How to correct elevated lysis on thromboelastography?

Management of Elevated LY30 on Thromboelastography (TEG)

Tranexamic acid is the first-line treatment for elevated LY30 on TEG, administered at a loading dose of 1g over 10 minutes followed by 1g over 8 hours to inhibit accelerated fibrinolysis. 1

Understanding Elevated LY30 on TEG

• Elevated LY30 (percent degradation of clot 30 minutes after reaching maximum amplitude) indicates hyperfibrinolysis, which can destabilize effective coagulation in clinical situations such as trauma, obstetric hemorrhage, and major organ surgery 1
• TEG thresholds between 3% and 7.5% LY30 have been associated with increased risk for massive transfusion and mortality 1
• Accelerated fibrinolysis can be identified by laboratory assay of d-dimers or fibrin degradation products, or by use of coagulation monitors such as TEG or ROTEM 1

First-Line Treatment: Antifibrinolytics

Tranexamic Acid (TXA)

• Tranexamic acid inhibits plasminogen activation and at high concentrations inhibits plasmin, effectively reversing established fibrinolysis 1
• Recommended dosing: 1g loading dose over 10 minutes followed by 1g over 8 hours 1
• TXA concentrations between 10-15 mg/L result in substantial inhibition of fibrinolysis, with concentrations between 5-10 mg/L being partly inhibitory 2
• Single bolus administration (1g or 2g) may be preferable to bolus plus infusion regimen as clinical outcomes and 24-hour fibrinolysis states are equivalent across different dosing strategies 3

Epsilon-Aminocaproic Acid (EACA)

• Alternative to TXA when TXA is unavailable or contraindicated 4
• Recommended dosing: 4-5g IV in 250mL of diluent administered during the first hour, followed by continuous infusion at 1g per hour in 50mL of diluent for approximately 8 hours or until bleeding is controlled 4
• EACA should only be administered with a definite diagnosis and/or laboratory finding indicative of hyperfibrinolysis 4

Monitoring and Follow-up

• Continue to monitor TEG parameters to guide ongoing treatment 1
• Thrombolytic infusion should be stopped when values return to normal or near normal 1
• If D-dimer and aPTT do not increase, and fibrinogen does not decrease at 24 hours of lytic treatment (failure to document a lytic state), the infusion can be discontinued 1

Special Considerations

Renal Dysfunction

• Use repeat doses of TXA with caution in patients with renal impairment, as the drug is predominantly excreted unchanged by the kidneys 1, 5
• Patients with chronic renal dysfunction may require dose adjustments to avoid excessive drug accumulation 5

Traumatic Brain Injury

• TXA has been shown to reduce mortality in patients with traumatic brain injury when given within 3 hours of injury 1
• Intraosseous administration of TXA may be considered when IV access is difficult, as it results in similar total drug exposure 6

Potential Complications and Management

Thrombotic Events

• While inhibition of fibrinolysis by antifibrinolytics may theoretically result in clotting or thrombosis, there is no definite evidence that administration of antifibrinolytics has been responsible for intravascular clotting 4
• Monitor for signs of thrombosis, particularly in high-risk patients 4

Contraindications

• TXA is contraindicated in patients with subarachnoid hemorrhage, as anecdotal experience suggests that cerebral edema and cerebral infarction may occur 1
• Rapid intravenous administration of EACA should be avoided since this may induce hypotension, bradycardia, and/or arrhythmia 4

Pitfalls to Avoid

• Do not rely solely on conventional coagulation tests (PT, aPTT) as they may not correlate well with clinical bleeding or TEG parameters 1
• Remember that TEG may be poorly sensitive to fibrinolysis in some cases, so integrate clinical assessment with laboratory findings 1
• Do not delay treatment while waiting for laboratory results in cases of severe bleeding 1