Basic-Clinician-Training-Module.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Basic Clinician TrainingModule 3,Basic bleeding profiles,Introduction to bleeding,Causes of bleeding,Mechanical vascular injury,Pathophysiological imbalance between the anticoagulant/antithrombotic and prothrombotic forces of the hemostatic system,Monitoring hemostasis finding,where the imbalance resides,Monitoring bleeding with the TEG,TEG analysis monitoring hemostatic components,and,their interactions.,Mechanical Normal TEG parameters,Pathophysiological,R:enzymatic pathway abnormality,Angle(a):fibrinogen deficiency,MA:platelet abnormality,LY30:fibrinolysis(See Module 6),EPL 15%,or,LY30 7.5%,Yes,No,R 10min,Yes,MA 55mm,No,Yes,No,Yes,Yes,No,Primary fibrinolysis,C.I.,3.0,i,Yes,Yes,No,No,Decision Tree,Fibrinolysis,Hypercoagulable,C.I.3.0,Low platelet,function,Low clotting,factors,Low fibrinogen,level,a,45,R 73mm,Enzymatic,hypercoagulability,Enzymatic&platelet,hypercoagulability,Secondary fibrinolysis,Hemorrhage,Patient status:bleeding,Probable cause(3):,Vessel injury,vWF,deficiency,Presence of platelet inhibitor,Patient status:bleeding,Probable cause,Common treatment:,Vessel injury,Suture,vWF,deficiency,DDAVP,Presence of platelet inhibitor,Run Platelet Mapping,Enzymatic pathway abnormalities,Characterized by a bleeding patient and a TEG tracing with an abnormally long R value.,Factor deficiency may also cause abnormalities in other TEG parameters(angle,MA),Probable causes:,Coagulation factor(s)deficiency,Coagulation factor dysfunction,Presence of anticoagulant(i.e.residual heparin),Effect:,Slow rate of thrombin generation leading to slow clot development,Insufficient thrombin generation leading to insufficient clot development,Enzymatic pathway abnormality:,Coagulation factor deficiency,Patient condition:bleeding,Probable cause:factor deficiency,Probable cause:Factor deficiency,Patient status:bleeding,Patient status:bleeding,Probable cause(s):,Factor deficiency,Platelet deficiency/dysfunction,Enzymatic pathway abnormality:,Coagulation factor deficiency,Enzymatic pathway abnormality:,Residual heparin,Characterized by a bleeding patient and a TEG tracing with an abnormally long R value(non-heparinase sample),Probable causes:,Residual heparin after protamine administration due to insufficient protamine dose.,Heparin rebound reappearance of heparin in circulation after initial reversal with protamine,Release of endogenous sources of heparin(i.e.reperfusion of transplanted liver),Effect:inhibition of thrombin action resulting in reduced fibrin formation and clot development.,Testing for residual heparin with the TEG analyzer,Run blood sample on two channels simultaneously,K=kaolin activated(clear cup),KH=kaolin with heparinase(blue cup),Results:,If R for K,KH,long R is not due to heparin,If R for K is long and for KH is normal,heparin is present in blood sample,R,for,K,KH,suggests presence of heparin,Testing for residual heparin with the TEG analyzer,Causes of fibrinogen deficiency,Liver disease or congestion,Disseminated intravascular coagulation(DIC)hypocoagulable stage,OB-GYN complications placental abruption,Hemodilution,Excessive consumption,Patient status:bleeding,Probable cause:fibrinogen deficiency,Fibrinogen deficiency,Fibrinogen deficiency,Patient status:Bleeding,Probable cause:,Fibrinogen deficiency,Common treatment:,Cryoprecipitate or FFP,Platelet abnormality,Characterized by a bleeding patient and a TEG tracing with an abnormally low MA value,A low MA value may also be associated with an elongated R and/or a low angle values,Probable causes:,Low platelet number,Low platelet function,Note:The TEG cannot distinguish between a low platelet count and low platelet function,Effect:formation of a clot with low clot strength that is insufficient to stop vascular bleeding.,In certain disease states platelet counts may be reduced,but the remaining platelets may be hyperfunctional and hypersensitive,resulting in normal or high clot strength(normal to high MA).,Example:cancer patients,Platelet abnormality:,A note on low platelet counts,Platelet abnormality,Platelet dysfunction-Mechanisms,Activation,inhibition or dysfunction of platelet receptors,Adhesion,inhibition or dysfunction of GPIb receptor preventing adhesion of platelet to endothelium,Aggregation,inhibition or dysfunction of GPIIb/IIIa receptors preventing the development of a platelet plug,Secretion,inhibition or dysfunction of secretory pathways resulting in reduced platelet activation,Procoagulant activity,reduction of thrombin generation on platelet surface,Platelet abnormality,Low platelet function-causes,Cardiopulmonary bypass,Antiplatelet therapies,Platelet antibodies,Congenital disorders,Liver disease,Uremia,Consumption,Patient status:bleeding,Probable cause(s):,Low platelet count+/or,Low platelet