The effect of sepsis and septic shock on the viscoelastic properties of clot quality and mass using rotational thromboelastometry: A prospective observational study

Davies, Gareth; Lawrence, Matthew; Pillai, Suresh; Mills, Gavin; Aubrey, Robert; Thomas, Dafydd; Williams, Rhodri; Morris, Keith; Evans, P A

doi:10.1016/j.jcrc.2017.09.183

Cited by 33 publications

(50 citation statements)

References 29 publications

(31 reference statements)

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“…Previous reports have described the varying incidence of hypercoagulable, normal, and hypocoagulable states in adults and neonates with severe sepsis (1–4, 16–23). The incidence of hypercoagulability has been reported in 30–100% of adults with severe sepsis (31).…”

Section: Discussionmentioning

confidence: 99%

“…However, although hypercoagulability is frequently described in the early stages of sepsis, development of a hypocoagulable state on TEG is consistently associated with increased morbidity and mortality in adults and neonates with severe sepsis (16–18, 22, 23, 29). Clot strength and formation are largely preserved despite prolongation in clot formation and impairment of fibrinolysis on rotational thromboelastrometry (ROTEM) assays, another viscoelastic assay, in adults with septic shock (23). The kinetics of clot growth utilizing ROTEM assays have been shown to strongly correlate with mortality in adults with severe sepsis (22).…”

Section: Discussionmentioning

confidence: 99%

“…While there is limited adult and neonatal data on TEG based evaluation of sepsis-induced coagulopathy (SIC) (16–23), to date, there is no published pediatric data. In this study of children with severe sepsis or septic shock, we aimed to describe in detail the incidence of hemostatic dysfunction as defined using TEG variables.…”

Section: Introductionmentioning

confidence: 99%

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Thromboelastography Variables, Immune Markers, and Endothelial Factors Associated With Shock and NPMODS in Children With Severe Sepsis

Saini¹,

Spinella²,

Ignell³

et al. 2019

Front. Pediatr.

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Objective: Evaluate hemostatic dysfunction in pediatric severe sepsis by thromboelastography (TEG) and determine if TEG parameters are associated with new or progressive multiple organ dysfunction syndrome (NPMODS) or shock, defined as a lactate ≥2mmol/L. We explored the relationship between TEG variables, selective cytokines, and endothelial factors.Design: Prospective observational.Setting: Single-center, quaternary care pediatric intensive care unit.Patients: Children aged 6- months to 14- years with severe sepsis with expected PICU stay for >72 h.Interventions: None.Measurements and Main Results: Twenty-eight children were enrolled with median (IQR) age of 7.3 years (4.4–11.4), PELOD score (study day-1) of 11(1.25–13), and PICU length of stay of 10 days (5–28). TEG-defined hypercoagulable state occurred most commonly in 73% (94/129) of samples, followed by hypocoagulable state in 7.8% (10/129) and mixed coagulation state in 1.5% (2/129) of samples in the study cohort. In contrast, hypocoagulable state occurred most commonly in 66% (98/148) of samples based on standard coagulation parameters. In the seven children who developed shock with NPMODS compared to eight patients with shock without NPMODS and 12 patients with severe sepsis only, we found more profound coagulopathy [thrombocytopenia (p = 0.04), elevated INR (p = 0.038), low fibrinogen level (p = 0.049), and low TEG-G value (p = 0.01)] and higher peak of interleukin-6 (p = 0.0014) and IL-10 (p = 0.007). Peak lactate in the first 5 study days had moderate correlation with standard coagulation assays, TEG parameters, and selective cytokines. Peak lactate did not correlate with markers of endothelial activation. Lowest TEG -G value had moderate correlation with peak IL-10 (ρ −0.442, p =0.019), peak VCAM (ρ − 0.495, p = 0.007), and peak lactate (ρ −0.542, p = 0.004) in the first 5 study days. A combination of TEG-G value and IL-6 concentration best discriminated children with shock and NPMODS [AUC 0.979 (95%CI 0.929–1.00), p < 0.001].Conclusion: This exploratory analysis of hemostasis dysfunction on TEG in pediatric severe sepsis suggests that while hypercoagulability is more common, a hypocoagulable state is associated with shock and NPMODS. In addition, TEG abnormalities are also associated with immune and endothelial factors. A larger cohort study is needed to validate these findings.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Thromboelastography Variables, Immune Markers, and Endothelial Factors Associated With Shock and NPMODS in Children With Severe Sepsis

Saini¹,

Spinella²,

Ignell³

et al. 2019

Front. Pediatr.

