1. Basic Clinician Training Module 6
Fibrinolysis and Hyperfibrinolysis
TEG Analysis

2. 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

7. Primary vs. Secondary Hyperfibrinolysis Treatment & 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.

10. Primary hyperfibrinolysis As shown by TEG analysis
Common treatment:
Antifibrinolytic agent

11. Secondary hyperfibrinolysis As shown by TEG analysis
Common treatment:
Anticoagulant

12. 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

13. DIC Characteristics
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)

14. DIC Diagnostic 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

15. Progression of DIC TEG analysis
Hypercoagulable phase
Secondary to an underlying disorder
- Inflammatory state
- Downregulation of
physiological anti-
coagulant mechanisms
Intravascular deposition of fibrin
Activation of fibrinolysis
Secondary fibrinolysis
Degradation of fibrin and fibrinogen
Generation of FDPs
FDP’s compromise clot formation and integrity
Consumption of factors and platelets
Hypocoagulable
Depletion of factors and platelets
Bleeding

16. Progression of DIC Common treatments
Hypercoagulable phase
Treat underlying disorder
Restore anticoagulation pathways
Anticoagulant therapy
ATIII
APC
Platelet inhibition
Secondary fibrinolysis
Hypocoagulable
Replacement therapy (FFP, platelets, cryoprecipitate)
- Note: may amplify inflammatory response and mediate a hyper- coagulable state, even though patient is bleeding

17. Interpretation exercises
Fibrinolysis

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. Exercise 10 Exercise Answer Next
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

28. 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

29. 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

30. 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

31. 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

32. 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

33. Exercise 6 Back Next 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

34. 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

35. 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

36. 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

37. Exercise 10 Exercise Back Next
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

38. End of Module 6