function,Platelet abnormality,Patient status:bleeding,Probable cause(s):,Low platelet count+/or,Low platelet function,Platelet abnormality,Patient status:bleeding,Probable cause(s),Common treatment,Low platelet count,platelet transfusion,Low platelet function,platelet transfusion,Platelet abnormality,Patient status:bleeding,Probable cause(s),Common treatment(s):,Factor deficiency,FFP+/or,Low platelet count,platelet transfusion,Low platelet function,platelet transfusion,Platelet abnormality,The inhibition of platelets by platelet inhibitors may not be revealed by the TEG using a kaolin activated sample.This is due to thrombin generation in the blood sample which results in maximum activation of platelets which overrides other activation pathways.,An important factor to consider in,induced platelet dysfunction,(i.e.,treatment with antiplatelet drugs)is the,monitoring of platelet inhibition,.,PlateletMapping,assays measure the degree of inhibition at the ADP receptor and arachadonic acid pathways as well as provide a reference point against which to interpret the inhibition(See Module 6),Platelet abnormalities,Special considerations,Interpretation Exercises,Hemorrhage,Exercise 1,Black tracing:Kaolin,Green tracing,:Kaolin with heparinase,Using the TEG Decision Tree,what is your interpretation of this TEG tracing?,Select all that apply,Factor deficiency,Platelet deficiency or dysfunction,Low fibrinogen level,Fibrinolysis,Normal,Has heparin been reversed in this patient?,Yes or No.,Answer,Next,Exercise 2,Post-protamine,Using the TEG Decision Tree,what is your interpretation of this TEG tracing?,Select all that apply,Factor deficiency,Platelet deficiency or dysfunction,Low fibrinogen level,Fibrinolysis,Normal,What,treatment(s,)would you consider for this patient?,Patient status:bleeding,Answer,Next,Exercise 3,Patient status:Bleeding,Using the TEG Decision Tree and the available information from the TEG tracing:,Is it likely the patient will require more,protamine,as a treatment for bleeding?Yes or No.,Is it likely the patient will require FFP as a treatment for bleeding?Yes or No.,Answer,Next,Exercise 4,Patient status:Bleeding,Using the TEG Decision Tree what is a likely cause(s)of bleeding in this patient?,Select all that apply,Factor deficiency,Platelet deficiency or dysfunction,Low fibrinogen level,Fibrinolysis,Surgical bleeding,What,treatment(s,)would you consider for this patient?,Answer,Next,Exercise 5,Using the TEG Decision Tree what is your interpretation of this TEG tracing?,Select all that apply,Factor deficiency,Platelet deficiency or dysfunction,Low fibrinogen level,Fibrinolysis,Normal,If this patient was bleeding,what,treatment(s,)would you consider?,Next,Answer,Exercise 6,Using the TEG Decision Tree what is your interpretation of this TEG tracing?,Select all that apply,Factor deficiency,Anticoagulant effect,Platelet deficiency or dysfunction,Low fibrinogen level,Surgical bleeding,What,treatment(s,)would you consider for this patient?,Next,Post-protamine,Patient status:bleeding,Answer,Exercise 7,Black tracing:Kaolin,Green tracing,:Kaolin with heparinase,Patient status:bleeding,Using the TEG Decision Tree what is your interpretation of this TEG tracing?,Select all that apply,Factor deficiency,Anticoagulant effect,Platelet deficiency or dysfunction,Low fibrinogen level,Surgical bleeding,How would you treat this patient?,Answer,Next,Exercise 8,Post-protamine,-The above patient is bleeding after administration of protamine.What are the possible,causes of bleeding(select all that apply)?,-For each selection,identify one treatment consideration.,Surgical bleeding,Factor deficiency,Residual platelet inhibitor effect,Diminished platelet adhesion,Anticoagulant effect,Answer,Next,Exercise 9,The above is the baseline TEG(post-induction)of a female patient(70 yr,54kg)requiring,CABG with CPB.The patient has not been taking aspirin for 7 days(81 mg/d).,Based on this TEG and the patient history,is this patient at risk for bleeding post-CPB?Yes or No.,If so,what will be the most likely cause(s)of bleeding?,Surgical bleeding,Factor deficiency,Platelet deficiency/dysfunction,Fibrinolysis,Anticoagulant effect,Answer,Next,Exercise 10,Green,:Post-protamine,Black:ICU,The above patient has started bleeding approximately 1 hr post-op.What is the most likely,cause(s)of bleeding?,Surgical bleeding,Factor deficiency,Platelet deficiency/dysfunction,Fibrinolysis,Anticoagulant effect,How would you treat this patient?,Answer,END,Exercise 1,Black tracing:Kaolin,Green tracing,:Kaolin with heparinase,Using the TEG Decision Tree what is your interpretation of this TEG tracing?,Factor deficiency,Platelet deficiency or dysfunction,Low fibrinogen level,Fibrinolysis,Normal all parameters are within normal range,Has heparin been reversed in this patient?,Yes,or No.,Since