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“…Measuring D‐dimer or fibrinogen concentrations could assess this pathologic phenomenon if viscoelastic testing was unavailable 10,11 . The utility of viscoelastic testing in COVID‐19 needs to be further assessed to better understand the usefulness and limitations of this technology in these critically ill patients with a hypercoagulable state 12 …”

Section: Figurementioning

confidence: 99%

Viscoelastic testing in COVID‐19: a possible screening tool for severe disease?

et al. 2020

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Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19) that manifests with variable severity. 1 A subset of symptomatic individuals develop proinflammatory or prothrombotic profiles requiring additional testing and interventions. [2][3][4][5] It is unclear which COVID-19 patients will ultimately develop severe disease that would have benefitted from early and aggressive interventions.A 63-year-old man was admitted with rapidly progressive COVID-19 pneumonia with hypoxia. Given the patient's worsening clinical status, laboratory coagulation analysis, including viscoelastic testing by rotational thromboelastometry (ROTEM delta, Instrumentation Laboratory Co., Bedford, MA), was performed immediately upon hospital admission. He subsequently developed acute respiratory distress syndrome and shock that required mechanical ventilation and vasopressor support.Routine coagulation testing demonstrated a prothrombin time (PT) of 12.2 seconds (normal 9.4-15.4 seconds), a partial thromboplastin time (PTT) of 30 seconds (normal 26-38 seconds), and D-dimers of 2143 ng/mL fibrinogen equivalent units (FEU; normal <600 ng/mL FEU), the last associated with severe COVID-19. 6 Viscoelastic testing demonstrated a hypercoagulable profile (see Fig. 1). 7 In particular, there was elevated maximum clot firmness observed on EXTEM (78 mm), INTEM Fig 1 Viscoelastic testing tracings from an intensive care unit patient with severe COVID-19. (A) EXTEM tracing; (B) INTEM tracing; (C) FIBTEM tracing; (D) APTEM tracing.

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“…Corona virus disease 2019 (COVID- 19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has taken hold of the world and spread globally with presently more than 20 million con rmed cases 1 . The lungs are the main target organ for COVID-19, and patients who become critically ill generally suffer from respiratory distress leading to di culties in ventilation and oxygenation.…”

Section: Introductionmentioning

confidence: 99%

Rotational Thromboelastometry Predicts Care Level in COVID-19: A Prospective, Observational Study.

Almskog

Wikman

Svensson

et al. 2020

Preprint

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BackgroundHigh prevalence of thrombotic events in severely ill COVID-19 patients have been reported. Pulmonary embolism as well as microembolization of vital organs may in these individuals be direct causes of death. The identification of patients at high risk of developing thrombosis may lead to targeted, more effective prophylactic treatment. The aim of this study was to test whether Rotational Thromboelastometry (ROTEM) indicates hypercoagulopathy in COVID-19 patients, and whether patients with severe disease have a more pronounced hypercoagulopathy compared with less severely ill patients. MethodsThe study was designed as a prospective observational study where COVID-19 patients over 18 years admitted to hospital were eligible for inclusion. Patients were divided into two groups depending on care level: 1) regular wards or 2) wards with specialized ventilation support. ROTEM was taken after admission and the data were compared with ROTEM in healthy controls.ResultsThe ROTEM variables Maximum Clot Firmness (EXTEM-/FIBTEM-MCF) were higher in COVID-19 patients compared with healthy controls (p<0.001) and higher in severely ill patients compared with patients at regular wards (p<0.05). Coagulation Time (EXTEM-CT) was longer and Clot Formation Time (EXTEM-CFT) shorter in COVID-19 patients compared with healthy controls. Our results suggest that hypercoagulopathy is present in hospitalized patients with mild to severe COVID-19 pneumonia. ConclusionsROTEM variables were significantly different in COVID-19 patients early after admission compared with healthy controls. This pattern was more pronounced in patients with increased disease severity, suggesting that ROTEM-analysis may be useful to predict thromboembolic complications in these patients.

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The effect of sepsis and septic shock on the viscoelastic properties of clot quality and mass using rotational thromboelastometry: A prospective observational study

Cited by 33 publications

References 29 publications

Thromboelastography Variables, Immune Markers, and Endothelial Factors Associated With Shock and NPMODS in Children With Severe Sepsis

Thromboelastography Variables, Immune Markers, and Endothelial Factors Associated With Shock and NPMODS in Children With Severe Sepsis

Viscoelastic testing in COVID‐19: a possible screening tool for severe disease?

Rotational Thromboelastometry Predicts Care Level in COVID-19: A Prospective, Observational Study.

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