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.

2nd Faculty of Medicine Department of Anaesthesiology and Intensive Care Medicine Charles University Motol University Hospital Prague Czech Republic Europe

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Mohammed M, Fayed N, Hassanen A, et al. Rotational thromboelastometry and standard coagulation tests for live liver donors. Clin Transplant. 2013;27(2):E101–E108. PubMed

Urwyler N, Theiler L, Hirschberg M, Kleine-Brueggeney M, Colucci G, Greif R. Standard vs. point-of-care measurement of fibrinogen: potential impact on clinical decisions. Minerva Anestesiol. 2012;78(5):550–555. PubMed

Haas T, Spielmann N, Mauch J, et al. Comparison of thromboelastometry (ROTEM(R)) with standard plasmatic coagulation testing in paediatric surgery. Br J Anaesth. 2012;108(1):36–41. PubMed

Keene DD, Nordmann GR, Woolley T. Rotational thromboelastometry-guided trauma resuscitation. Curr Opin Crit Care. 2013;19(6):605–612. PubMed

Hoffman M, Monroe DM III. A cell-based model of hemostasis. Thromb Haemost. 2001;85(6):958–965. PubMed

Ostrowski SR, Windelov NA, Ibsen M, Haase N, Perner A, Johansson PI. Consecutive thrombelastography clot strength profiles in patients with severe sepsis and their association with 28-day mortality: a prospective study. J Crit Care. 2013;28(3):317 e311-311. PubMed

van Rheenen-Flach LE, Zweegman S, Boersma F, Lenglet JE, Twisk JW, Bolte AC. A prospective longitudinal study on rotation thromboelastometry in women with uncomplicated pregnancies and postpartum. Aust N Z J Obstet Gynaecol. 2013;53(1):32–36. PubMed

de Lange NM, van Rheenen-Flach LE, Lance MD, et al. Peri-partum reference ranges for ROTEM(R) thromboelastometry. Br J Anaesth. 2014;112(5):852–859. PubMed

Park MS, Martini WZ, Dubick MA, et al. Thromboelastography as a better indicator of hypercoagulable state after injury than prothrombin time or activated partial thromboplastin time. J Trauma. 2009;67(2):266–275; discussion 275-266. PubMed PMC

Prakash S, Verghese S, Roxby D, Dixon D, Bihari S, Bersten A. Changes in fibrinolysis and severity of organ failure in sepsis: a prospective observational study using point-of-care test--ROTEM. J Crit Care. 2015;30(2):264–270. PubMed

De Pietri L, Bianchini M, Montalti R, et al. Thrombelastography-guided blood product use before invasive procedures in cirrhosis with severe coagulopathy: a randomized, controlled trial. Hepatology. 2016;63(2):566–573. PubMed

Durila M, Lukas P, Astraverkhava M, Berousek J, Zabrodsky M, Vymazal T. 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. BMC Anesthesiol. 2015;15:89. PubMed PMC

Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801–810. PubMed PMC

Khalafallah A, Jarvis C, Morse M, et al. Evaluation of the innovance d-dimer assay for the diagnosis of disseminated intravascular coagulopathy in different clinical settings. Clin Appl Thromb Hemost. 2014;20(1):91–97. PubMed

Muller MC, Arbous MS, Spoelstra-de Man AM, et al. Transfusion of fresh-frozen plasma in critically ill patients with a coagulopathy before invasive procedures: a randomized clinical trial (CME). Transfusion. 2015;55(1):26–35; quiz 25. PubMed

Li J, Liu Y, Yin W, et al. Alterations of the preoperative coagulation profile in patients with acute appendicitis. Clin Chem Lab Med. 2011;49(8):1333–1339. PubMed

Zeerleder S, Hack CE, Wuillemin WA. Disseminated intravascular coagulation in sepsis. Chest. 2005;128(4):2864–2875. PubMed

Daudel F, Kessler U, Folly H, Lienert JS, Takala J, Jakob SM. Thromboelastometry for the assessment of coagulation abnormalities in early and established adult sepsis: a prospective cohort study. Crit Care. 2009;13(2):R42. PubMed PMC

Collins PW, Macchiavello LI, Lewis SJ, et al. Global tests of haemostasis in critically ill patients with severe sepsis syndrome compared to controls. Br J Haematol. 2006;135(2):220–227. PubMed

Levi M, Hunt BJ. A critical appraisal of point-of-care coagulation testing in critically ill patients. J Thromb Haemost. 2015;13(11):1960–1967. PubMed

Simmons J, Pittet JF. The coagulopathy of acute sepsis. Curr Opin Anaesthesiol. 2015;28(2):227–236. PubMed PMC

Lipinska-Gediga M. Coagulopathy in sepsis - a new look at an old problem. Anaesthesiol Intensive Ther. 2016;48(5):352–359. PubMed

Muller MC, Meijers JC, Vroom MB, Juffermans NP. Utility of thromboelastography and/or thromboelastometry in adults with sepsis: a systematic review. Crit Care. 2014;18(1):R30. PubMed PMC

Mackman N, Tilley RE, Key NS. Role of the extrinsic pathway of blood coagulation in hemostasis and thrombosis. Arterioscler Thromb Vasc Biol. 2007;27(8):1687–1693. PubMed

Hagemo JS, Christiaans SC, Stanworth SJ, et al. Detection of acute traumatic coagulopathy and massive transfusion requirements by means of rotational thromboelastometry: an international prospective validation study. Crit Care. 2015;19:97. PubMed PMC

Gorlinger K, Saner FH. Prophylactic plasma and platelet transfusion in the critically Ill patient: just useless and expensive or even harmful? BMC Anesthesiol. 2015;15:86. PubMed PMC

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

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ClinicalTrials.gov
NCT02971111