decision Tree, what is your interpretation of this tracing? • (select all that apply) • Platelet hypercoagulability • Enzymatic hypercoagulability • Platelet and enzymatic hypercoagulability • Secondary fibrinolysis • What would be an appropriate treatment, if any for this patient? Answer Next

  19. Exercise 2 • Using the TEG Decision Tree, what is your interpretation of this tracing? • (select all that apply) • Platelet hypercoagulability • Enzymatic hypercoagulability • Platelet and enzymatic hypercoagulability • Secondary fibrinolysis • What would be an appropriate treatment, if any for this patient? Answer Next

  20. Exercise 3: Off-pump CABG patient Kaolin with heparinase Green: Pre-op Black: Before protamine • The above are tracings from a patient who has undergone an off-pump • CABG. What is this patient’s current hemostatic state (black tracing)? • Platelet hypercoagulability • Enzymatic hypercoagulability • Platelet and enzymatic hypercoagulability • Secondary fibrinolysis • What would be an appropriate treatment, if any for this patient? Answer Next

  21. Exercise 4 • Using the TEG Decision Tree, what is your interpretation of this tracing? • (select all that apply) • Platelet hypercoagulability • Enzymatic hypercoagulability • Platelet and enzymatic hypercoagulability • Secondary fibrinolysis • What would be an appropriate treatment, if any for this patient? Answer Next

  22. Exercise 5 • Using the TEG Decision Tree, what is your interpretation of this tracing? • (select all that apply) • Platelet hypercoagulability • Enzymatic hypercoagulability • Platelet and enzymatic hypercoagulability • Secondary fibrinolysis • What would be an appropriate treatment, if any, for this patient? Answer Next

  23. Exercise 6 • Using the TEG Decision Tree, what is your interpretation of this tracing? • (select all that apply) • Platelet hypercoagulability • Enzymatic hypercoagulability • Platelet and enzymatic hypercoagulability • Secondary fibrinolysis • If this was a tracing from a pre-bypass cardiac surgical patient, • what type of antifibrinolytic treatment would you consider? Answer Next

  24. Exercise 1 • Using the TEG Decision Tree, what is your interpretation of this tracing? • (select all that apply) • Platelet hypercoagulability • Enzymatic hypercoagulability • Platelet and enzymatic hypercoagulability • Secondary fibrinolysis • What would be an appropriate treatment, if any for this patient? • Consider an anti-platelet agent. Back Next

  25. Exercise 2 • Using the TEG Decision Tree, what is your interpretation of this tracing? • (select all that apply) • Platelet hypercoagulability • Enzymatic hypercoagulability • Platelet and enzymatic hypercoagulability • Secondary fibrinolysis • What would be an appropriate treatment, if any for this patient? • Consider treatment with both an anticoagulant and anti-platelet • agent. Back Next

  26. Exercise 3: Off-pump CABG patient Kaolin with heparinase Green: Pre-op Black: Before protamine • The above are tracings from a patient who has undergone an off-pump • CABG. What is this patient’s current hemostatic state (black tracing)? • Platelet hypercoagulability • Enzymatic hypercoagulability • Platelet and enzymatic hypercoagulability • Secondary fibrinolysis • What would be an appropriate treatment, if any for this patient? • Although the R value is within normal range, the pre-op value was • lower than normal. Consider half the normal protamine dose plus • an anti-platelet agent. Back Next

  27. Exercise 4 • Using the TEG Decision Tree, what is your interpretation of this tracing? • (select all that apply) • Platelet hypercoagulability • Enzymatic hypercoagulability • Platelet and enzymatic hypercoagulability • Secondary fibrinolysis • What would be an appropriate treatment, if any for this patient? • Consider treatment with an anticoagulant. Back Next

  28. Exercise 5 • Using the TEG Decision Tree, what is your interpretation of this tracing? • (select all that apply) • Platelet hypercoagulability • Enzymatic hypercoagulability • Platelet and enzymatic hypercoagulability • Secondary fibrinolysis • What would be an appropriate treatment, if any, for this patient? • Consider an anticoagulant plus an anti-platelet agent. Back Next

  29. Exercise 6 • Using the TEG Decision Tree, what is your interpretation of this tracing? • (select all that apply) • Platelet hypercoagulability • Enzymatic hypercoagulability • Platelet and enzymatic hypercoagulability • Secondary fibrinolysis • If this was a tracing from a pre-bypass cardiac surgical patient, • what type of antifibrinolytic treatment would you consider? Since the patient • is hypercoagulable, treatment with an antifibrinolytic agent may be contra- • indicated at this phase in the surgery. Repeat a TEG during CPB to determine • if fibrinolysis has developed and treat accordingly. Back Next

  30. End of Module 5

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