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Basic Clinician Training Module 6. Fibrinolysis and Hyperfibrinolysis TEG Analysis. Introduction. Fibrinolysis is an essential component of hemostasis . Associated with wound healing Protective mechanism to clear thrombi from the microvasculature

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basic clinician training module 6

Basic Clinician TrainingModule 6

Fibrinolysis and Hyperfibrinolysis

TEG Analysis

introduction
Introduction
  • Fibrinolysis is an essential component of hemostasis.
    • Associated with wound healing
    • Protective mechanism to clear thrombi from the microvasculature
  • Excessive activation of the fibrinolytic pathway (hyperfibrinolysis) can cause bleeding by several mechanisms, depending on the cause and magnitude:
    • Breakdown of formed fibrin clot
    • Degradation of coagulation factors (i.e. DIC)
    • Impair clot formation due to excess generation of fibrin degradation products
      • Interfere with fibrin cross-linking
      • Inhibit platelet function
primary vs secondary hyperfibrinolysis treatment monitoring
Primary vs. Secondary HyperfibrinolysisTreatment & monitoring
  • Identification of type of hyperfibrinolysis is crucial since therapies are different
    • The wrong therapy can be fatal
  • TEG analysis is able to distinguish between primary and secondary fibrinolysis.
primary hyperfibrinolysis as shown by teg analysis
Primary hyperfibrinolysisAs shown by TEG analysis

Common treatment:

Antifibrinolytic agent

disseminated intravascular coagulation dic
Disseminated intravascular coagulation (DIC)

Systemic and ongoing

activation of coagulation

Intravascular deposition

of fibrin

Depletion of factors

and platelets

Thrombosis of small

and midsize vessels

Bleeding

Tissue ischemia

and organ failure

Levi, M & TenCate, H. NEJM. 1999;341:1999

dic characteristics
DICCharacteristics
  • DIC is an acquired disorder that occurs in a variety of clinical conditions
    • Bacterial infections/sepsis
    • Systemic infections
    • Liver transplants
    • Vascular disorders
    • Severe trauma
    • Solid tumors and hematological malignancies
    • Obstetrical complications
      • Placental abruptions
      • Amniotic fluid emboli
    • Reaction to toxins (snake venom, amphetamines, drugs)
dic diagnostic characteristics
DICDiagnostic characteristics
  • No single laboratory test can establish or rule out diagnosis
  • Diagnosis requires a clinical presentation plus a combination of test results
    • Clinical presentation - bleeding and/or disease state known to be associated with DIC
    • Laboratory tests:
      • Presence of soluble fibrin monomer complexes
      • Platelet count < 100,000/dL or rapidly decreasing platelet count
      • Increased clotting times (PT, aPTT)
      • Presence of FDPs
      • Low levels of coagulation inhibitors (ATIII)
  • TEG analysis also demonstrates progression of DIC
slide18

Exercise 1

  • Using the TEG Decision Tree what is a likely cause(s) of bleeding in this patient?
  • [Select all that apply]
  • Residual anticoagulant
  • Surgical bleeding
  • Primary fibrinolysis
  • Secondary fibrinolysis
  • What treatment(s) would you consider for this patient?

Answer

Next

slide19

Exercise 2

  • Using the TEG Decision Tree what is a likely cause(s) of bleeding in this patient?
  • [Select all that apply]
  • Residual anticoagulant
  • Surgical bleeding
  • Primary fibrinolysis
  • Secondary fibrinolysis
  • What treatment(s) would you consider for this patient?

Answer

Next

slide20

Exercise 3

  • Using the TEG Decision Tree what is a likely cause(s) of bleeding in this patient?
  • [Select all that apply]
  • Residual anticoagulant
  • Surgical bleeding
  • Primary fibrinolysis
  • Secondary fibrinolysis
  • What treatment(s) would you consider for this patient?

