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Basic Clinician Training Module 5 Hypercoagulable states.

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Presentation on theme: "Basic Clinician Training Module 5 Hypercoagulable states."— Presentation transcript:

1 Basic Clinician Training Module 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 Percentage of Patients with a Thrombotic Complication By Quartiles of MA Value McGrath DJ et al. Anesth Analg 96: SCA1-141, 2003 MA range % with Thrombotic complication

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

7 Hypercoagulable states Platelet 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.

8 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

9 Platelet hypercoagulability Common conditions Antithrombin III deficiency Thrombomodulin-Protein C dysfunction or APC resistance Diminished nitric oxide synthesis/release Dysplasminogenemia High plasminogen activator inhibitor Hyperhomocysteinemia Malignancy DIC

10 Platelet hypercoagulability As shown by TEG Patient status: high risk for thrombotic event Probable cause: Rapid clot formation and strong clot development Common treatment: Platelet inhibitor

11 Platelet hypercoagulability Treatment 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

12 Platelet hypercoagulability Common therapy algorithm

13 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

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

15 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 Enzymatic hypercoagulability Special considerations

16 Heart assist device Lupus anticoagulant Cancer Orthopedic surgery Pregnancy Trauma Burns Sepsis Platelet & enzymatic hypercoagulability Common conditions

17 Platelet & enzymatic hypercoagulability As 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

18 Interpretation Exercises Prothrombotic states

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

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

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

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

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

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

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

26 Exercise 2 Using the TEG Decision Tree, what is your interpretation of this tracing? (select all that apply) a.Platelet hypercoagulability b.Enzymatic hypercoagulability c.Platelet and enzymatic hypercoagulability d.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

27 Exercise 3: Off-pump CABG patient The above are tracings from a patient who has undergone an off-pump CABG. What is this patient’s current hemostatic state (black tracing)? a.Platelet hypercoagulability b.Enzymatic hypercoagulability c.Platelet and enzymatic hypercoagulability d.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. Green: Pre-op Black: Before protamine Kaolin with heparinase Back Next

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

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

30 Exercise 6 Back Next Using the TEG Decision Tree, what is your interpretation of this tracing? (select all that apply) a.Platelet hypercoagulability b.Enzymatic hypercoagulability c.Platelet and enzymatic hypercoagulability d.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.

31 End of Module 5


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