What is the treatment for high fibrinolysis on TEG?

Management of High Fibrinolysis on TEG

Tranexamic acid is the first-line treatment for elevated fibrinolysis (high FLEV/LY30) on thromboelastography (TEG), administered as a 1g loading dose over 10 minutes followed by 1g over 8 hours. 1, 2

Understanding Fibrinolysis on TEG

• Fibrinolysis is the process whereby established fibrin clot is broken down, which can occur in an accelerated fashion and destabilize effective coagulation 1
• Elevated LY30 (lysis at 30 minutes) on TEG indicates hyperfibrinolysis, commonly seen in trauma, obstetric hemorrhage, and major organ surgery including cardiothoracic and liver surgery 1, 2
• A TEG LY30 value of 3% or greater is considered clinically relevant hyperfibrinolysis and strongly predicts the requirement for massive transfusion and increased mortality risk 3

Treatment Algorithm

First-Line Treatment: Antifibrinolytics

• Tranexamic acid (TXA) is the primary treatment for hyperfibrinolysis 1, 2

  • Mechanism: Inhibits plasminogen activation and at high concentrations inhibits plasmin 1
  • Dosing: 1g loading dose over 10 minutes followed by 1g over 8 hours 1, 2
  • Most effective when administered early, ideally within 3 hours of injury in trauma cases 1

• Epsilon-aminocaproic acid is an alternative antifibrinolytic:

  • Dosing: 4-5g IV over first hour followed by continuous infusion at 1g per hour for approximately 8 hours 4

Second-Line Options

• For patients not responding to TXA or with contraindications:
  • Consider fibrinogen replacement if fibrinogen levels are low (<1 g/L) 1
  • Options include:
    • Fresh frozen plasma (FFP): at least 30 ml/kg 1
    • Fibrinogen concentrate: 30-60 mg/kg (faster and more predictable than cryoprecipitate) 1

Special Considerations

• Renal dysfunction: Adjust TXA dosing in patients with chronic renal dysfunction as TXA is primarily eliminated by the kidneys 5
• Contraindications: TXA is contraindicated in patients with subarachnoid hemorrhage due to risk of cerebral edema and infarction 1, 2
• Fibrinolytic phenotypes: TXA significantly improves clot strength in patients with hyperfibrinolysis but shows minimal benefit in patients with fibrinolytic shutdown 6

Monitoring Response

• Continue monitoring TEG parameters to guide ongoing treatment 2
• Consider repeat TEG after initial treatment to assess response and need for additional interventions 2
• Monitor for clinical improvement in bleeding 1

Pitfalls to Avoid

• Do not rely solely on conventional coagulation tests (PT, aPTT) as they may not correlate well with TEG parameters or clinical bleeding 1, 2
• Avoid confusing clot retraction with fibrinolysis on TEG - true fibrinolysis will show elevated D-dimer levels, while clot retraction (which can appear similar on TEG) will not 7
• Do not delay treatment while waiting for laboratory results in cases of severe bleeding 2
• Remember that TEG may be poorly sensitive to fibrinolysis in some cases, so integrate clinical assessment with laboratory findings 1, 2

Additional Measures

• Address other components of coagulopathy if present:
  • Maintain platelets ≥75 × 10^9/L 1
  • Correct hypofibrinogenemia (target >1 g/L) 1
  • Correct hypothermia and acidosis, which can exacerbate coagulopathy 1
  • Monitor and correct hypocalcemia and hypomagnesemia 1