Date Published: February 20, 2018
Publisher: Public Library of Science
Author(s): Tomaz Crochemore, Thiago Domingos Corrêa, Marcus D. Lance, Cristina Solomon, Ary Serpa Neto, João Carlos de Campos Guerra, Priscila Scolmeister Lellis, Livia Muller Bernz, Natalia Nunes, Cassio Massashi Mancio, Ana Paula Hitomi Yokoyama, Eliézer Silva, Chiara Lazzeri.
Transfusion therapy is associated with increased morbidity, mortality and costs. Conventional coagulation tests (CCT) are weak bleeding predictors, poorly reflecting coagulation in vivo. Thromboelastometry (ROTEM) provides early identification of coagulation disorders and can guide transfusion therapy by goals, reducing blood components transfusion.
The aim of this study is to describe coagulation profile of critically ill patients using ROTEM and evaluate the association between CCT and thromboelastometry.
This is a retrospective, observational study conducted in medical-surgical intensive care unit (ICU). Adult patients (≥18 years) admitted to ICU between November 2012 and December 2014, in whom ROTEM analyses were performed for bleeding management were included in this study. The first ROTEM and CCT after ICU admission were recorded simultaneously. Additionally, we collected data on blood components transfusion and hemostatic agents immediately after laboratory tests results.
The study included 531 patients. Most ROTEM tests showed normal coagulation profile [INTEM (54.8%), EXTEM (54.1%) and FIBTEM (53.3%)] with divergent results in relation to CCT: low platelet count (51.8% in INTEM and 55.9% in EXTEM); prolonged aPTT (69.9% in INTEM and 63.7% in EXTEM) and higher INR (23.8% in INTEM and 27.4% in EXTEM). However 16,7% of patients with normocoagulability in ROTEM received platelet concentrates and 10% fresh frozen plasma.
The predominant ROTEM profile observed in this sample of critically ill patients was normal. In contrast, CCT suggested coagulopathy leading to a possibly unnecessary allogenic blood component transfusion. ROTEM test may avoid inappropriate allogeneic blood products transfusion in these patients.
The hemostatic system, composed by soluble coagulation proteins, platelets, endothelium, natural anticoagulants, fibrinolytic system and their inhibitors, is driven by several regulatory mechanisms responsible for initiation, propagation, stabilization and clot lysis . Countless diseases in intensive care unit (ICU) are associated with systemic inflammatory response syndrome (SIRS) and endothelial damage, which compromise the delicate and complex balance between anticoagulant and procoagulant systems . As a result, clinical manifestations of varying degrees of hemorrhage or thrombosis may occur, impacting on patients outcomes .
The main purpose of this study was to describe the coagulation profile of critically ill bleeding patients admitted to the ICU based on ROTEM and CCT. Additionally, we aimed to determine the frequency of allogeneic blood transfusion and hemostatic drugs administration in this population of critically ill patients.
The main finding of our study was that approximately half of bleeding patients with a normocoagulable state by ROTEM showed coagulopathy according to CCT, expressed predominantly by thrombocytopenia and prolongation of aPTT. Moreover, approximately one in five patients received platelet concentrates transfusion based on a low platelet count and more than 10% received FFP based on changes in CCT, yet both groups presented normal thromboelastometry.
Most of the critically ill patients admitted to ICU exhibited a normal coagulation profile according to ROTEM, although CCT suggested presence of coagulopathy. Transfusion therapy based on CCT led to a large number of patients receiving allogeneic blood transfusion, possibly unnecessarily. The use of ROTEM to identify the underlying coagulopathy and as a transfusion guide in this population of critically ill patients has the potential to avoid inappropriate allogeneic blood product transfusions.