Answer

Next

slide21

Exercise 4

  • The above patient was brought to the OR for CABGx4, on pump. Due to the initial hyper-
  • coagulable state (black tracing), no prophylactic antifibrinolytic was administered. The
  • rewarming TEG (green tracing) demonstrated the development of primary fibrinolysis.
  • What would be a common treatment plan for this patient?
  • Administer antifibrinolytic agent before termination of CPB. Repeat TEG.
  • Administer antifibrinolytic agent after CPB and protamine administration.
  • Repeat TEG.
  • Do not treat. Repeat TEG post-protamine.
  • Administer antifibrinolytic agent during CPB and platelets post-protamine.

Answer

Next

slide22

Exercise 5

  • The above patient was brought to the OR for CABGx4, on pump. While opening the chest,
  • the surgeon commented that the patient was ‘oozy’. What is the mostly likely cause
  • of this condition?
  • Fibrinogen deficiency
  • Platelet deficiency/defect
  • Fibrinolysis
  • Hemodilution
  • Would treatment with an antifibrinolytic agent be contra-indicated? Yes or No.
  • If no, which antifibrinolytic agent would you use?

Answer

Next

slide23

Exercise 6

Kaolin

  • Using the TEG Decision Tree what is a likely cause(s) of bleeding in this patient?
  • [Select all that apply]
  • Residual anticoagulant
  • Surgical bleeding
  • Primary fibrinolysis
  • Secondary fibrinolysis
  • What treatment(s) would you consider for this patient?

Answer

Next

slide24

Exercise 7

Kaolin

  • Using the TEG Decision Tree what is a likely cause of bleeding in this patient?
  • [Select all that apply]
  • Factor deficiency
  • Platelet deficiency/dysfunction
  • Primary fibrinolysis
  • Secondary fibrinolysis
  • What treatment(s) would you consider for this patient?

Answer

Next

slide25

Exercise 8

Kaolin

  • Using the TEG Decision Tree, what is your interpretation of this tracing?
  • (select all that apply)
  • Primary fibrinolysis
  • Secondary fibrinolysis
  • Fibrinolysis
  • Surgical bleeding
  • Platelet adhesion defect

Answer

Next

slide26

Exercise 9

Kaolin

  • Using the TEG Decision Tree, what is your interpretation of this tracing?
  • (select all that apply)
  • Primary fibrinolysis
  • Secondary fibrinolysis
  • Factor deficiency
  • Surgical bleeding
  • Platelet adhesion defect

Answer

Next

slide27

Exercise 10

Exercise

Kaolin

  • Using the TEG Decision Tree, what is your interpretation of this tracing?
  • (select all that apply)
  • Primary fibrinolysis
  • Secondary fibrinolysis
  • Normal
  • Factor deficiency
  • Platelet deficiency/dysfunction
  • If this patient were bleeding, what treatment(s) would you consider using?

Answer

Next

slide28

Exercise 1

  • Using the TEG Decision Tree what is a likely cause(s) of bleeding in this patient?
  • [Select all that apply]
  • Residual anticoagulant
  • Surgical bleeding
  • Primary fibrinolysis
  • Secondary fibrinolysis
  • What treatment(s) would you consider for this patient? Consider treating the
  • underlying disorder plus an anticoagulant to inhibit or reduce thrombin
  • generation.

Back

Next

slide29

Exercise 2

  • Using the TEG Decision Tree what is a likely cause(s) of bleeding in this patient?
  • [Select all that apply]
  • Residual anticoagulant
  • Surgical bleeding
  • Primary fibrinolysis
  • Secondary fibrinolysis
  • What treatment(s) would you consider for this patient? Antifibrinolytic agent

Back

Next

slide30

Exercise 3

  • Using the TEG Decision Tree what is a likely cause(s) of bleeding in this patient?
  • [Select all that apply]
  • Residual anticoagulant
  • Surgical bleeding
  • Primary fibrinolysis
  • Secondary fibrinolysis
  • What treatment(s) would you consider for this patient? Explore surgical area(s) for
  • possible sites of bleeding and repair as needed.

