Whole-blood hypocoagulable profile correlates with a greater risk of death within 28 days in patients with severe sepsis.

BACKGROUND: Hypocoagulability and impaired platelet function have been associated with a high risk of death in sepsis. The aim of this cohort study was to determine whether sepsis-induced hypocoagulability and platelet dysfunction (assessed by ROTEM® and MULTIPLATE®, respectively) are increased in sepsis patients who died within 28 days after diagnosis compared with patients who died between 29 and 90 days after diagnosis. METHODS: Consecutive patients admitted to the intensive care unit of Padova University Hospital from March 2015 to March 2018 for severe sepsis were considered. We collected blood samples from all patients to determine ROTEM® and MULTIPLATE® parameters. Each enrolled patient underwent a 90-day follow-up and the mortality rate was recorded. RESULTS: Of 120 patients, 36 (30%) died within 28 days post-diagnosis (Group A), 23 (19%) died between days 29 and 90 post-diagnosis (Group B), and 61 (51%) were alive after 90 days (survivors). The clotting time in the ROTEM® test and clot formation time in the EXTEM test were significantly more prolonged in Group A than in B. Both groups showed a significantly higher hypocoagulability than survivors in the EXTEM test. MULTIPLATE® platelet function analysis showed that platelet function was significantly lower in Group A than in Group B. CONCLUSIONS: The present study showed that the combination of thromboelastometry and impedance aggregometry may help identifying sepsis patients at high risk of short-term death. Larger studies are warranted to corroborate our results.

Thromboelastography Parameters as Predictors for Long-Term Survival in Critically Ill Patients.

Thromboelastography (TEG) is used for monitoring abnormal blood coagulation in critically ill patients. However, the correlation between TEG parameters and long-term survival in these patients is unknown. We aimed to quantify the effect of TEG on long-term survival of critically ill patients. Critically ill patients undergoing TEG were retrospectively examined. Baseline patient characteristics and coagulation function indexes were compared. Cox regression, receiver-operating characteristic curve analysis, and Kaplan-Meier survival estimate curve were performed. We included 167 critically ill patients. Clot formation speed (K) and reaction time (R) were higher, whereas maximum amplitude (MA) and angle were lower in the mortality group than in the survival group (P < .01). All TEG parameters were risk factors for 2-year survival in critically ill patients (P < .01). The area under the curve of MA for predicting 2-year survival was 0.756 (95% confidence interval: 0.670-0.841). The Kaplan-Meier survival estimate curve analysis showed that MA predicted 2-year survival of critically ill patients(P < .01). Maximum amplitude can effectively predict 2-year survival of critically ill patients, indicating the influence of the coagulation system on these patients.

Hypercoagulability in relation to coronary artery bypass graft patency and clinical outcome.

OBJECTIVE: Hypercoagulability evaluated with thrombelastography (TEG) has been reported to be associated to thrombembolic events in patients undergoing coronary artery bypass graft surgery (CABG). The objective of this study was to test the hypothesis that graft patency and post-CABG thrombembolic events are related to the pre-surgical TEG status. DESIGN: 124 patients scheduled for CABG were matched according to mean age, gender and mean left ventricular ejection fraction in two groups defined by their pre-surgical TEG status (TEG-hypercoagulable and TEG-normocoagulable). Three months after the operation graft patency was assessed with multidetector computed tomography (MDCT). Major adverse cardiovascular and cerebral events (MACCE) were recorded for a median period of 7 months (range 3 to 37 months) after CABG. RESULTS: A total of 359 grafts were analyzed, 186 in TEG-hypercoagulable and 173 in TEG-normocoagulable patients. Frequency of bypass graft occlusion was not significantly different between the two groups (TEG-hypercoagulable = 21 and TEG-normocoagulable = 18, p = 0.9). The number of MACCE was significantly higher in the TEG-hypercoagulable compared to the TEG-normocoagulable group (TEG-hypercoagulable = 30% and TEG-normocoagulable = 9% p = 0.004). CONCLUSIONS: Hypercoagulability, as evaluated by TEG in patients undergoing CABG is associated with an increased risk of post-surgical thrombembolic events, however not accompanied by augmented coronary bypass graft failure.

Monitoring patients at risk of massive transfusion with Thrombelastography or Thromboelastometry: a systematic review.

BACKGROUND: Thrombelastography (TEG) and Thrombelastometry (ROTEM) are viscoelastic whole-blood assays evaluating the haemostatic capacity of blood. These devices are used in algorithms to guide transfusion of haemostatic blood components. METHODS: The methods used for this study were systematic reviews with meta-analyses and trial sequential analyses of randomised clinical trials (RCTs) of TEG/ROTEM-based algorithm compared with standard treatment in patients with bleeding. Primary outcome was all-cause mortality. We searched the literature in seven databases (up to 31 October 2010), reference lists, registers of ongoing trials, and contacted authors and experts. We extracted data from included studies related to study methods, interventions, outcomes, bias risk and adverse events using Cochrane methodology. All trials irrespective of blinding or language status were included. RESULTS: Nine trials involving 776 participants were included. Eight trials involved cardiac surgery with an average blood loss of 390-960 ml, and one trial investigated liver transplantations. One trial was classified as low-risk-of-bias trial. We found two ongoing trials. No impact was identified on mortality, amount of blood transfused, incidence of surgical reinterventions, time to extubation, or length of stay in hospital and intensive care unit. We identified a significant reduction in blood loss favouring the use of TEG/ROTEM {85 ml [95% confidence interval (CI) 29.4-140.7]} and in the proportion of patients receiving freshly frozen plasma and platelets [relative risk 0.39 (95%CI 0.27-0.57)]. CONCLUSION: There is currently weak evidence to support the use of TEG/ROTEM as a tool to guide transfusion in patients with severe bleeding. Further studies need to address other clinical settings and with larger blood losses.