Tracheostomy in intensive care unit patients can be performed without bleeding complications in case of normal thromboelastometry results (EXTEM CT) despite increased PT-INR: a prospective pilot study

Abstract

BackgroundCoagulopathy is often accompanied by prolongation of prothrombin time (PT) in septic and nonseptic patients in intensive care unit (ICU). The conventional way to correct the coagulopathy is to administer fresh frozen plasma (FFP) before invasive procedures to minimise the risk of bleeding. However, prolonged PT can be present even in hypercoagulation status, resulting in unnecessary administration of FFP. In the present study, we have assessed the reliability of thromboelastometry in case of prolonged PT and the relationship to bleeding complications during surgical tracheostomy.MethodsThe study was conducted during the period between April 2013 and April 2014 in patients undergoing surgical tracheostomy. Coagulation status was assessed using PT, and the status was reassessed by thromboelastometry for prolonged PT. Tracheostomy was performed in patients with normal thromboelastometry results without administering FFP.ResultsTracheostomy was performed in total 119 patients. Normal value of PT as measured by international normalized ratio (INR) ≤ 1.2 was found in 64 (54 %) patients, while prolonged INR > 1.2 was found in 55 (46 %) patients. Patients with INR ≥ 1.3 (with INR min- 1.3, max- 1.84, and median- 1.48) were further analysed by thromboelastometry. Despite prolonged INR, thromboelastometry results were in normal ranges in all cases except one. With normal thromboelastometry, tracheostomy was performed safely without any bleeding complication.ConclusionsSurgical tracheostomy in septic and nonseptic patients can be performed without bleeding complications in case of normal thromboelastometry results (EXTEM CT) despite increased PT-INR. This method can help physicians to reduce unnecessary administration of FFP in patients.

British Society of Haematology Guidelines on the spectrum of fresh frozen plasma and cryoprecipitate products: their handling and use in various patient groups in the absence of major bleeding

“…A prospective study of 119 intensive care patients undergoing tracheostomy demonstrated no difference in bleeding between patients with INR of ≤ 1Á2 or 1Á3-1Á84. These patients also had thromboelastometry profiles carried out with results being within the normal range in all cases except one (Durila et al, 2015).…”

Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology

“…147 169 Increasing evidence shows that viscoelastic assays can be used to assess haemostatic status in patients with liver disease, with evidence that this can result in a reduction in blood products transfused. [170][171][172][173][174] This has become increasingly established in liver surgery but more recently for other procedures. In a small randomised trial, De Pietri 175 showed that in patients with cirrhosis and an INR >1.8 and/or platelet count <50×10 9 /L requiring invasive procedures, a thromboelastogram-guided transfusion strategy led to a significantly lower use of blood products (17% compared with 100% transfusion in the standard of care group) without an increase in bleeding complications; only one major bleed occurred, which was in the standard of care group.…”

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.…”