Thromboelastography for evaluation of coagulopathy in nonbleeding patients with sepsis at intensive care unit admission

Abstract

Background:Thromboelastography (TEG) is a global test of coagulation which analyzes the whole coagulation process. TEG is popular in trauma, liver transplant, and cardiac surgeries, but studies in sepsis are limited. We have assessed the utility of TEG for evaluating coagulopathy in nonbleeding patients with sepsis.Materials and Methods:A prospective, observational study was done in 12-bedded Intensive Care Unit (ICU) of a tertiary care hospital in North India, during May 2014-November 2014. After ethical clearance, all patients at ICU admission with sepsis were included in the study. Exclusion criteria were age <18 years, plasma/platelet transfusion before admission, patients on oral antiplatelets/anticoagulants, or with underlying hematological disorders. At admission, blood samples for TEG were analyzed by kaolin-based TEG analyzer within an hour of collecting 2.7 ml citrated blood from arterial line. TEG parameters included reaction time (R), K time (K), alpha angle (a), maximum amplitude (MA), coagulation index (CI), and lysis index (LY 30).Results:In TEG, mean values of R, K, a, MA, CI, and LY30 were 6.45 ± 2.59 (min), 1.67 ± 0.96 (min), 66.37 ± 10.44 (0), 67.08 ± 10.33 (mm), 0.63 ± 3.46, and 2.23 ± 4.08 (%), respectively. In conventional coagulation assay (CCA), mean values of international normalized ratio (INR), platelet, and fibrinogen were 1.63 ± 0.57, 153.96 ± 99.16 (×103 /mm3), and 301.33 ± 112.82 (mg/dl), respectively. In those with deranged INR (INR ≥1.6), 60% were normocoagulable and 20% were hypercoagulable. Similarly, 81% patients with thrombocytopenia (platelet count <1,00,000/mL) were normocoagulable.Conclusion:TEG could differentiate among normocoagulant, hypocoagulant, hypercoagulant states (unlike CCAs). Patients with septic shock had trend toward hypocoagulant state while those without shock had trend toward hypercoagulant state.

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

“…Hypercoagulability was observed in the early stage of sepsis, consistent with the aforementioned hypothesis of "immunothrombosis" defense (1,3,15). The development of hypocoagulability is commonly associated with the increasing severity of each stage (severe sepsis and septic shock) (12,15,16,27). Previous studies observed hemostatic response by a rapid increase in clot mass development (with higher α and MCF), possibly indicating a hypercoagulable phase and potential thromboembolic risk in the early stage of sepsis followed by the progression of hypocoagulable trends (with prolonged CT and CFT) in the later phase (6,28).…”

Thromboelastography Profile of Patients with COVID-19 Admitted to Intensive Care Unit: A Single-center Retrospective Study from India

“… 6 , 22 Thromboelastography can be an easy and helpful test to learn about this new disease and may have potential in deciding appropriate anticoagulant doses and duration. 7 , 23 , 24 Some experts advise TEG in patients with severe COVID-19 for monitoring coagulation and adjusting the heparin dosage. 25 More studies are needed to evaluate the applicability of TEG in understanding the disease, identifying appropriate doses and duration of thromboprophylaxis, and predicting outcomes.…”

World Academic Council of Emergency Medicine experience document: Implementation of point-of-care thromboelastography at an academic emergency and trauma center

“…Therefore, this goal-directed management which has been since several years incorporated as a Grade 1C recommendation in the latest edition of the European guideline on management of major bleeding and coagulopathy following trauma should be more frequently considered to be used as goal-directed therapy. [224]…”

“…TEG is not an alternative to the conventional laboratorial coagulation tests such as INR and aPTT; however, it adds more information to guide blood transfusions such as clot strength and fibrinolysis and to differentiate between normocoagulant, hypocoagulant, and hypercoagulant states in septic patients. [12] However, a recent systematic review demonstrates that the evidence to show the accuracy of TEG and ROTEM in trauma still needs further evaluation and more research involvement with prospective, randomized controlled trials. [34]…”