Thromboelastographic Analysis of Hemostatic Abnormalities in Dengue Patients Admitted in a Multidisciplinary Intensive Care Unit: A Cross-Sectional Study.

Sir,

We read with immense interest the study entitled “Thromboelastographic analysis of hemostatic abnormalities in dengue patients admitted in a multidisciplinary intensive care unit: a cross-sectional study” by Sureshkumar et al. published in April 2018 issue of your journal.[1] The authors have recorded and provided vital information on a relatively unexplored area and rightly pointed out that thromboelastography (TEG) may be helpful in understanding the pathophysiology of hemostatic abnormalities in patients with dengue.

We would like to comment on the following points which may need further elaboration:

TEG was done only at admission in this study. Serial analysis of TEG parameters would have better elucidated the dynamics of hemostatic abnormalities in these patients

Factors such as blood sample collection technique, transportation time of sample from the Intensive Care Unit (ICU) to laboratory and the TEG assay used (e.g., kaolin or heparinase TEG) are also crucial for an accurate interpretation of the coagulation pattern by TEG.[23] This information needs to be clearly mentioned in the methodology

TEG per se is not a good method for assessment of platelet function, for which better modalities are available.[45] It is difficult to correlate platelet count with platelet function using TEG

Some patients with dengue might have been in sepsis as well, which can further influence the coagulation profile

The references cutoff values for TEG have been provided by manufacturer (from studies on western population), which may not be applicable to our setup. Studies on healthy Indian cohorts can generate the normal reference range values for TEG parameters in our population.

A similar study was performed and published by us recently on the evaluation of coagulopathy in nonbleeding patients with sepsis at ICU admission. We found that TEG (unlike conventional coagulation assays) could delineate three types of coagulation patterns in patients with sepsis: normocoagulant, hyper- and hypocoagulant patterns. Besides, patients with septic shock had a trend toward hypocoagulation while those without shock had trend toward hypercoagulation.[6]

It has been aptly pointed out by the authors that the correlation of TEG with usage of blood component therapy or guiding the usage of drug therapies would definitely be more relevant to the clinicians. To conclude, TEG is emerging as a pivotal tool for assessment of hemostatic dysfunction in different areas (like sepsis) besides its classical role in trauma and cardiac surgeries. Larger studies are further needed for evaluating the role of TEG in guiding transfusion practices, monitoring, or instituting drug therapy and for prognostication of outcome.[7]

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