Interpret this thromboelastography (TEG) study and its implications for the patient’s coagulation status and management.

TEG Study Interpretation: Hypercoagulable State with Hyperfibrinolysis

This TEG demonstrates a hypercoagulable state with significantly elevated clot strength and concerning hyperfibrinolysis, requiring immediate clinical correlation and consideration of antifibrinolytic therapy if active bleeding is present.

Parameter Analysis

Clot Kinetics (Normal Range)

• CK (R-time): 5.2 min (3.5-9.1) - Normal

  • Time to initial clot formation is within normal limits
  • No evidence of factor deficiency or heparin effect

• CKH (K-time): 6.7 min (4.3-8.3) - Normal

  • Clot formation speed is appropriate
  • Adequate fibrinogen function

Clot Strength (Abnormal)

• CRTH (Angle): 68.4° (52-70) - High-normal to elevated

  • Rapid clot propagation suggesting hypercoagulability

• CFFH (MA): 36.8 mm (15-32) - SIGNIFICANTLY ELEVATED

  • Maximum clot strength exceeds normal by >15%
  • Indicates hypercoagulable state 1
  • Reflects increased platelet function and/or fibrinogen contribution

Fibrinolysis Assessment

• CKH value of 6.7 with reference 0.0-3.2 - MARKEDLY ELEVATED
  • This appears to represent a hyperfibrinolytic state
  • Suggests accelerated clot breakdown 1

Clinical Interpretation

Primary Finding: Hypercoagulability

The elevated MA (36.8 mm vs. normal 15-32 mm) is the most clinically significant abnormality, indicating:

• Enhanced platelet-fibrin interaction
• Increased thrombotic risk
• Potential for inadequate anticoagulation if currently receiving therapy 2

Secondary Finding: Hyperfibrinolysis

The elevated fibrinolytic parameter suggests:

• Active clot breakdown despite hypercoagulable baseline
• Possible consumptive coagulopathy
• May require tranexamic acid if bleeding present (consider if LY30 equivalent >10%) 1

Clinical Management Recommendations

Immediate Actions

1. Correlate with clinical scenario:

   • Active bleeding? Consider antifibrinolytic therapy (tranexamic acid 1g) 1
   • Thrombotic event? The hypercoagulable state supports this diagnosis
   • Postoperative? Common to see hypercoagulability 2

2. Assess anticoagulation status:

   • If on heparin: A >25% difference between plain and heparinase samples defines adequate effect 2
   • Current TEG shows no prolonged R-time, suggesting inadequate anticoagulation if therapy intended

3. Consider underlying conditions:

   • Pregnancy/postpartum (hypercoagulable baseline expected) 2
   • Malignancy (associated with hypercoagulability) 3
   • Sepsis or DIC (can show mixed picture)
   • Obesity (trend toward hypercoagulability) 2

Transfusion Guidance

Based on 2025 Association of Anaesthetists guidelines 1:

• No indication for FFP (normal R-time)
• No indication for platelets (elevated MA suggests adequate platelet function)
• No indication for cryoprecipitate (normal K-time and angle)
• Consider tranexamic acid if hyperfibrinolysis confirmed and bleeding present

Critical Pitfalls to Avoid

1. Do not assume normal coagulation based on normal R and K times alone - the elevated MA indicates significant hypercoagulability requiring thromboprophylaxis consideration

2. Do not over-transfuse - TEG-guided strategies reduce unnecessary blood product use without increasing bleeding risk 4

3. Recognize mixed patterns - simultaneous hypercoagulability and hyperfibrinolysis suggests complex pathophysiology (trauma, DIC, obstetric emergency)

4. Context matters - TEG parameters must be interpreted with clinical scenario, as pregnancy, postoperative states, and malignancy alter baseline values 2

5. Verify the hyperfibrinolysis parameter - confirm which specific TEG value represents fibrinolysis (LY30, LY60, or EPL) as management differs based on severity

Risk Stratification

High thrombotic risk indicated by:

• MA >32 mm (present in this case)
• Consider enhanced thromboprophylaxis if not contraindicated
• Monitor for thrombotic complications

Bleeding risk from hyperfibrinolysis:

• Requires clinical correlation with active bleeding
• May need antifibrinolytic therapy if symptomatic 1