Patryck Lloyd-Donald1, Abhinav Vasudevan1, Peter Angus1, Paul Gow1, Johan Mårtensson2, Neil Glassford1, Glenn M Eastwood1, Graeme K Hart1, Rinaldo Bellomo3. 1. Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia. 2. Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia; Department of Anesthesia and Intensive Care Medicine, Karolinska University Hospital, Solna SE-171 77, Sweden; Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm SE-171 77, Sweden. 3. Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia; The University of Melbourne, Department of Intensive Care, Austin Hospital, Melbourne, Australia.. Electronic address: rinaldo.bellomo@austin.org.au.
Abstract
BACKGROUND AND AIMS: There is controversy about the true coagulation state of acutely ill patients with chronic liver disease (CLD) due to simultaneous pro- and anticoagulant factor deficits and limitations of conventional coagulation tests (CCTs). Thromboelastography (TEG) may provide more physiologically relevant insights. METHODS: In acutely ill patients with severe (Child-Pugh C) CLD, we conducted a prospective observational study of daily coagulation assessment with both CCTs and TEG. RESULTS: We studied 34 patients with CLD on a total of 109 occasions (median of 3 samples per patient), comparing findings with 157 healthy controls. Conventional coagulation tests and TEG both demonstrated clear hypocoagulability. Thromboelastography-confirmed delayed clot formation was demonstrated by longer reaction time (1.1 minutes vs 0.6 minutes on rapid TEG; P<.01), longer kinetic time (2.9 minutes vs 1.3; P<.01), more acute α angle (65° vs 72.2°; P<.01), and longer activated clotting time (157 seconds vs 105 seconds; P<.01). Patients with CLD demonstrated weaker thrombus strength (maximum amplitude, 43.3 mm vs 61.8 mm; P<.01) and reduced clot lysis (0% vs 1% on rapid TEG; P<.01). CONCLUSIONS: In acutely ill patients with CLD, TEG demonstrates delayed clot formation and weaker thrombus strength despite decreased clot lysis. This challenges the notion that such patients experience a balanced coagulation state, highlighting the complexity of their coagulopathies.
BACKGROUND AND AIMS: There is controversy about the true coagulation state of acutely ill patients with chronic liver disease (CLD) due to simultaneous pro- and anticoagulant factor deficits and limitations of conventional coagulation tests (CCTs). Thromboelastography (TEG) may provide more physiologically relevant insights. METHODS: In acutely ill patients with severe (Child-Pugh C) CLD, we conducted a prospective observational study of daily coagulation assessment with both CCTs and TEG. RESULTS: We studied 34 patients with CLD on a total of 109 occasions (median of 3 samples per patient), comparing findings with 157 healthy controls. Conventional coagulation tests and TEG both demonstrated clear hypocoagulability. Thromboelastography-confirmed delayed clot formation was demonstrated by longer reaction time (1.1 minutes vs 0.6 minutes on rapid TEG; P<.01), longer kinetic time (2.9 minutes vs 1.3; P<.01), more acute α angle (65° vs 72.2°; P<.01), and longer activated clotting time (157 seconds vs 105 seconds; P<.01). Patients with CLD demonstrated weaker thrombus strength (maximum amplitude, 43.3 mm vs 61.8 mm; P<.01) and reduced clot lysis (0% vs 1% on rapid TEG; P<.01). CONCLUSIONS: In acutely ill patients with CLD, TEG demonstrates delayed clot formation and weaker thrombus strength despite decreased clot lysis. This challenges the notion that such patients experience a balanced coagulation state, highlighting the complexity of their coagulopathies.
Authors: Hani Shamseddeen; Kavish R Patidar; Marwan Ghabril; Archita P Desai; Lauren Nephew; Sandra Kuehl; Naga Chalasani; Eric S Orman Journal: Am J Med Date: 2020-05-29 Impact factor: 4.965