case_images: PMC8337149_01
case_images: Nine days after admission, the aPTT and TEG concurred with a supratherapeutic hypocoagulable state, and the heparin drip was stopped (dashed lines). The next day, TEG demonstrated a hypercoagulable state and aPTT was discovered to be falsely prolonged due to the hypertriglyceridemia (dotted lines). R: reaction time; K: clot formation time; alpha: alpha angle; MA: maximum amplitude; LY30: percent lysis at 30 minutes.
case_images: CRIM2021-5568982.001.jpg
case_images: PMC8337149_01_CRIM2021-5568982.001.jpg
case_images: fig1
case_images: Nine days after admission, he had an activated partial thromboplastin time (aPTT) of 50.2 seconds; however, TEG demonstrated excessive hypocoagulability with a prolonged reaction time (R) (Figure 1). Innovin and CaCl2, Siemens Medical Solutions, Malvern, Pennsylvania, USA) (Figure 1). Triglycerides were 1,456 mg/dL and D-dimer was trending upward. It was discovered that the aPTT measurement by optical clot detection is only accurate to triglyceride levels <331 mg/dL according to the manufacturer, and thus, aPTT was falsely prolonged due to the lipemia.
case_images: PMC8337149_02
case_images: Nine days after admission, TEG demonstrated subtherapeutic anticoagulation in the setting of prolonged aPTT because of hemoconcentration and polycythemia. R: reaction time; K: clot formation time; alpha: alpha angle; MA: maximum amplitude; LY30: percent lysis at 30 minutes.
case_images: CRIM2021-5568982.002.jpg
case_images: PMC8337149_02_CRIM2021-5568982.002.jpg
case_images: fig2
case_images: Based on the elevated aPTT, the clinical team reviewed the patient's TEG tracing which demonstrated a lack of full anticoagulation despite an elevated aPTT (Figure 2).
case_images: PMC8337149_03
case_images: One day after admission, despite prophylactic anticoagulation dosing, a patient with factor V Leiden mutation demonstrated borderline hypercoagulability on his TEG tracing (dashed lines). Persistent heparin resistance prompted a dose increase to achieve therapeutic anticoagulation on TEG (dotted lines). R: reaction time; K: clot formation time; alpha: alpha angle; MA: maximum amplitude; LY30: percent lysis at 30 minutes.
case_images: CRIM2021-5568982.003.jpg
case_images: PMC8337149_03_CRIM2021-5568982.003.jpg
case_images: fig3
case_images: TEG demonstrated borderline hypercoagulability (Figure 3). For the rest of his hospitalization, TEG guided goal-directed anticoagulation despite his hypercoagulable baseline (Figure 3), enabling us to achieve target aPTT of 40-50 seconds and R of 12-17 minutes with IV UFH 12-13 units/kg/hr.