the R values for both,the kaolin and kaolin with,heparinase,samples are the same suggests that the,heparin has been reversed.,Back,Exercise 2,Using the TEG Decision Tree what is your interpretation of this TEG tracing?,Select all that apply,Factor deficiency,Platelet deficiency or dysfunction,Low fibrinogen level,Fibrinolysis,Normal,What,treatment(s,)would you consider for this patient?,After completion of,protamine,administration,consider treating with platelets first.Repeat TEG.If R value is still,elongated and the patient is bleeding,consider treating with FFP.,Patient status:bleeding,Post-protamine,Back,Exercise 3,Patient status:Bleeding,Using the TEG Decision Tree and the available information from the TEG tracing:,Is it likely the patient will require more,protamine,as a treatment for bleeding?Yes or,No,.,This is a tracing from a kaolin activated sample.The presence of heparin in a kaolin sample,would result in an elongated R value.An R within normal range suggests heparin is not present,thus additional,protamine,is not required.,Is it likely the patient will require FFP as a treatment for bleeding?Yes or,No,.,An R value within normal range suggests that factor deficiency is not the cause,of bleeding in this patient.,Back,Exercise 4,Patient status:Bleeding,Using the TEG Decision Tree what is a likely cause(s)of bleeding in this patient?,Select all that apply,Factor deficiency,Platelet deficiency or dysfunction,Low fibrinogen level,Fibrinolysis,Surgical bleeding,A slightly elongated R may suggest factor deficiency,however surgical bleeding cannot,be ruled out.,What,treatment(s,)would you consider for this patient?,The R value is less than the,trigger point for FFP transfusion.If patient is oozing,wait an hour and repeat the,TEG.If R is still elongated and the patient is still oozy,consider treating with FFP.,Back,Exercise 5,Using the TEG Decision Tree what is your interpretation of this TEG tracing?,Select all that apply,Factor deficiency,Platelet deficiency or dysfunction,Low fibrinogen level,Fibrinolysis,Normal,If this patient was bleeding,what,treatment(s,)would you consider?,Cryoprecipitate or FFP,Back,Exercise 6,Using the TEG Decision Tree what is your interpretation of this TEG tracing?,Select all that apply,Factor deficiency,Anticoagulant effect,Platelet deficiency or dysfunction,Low fibrinogen level,Surgical bleeding,What,treatment(s,)would you consider for this patient?,Platelet transfusion,Post-protamine,Patient status:bleeding,Back,Exercise 7,Black tracing:Kaolin,Green tracing,:Kaolin with heparinase,Patient status:bleeding,Using the TEG Decision Tree what is your interpretation of this TEG tracing?,Select all that apply,Factor deficiency(cannot rule out),Anticoagulant effect(incomplete reversal of heparin),Platelet deficiency or dysfunction(cannot rule out),Low fibrinogen level,Surgical bleeding,How would you treat this patient?,A common treatment protocol would likely,include administration of additional,protamine,to reverse the heparin effect.,If the patient continues to bleed,repeat the TEG to determine the probable,cause.Most likely platelet deficiency/dysfunction.,Back,Exercise 8,Post-protamine,-The above patient is bleeding after administration of protamine.What are the possible,causes of bleeding(select all that apply)?,-For each selection,identify one treatment consideration.,Surgical bleeding:,check for bleeding site and repair,Factor deficiency,Residual platelet inhibitor effect:,platelet transfusion,Diminished platelet adhesion:,DDAVP,Anticoagulant effect:,Since this is a KH sample,there is a possibility of,residual heparin.Compare R values for the K and KH samples.If they are,similar,the cause of bleeding is not residual heparin.,Back,Exercise 9,The above is the baseline TEG(post-induction)of a female patient(70 yr,54kg)requiring,CABG with CPB.The patient has not been taking aspirin for 7 days(81 mg/d).,Based on this TEG and the patient history,is this patient at risk for bleeding post-CPB?,Yes,or No.,If so,what will be the most likely cause(s)of bleeding?,Surgical bleeding,Factor deficiency,(cannot be ruled out),Platelet deficiency/dysfunction,(Most likely cause of post-CPB bleeding since the patient is,starting out with a low platelet count/function.Consider using,aprotinin,as,antifibrinolytic,agent.,Rewarming,TEG should demonstrate effect of CPB on platelets and factors).,Fibrinolysis,Anticoagulant effect,Back,Exercise 10,Green,:Post-protamine,Black:ICU,The above patient has started bleeding approximately 1 hr post-op.What is the most likely,cause(s)of bleeding?,Surgical bleeding,Factor deficiency,Platelet deficiency/dysfunction,Fibrinolysis,Anticoagulant effect,(since kaolin sample,a heparin effect is not considered),How would you treat this patient?,Return to OR for re-exploration.,Back,End of Module 3,