Evaluation of Thromboelastometry in Sepsis in Correlation With Bleeding During Invasive Procedures

Abstract

Prolongation of prothrombin time (PT) is often encountered in patients with sepsis. On the other hand, thromboelastometry as a global coagulation test might yield normal results. The aim of our study was to evaluate whether prolonged PT in the presence of normal thromboelastometry parameters is associated with severe bleeding in patients with sepsis undergoing invasive procedures. In patients with sepsis undergoing low-risk bleeding invasive procedures (central venous catheter placement, dialysis catheter insertion, drain insertion, and so on) or high-risk bleeding invasive procedures (surgical tracheostomy, surgical laparotomy, thoracotomy, and so on), coagulation was assessed by thromboelastometry using EXTEM test (test for evaluation of the extrinsic pathway of coagulation, contains activator of extrinsic pathway) and with PT. For period of years 2013 to 2016, we assessed occurrence of severe bleeding during those procedures and 24 hours later in patients with prolonged PT and normal thromboelastometry results. This retrospective study was performed at Department of Anaesthesiology and Intensive Care Medicine of Motol University Hospital in Prague. Data from 76 patients with sepsis were analyzed. Median value of international normalized ratio (INR) was 1.59 (min-1.3 and max-2.56), and median value of prothrombin ratio (PR) was 1.5 (min-1.23 and max-2.55) with normal thromboelastometry finding. Despite prolonged INR/PR, no severe bleeding was observed during invasive procedures. Our data show that sepsis may be accompanied by normal thromboelastometry results, despite prolonged values of PT, and invasive procedures were performed without severe bleeding. This approach to coagulation assessment in sepsis may reduce administration of fresh frozen plasma to the patients. The study was registered at Clinical Trials.gov with assigned number NCT02971111.

Thromboelastometry as an Alternative Method for Coagulation Assessment in Pediatric Patients Undergoing Invasive Procedures: A Pilot Study

“…15 Recently, we published results of study done in adult patients which supported the findings of Müller et al and ROTEM seems to be providing more light into this phenomenon and coagulation process of critically ill adult patients. 17 No analogous study was performed in pediatric patients and our findings suggest that the results in the pediatric population might be very similar, but more studies are needed. Fresh frozen plasma is often used in pediatric patients in daily practice to correct prolonged PT/ aPTT, although it is well known that prophylactic plasma is not effective in the correction of INR and, even worse, it can be harmful for patients and is associated with increased morbidity and mortality of patients.…”

“…and the methodology was analogous to our previous study done in adults patients. 17 Patients with prolonged aPTT represented by aPTT ratio (aPTT-R) or PT represented by international normalized ratio (INR) and PT ratio (PT-R) and with normal ROTEM tests-internal thromboelastometry (INTEM) (assessing internal pathway of coagulation, contains activator of intrinsic pathway) and external thromboelastometry (EXTEM) (assessing external pathway of coagulation, contains activator of extrinsic pathway)-were included in the study. In case of normal ROTEM results, they were not administered fresh frozen plasma preventively before intervention despite prolonged aPTT or PT.…”

“…[10][11][12][13][14] Administration of fresh frozen plasma in patients with prolonged PT preventively prior to invasive procedures has been disputed and studies in critically ill adult patients showed that despite prolonged PT, there was no increased bleeding during invasive procedures. [15][16][17] Compared to adult perioperative medicine, studies using ROTEM in perioperative medicine in children are scarce. In our study, we decided to find out if there was any severe bleeding during or after invasive procedures in pediatric patients if ROTEM test was normal despite prolonged values of aPTT/PT.…”

Can We Measure the Individual Prothrombotic or Prohemorrhagic Tendency by Global Coagulation Tests?

“…[50][51][52] It has been shown that in septic patients with prolonged prothrombin time but normal or hypercoagulable parameters of viscoelastometric testing, invasive procedures are not associated with an increased bleeding risk. 53,54 This is also reflected by the discordance that has been observed between international normalized ratio and TEG R times in previous studies. 55 Also, both hyperor hypofibrinolysis can be detected by viscoelastometric testing in trauma patients and patients with sepsis, DIC, or liver disease.…”

Rotational Thromboelastometry Helps to Reduce Blood Product Consumption in Critically Ill Patients during Small Surgical Procedures at the Intensive Care Unit - a Retrospective Clinical Analysis and Literature Search

“…Therefore, in case of normal ROTEM, we did not see any bleeding complication during small surgical procedures or afterwards despite prolonged PT/aPTT or low platelets count [4]. The authors also demonstrated no bleeding complications in septic patients [13]. …”