Back

Next

slide31

Exercise 4

  • The above patient was brought to the OR for CABGx4, on pump. Due to the initial hyper-
  • coagulable state (black tracing), no prophylactic antifibrinolytic was administered. The
  • rewarming TEG (green tracing) demonstrated the development of primary fibrinolysis.
  • What would be a common treatment plan for this patient?
  • Administer antifibrinolytic agent before termination of CPB. Repeat TEG.
  • Administer antifibrinolytic agent after CPB and protamine administration.
  • Repeat TEG.
  • Do not treat. Repeat TEG post-protamine.
  • Administer antifibrinolytic agent during CPB and platelets post-protamine.

Back

Next

slide32

Exercise 5

  • The above patient was brought to the OR for CABGx4, on pump. While opening the chest,
  • the surgeon commented that the patient was ‘oozy’. What is the mostly likely cause
  • of this condition?
  • Fibrinogen deficiency
  • Platelet deficiency/defect
  • Fibrinolysis
  • Hemodilution
  • Would treatment with an antifibrinolytic agent be contra-indicated? Yes or No.
  • If no, which antifibrinolytic agent would you use? Consider aprotinin for potential
  • platelet protecting effects.

Back

Next

slide33

Exercise 6

Kaolin

  • Using the TEG Decision Tree what is a likely cause(s) of bleeding in this patient?
  • [Select all that apply]
  • Residual anticoagulant
  • Surgical bleeding
  • Primary fibrinolysis
  • Secondary fibrinolysis
  • What treatment(s) would you consider for this patient? Consider treating first with
  • antifibrinolytic agent. If patient continues to bleed, repeat TEG to determine
  • need for platelets or factors.

Back

Next

slide34

Exercise 7

Kaolin

  • Using the TEG Decision Tree what is a likely cause of bleeding in this patient?
  • [Select all that apply]
  • Factor deficiency
  • Platelet deficiency/dysfunction
  • Primary fibrinolysis
  • Secondary fibrinolysis
  • What treatment(s) would you consider for this patient? Consider treating with
  • platelet transfusion. If patient continues to bleed, repeat the TEG to determine
  • possible contribution of fibrinolysis.

Back

Next

slide35

Exercise 8

Kaolin

  • Using the TEG Decision Tree, what is your interpretation of this tracing?
  • (select all that apply)
  • Primary fibrinolysis (cannot rule out)
  • Secondary fibrinolysis (cannot rule out)
  • Fibrinolysis
  • Surgical bleeding
  • Platelet adhesion defect
  • Although fibrinolysis is present, the CI value is outside the values indicated for
  • the designation as primary or secondary. Knowledge of patient history, drug
  • history, other laboratory tests, and bleeding status would be required to make a
  • definitive diagnosis. A clinical presentation of DIC would suggest secondary
  • fibrinolysis, and treatment with an anticoagulant. If patient continues to bleed,
  • repeat the TEG and consider treatment with an antifibrinolytic agent.

Back

Next

slide36

Exercise 9

Kaolin

  • Using the TEG Decision Tree, what is your interpretation of this tracing from a patient who is
  • bleeding? (select all that apply)
  • Primary fibrinolysis
  • Secondary fibrinolysis (cannot rule out)
  • Factor deficiency (Present, but not primary cause of bleeding. Consider treatment with
  • antifibrinolytic agent first. Monitor patient bleeding status. If patient still bleeding, repeat
  • the TEG to determine extent of factor deficiency in the absence of fibrinolysis.
  • Surgical bleeding
  • Platelet adhesion defect

Back

Next

slide37

Exercise 10

Exercise

Kaolin

  • Using the TEG Decision Tree, what is your interpretation of this tracing?
  • (select all that apply)
  • Primary fibrinolysis (cannot rule out)
  • Secondary fibrinolysis (cannot rule out)
  • Normal
  • Factor deficiency
  • Platelet deficiency/dysfunction
  • If this patient were bleeding, what treatment(s) would you consider using?
  • Although some fibrinolysis is present, it is still within normal range. Consider
  • checking for surgical bleeding or treatment with DDAVP. Also, check patient
  • history of platelet inhibitors or possible presence of DIC. Treat accordingly.

Back

Next