Thromboelastography profiles in critically ill children with multisystem inflammatory syndrome

Abstract

Objectives: To describe critically ill children's coagulation profile with the multisystem inflammatory syndrome (MIS-C) related to coronavirus. Study design: Single-center, observational study at a tertiary, pediatric intensive care unit (PICU) in children aged 1 month to 18 years. Measurements and main results: Sixteen children, with a median age of 5.4 years (interquartile range [IQR] 2.1, 11.75), 56% female, admission Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score of 3.5 (IQR 2, 5), and median PICU length of stay 3 days (IQR 1.5, 4), met criteria of MIS-C. All patients received acetylsalicylic acid (80-100 mg/kg) and none received anticoagulation. Sixty-three percent (10/16) of children had out-of-normal range values on thromboelastography (TEG) (44% [7/16] with hypercoagulability and 19% [3/16] with hypocoagulability). Of those with hypercoagulability, 19% (3/16) had rapid clot formation, and 25% (4/16) had increased clot strength. In 69% (11/16) of children, there was impaired fibrinolysis (0% lysis at 30 minutes) on TEG. Seventy-five percent (12/16) of children had out-of-normal range value on standard coagulation assays (37.5% [6/16] with hypocoagulability and 37.5% [6/16] with hypercoagulability). TEG-G (clot strength as measured by TEG) value (ρ −.553, p = .033) and platelet count (ρ −.840, p < .0001) were correlated with admission PELOD-2 score. TEG-G value (ρ −.506, p = .04) and platelet count (ρ −.539, p = .03) were correlated with the duration of intensive care unit stay. Conclusions: Coagulation abnormalities are frequent in children with MIS-C. TEG parameter and platelet count are correlated with the severity of multiorgan dysfunction and the duration of intensive care stay. Multicenter studies are needed to confirm the clinical implications of these coagulation abnormalities.

Thromboembolic complications in children with COVID-19 and MIS-C: A narrative review

“…Ankola et al demonstrated that patients with MIS-C had evidence of hypercoagulability on thromboelastography (TEG); their TEG profiles were consistent with faster clot formation, increased clot strength, and slower fibrinolysis (72). This novel finding has been confirmed by the study of Morparia et al and provides a potential unique biomarker to distinguish the risk for thrombosis in the pediatric patients (73).…”

Viscoelastic Testing in Pediatric Mechanical Circulatory Support

“…In pediatric MIS-C, a single center report (n = 30) showed patients had evidence of hypercoagulability on TEG R but similarly did not demonstrate any symptomatic thrombotic event or major bleeding (86). In a single center cohort (n = 22) of pediatric patients with acute COVID-19 and MIS-C, TEG R uncovered a pattern of accelerated clot formation and increased clot strength in a subset of children and unlike the previous reports this cohort included two patients with significant thrombotic complications (87).…”

Thrombotic Events in MIS-C Patients: A Single Case Report and Literature Review

“…MIS-C patients are subjected to a hyperinflammatory state leading to a higher risk of thrombotic manifestations by the activation of the coagulation system, especially in the event of a more severe clinical course [ 7 , 8 , 10 , 50 , 51 , 52 ]. The incidence of TEs ranges from 1 to 6.5% in the largest series [ 3 , 10 , 21 , 50 , 51 ] and their occurrence is more frequent among adolescents, accounting for 7–19% in patients older than 12 years.…”

“…The most commonly reported coagulation abnormalities are the elevation of D-dimer and fibrinogen levels [ 3 , 4 , 6 ]. In addition, the prothrombotic state seems to be promoted by high clot strength and a consequent slowing of the fibrinolytic process [ 7 , 8 ]. To prevent TEs, the use of antiplatelets and/or anticoagulants has been recommended, largely based on experience in similar pediatric conditions, specifically Kawasaki disease and myocarditis [ 6 ].…”