Hypocoagulable Tendency on Thromboelastometry Associated With Severity and Anticoagulation Timing in Pediatric Septic Shock: A Prospective Observational Study

Abstract

Objective: To identify whether coagulation profiles using thromboelastometry are associated with outcomes in pediatric septic shock. The primary outcomes were the development of disseminated intravascular coagulation (DIC) and the severity of the pediatric intensive care unit (PICU) existing scoring systems, while the secondary outcome was hospital mortality. This study aimed to contribute to current findings of the limitations of conventional tests in determining the optimal timing of anticoagulation in sepsis.Design: A prospective, observational study conducted between August 2019 and August 2020.Setting: PICU at a pediatric tertiary hospital in Hanoi, Vietnam.Patients: Fifty-five pediatric patients who met the septic shock criteria were enrolled.Measurements and Main Results: Fifty-five patients with septic shock were recruited. At the time of diagnosis, thromboelastometry revealed normocoagulability, hypercoagulability, and hypocoagulability in 29, 29, and 42% of the patients, respectively (p > 0.05); however, most patients in the overt DIC and non-survival groups progressed to hypocoagulability (82 and 64%, respectively). The overt DIC, PELOD-2 > 8, PRISM-III > 11, and non-survival group had a significant hypocoagulable tendency according to thromboelastometry parameters [prolonged clotting time (CT) and clot formation time (CFT); and reduced α-angle (α), maximum clot firmness (MCF), thrombodynamic potential index (TPI)] compared to the non-overt DIC, PELOD-2 ≤ 8, PRISM-III score ≤ 11 and survival group (p < 0.05). Conventional parameters between the normocoagulable and hypercoagulable groups were not different (p > 0.05). Hypocoagulability was characterized by lower platelet count and fibrinogen level, higher prolonged prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (APTT), and higher D-dimer level than in hypercoagulability (p < 0.05). Hypocoagulable tendency on thromboelastometry had a higher hazard at a PT > 16.1 s [area under the curve (AUC) = 0.747, odds ratio (OR) = 10.5, p = 0.002], INR > 1.4 (AUC = 0.754, OR = 6.9, p = 0.001), fibrinogen <3.3 g/L (AUC = 0.728, OR = 9.9, p = 0.004), and D-dimer > 3,863 ng/mL (AUC = 0.728, OR = 6.7, p = 0.004).Conclusions: Hypocoagulable tendency using thromboelastometry is associated with the severity of septic shock. Conventional coagulation tests may fail to detect hypercoagulability, which is crucial in determining anticoagulation timing.

Rotational Thromboelastometry and Clot Waveform Analysis as Point-of-Care Tests for Diagnosis of Disseminated Intravascular Coagulation in Critically Ill Children in Thailand*

“…Based on this insight, alterations in CT, CFT, α-angle, and MCF can lead to either a hypercoagulable or hypocoagulable state. Tuan et al focused on the global hemostatic tests and demonstrated a hypocoagulable state based on ROTEM parameters, which was defined as at least one of prolonged CT or CFT, reduced α-angle or MCF, in children with septic shock and ODIC (27). In this study, the hypocoagulable state in the ODIC group was more severe compared with the NDIC group.…”

“…Furthermore, only one prognostic study had been conducted on 56 children with SIC from the Vietnamese cohort. These publications revealed that a hypocoagulable state (prolonged CT, CFT, and reduced α-angle, MCF) and lower fibrinolytic activity (higher lysis indexes and lower ML) were associated with disease severity and mortality (27, 29). The Transfusion and Anemia Expertise Initiative–Control/Avoidance of Bleeding group recently emphasized the need for more research to ascertain the effectiveness of functional hemostasis and coagulation tests in predicting bleeding and in formulating test-based triggers for transfusions (42).…”

SHock-INduced Endotheliopathy (SHINE): A mechanistic justification for viscoelastography-guided resuscitation of traumatic and non-traumatic shock

“…Likewise, early use of VHAs in SIC enables early detection of the depth and duration of shock prior to coagulopathic manifestation by conventional coagulation tests (CCTs) and other standard clinical and biologic markers (Pavoni et al, 2020). Combined with CCTs, VHAs, and clinical and laboratory markers such as lactate and procalcitonin, a PBM approach to assess the depth and duration of shock is becoming a reality whether in TIC or SIC (Vorweg et al, 2013;Müller et al, 2014;Saraiva et al, 2016;Johansson et al, 2017a;Martínez et al, 2018;Stettler et al, 2019;Walsh et al, 2020b;Scarlatescu et al, 2020;Carge et al, 2021;Drost et al, 2021;Pape et al, 2021;Tuan et al, 2021;Bunch et al, 2022a).…”

Neonatal Sepsis and Hemostasis

“…Interestingly, the hypercoagulable tendency was shown by ROTEM, but conventional testing failed to provide clear evidence of hypercoagulability. The alterations in the hemostatic profile were clear and determined the time-point for intervention in the event of impending complications, namely guided transfusion in the case of bleeding [ 67 ]. The main limitation of the validated use of these modalities is the inability to assess platelet function.…”