Role of thromboelastography in the evaluation of septic shock patients with normal prothrombin time and activated partial thromboplastin time

Abstract

Coagulopathy is frequent in septic shock and plays a key role in multiple organ dysfunction. The aim of this study is to investigate application values of thromboelastography (TEG) for outcome in septic shock patients with a normal value of prothrombin time (PT) and active partial thromboplastin time (aPTT). Prospective observational study using 1298 consecutive septic shock patients with TEG at admission was conducted at the emergency department (ED) of a tertiary care hospital in South Korea between 2016 and 2019. After excluding overt-disseminated intravascular coagulation (DIC) defined by scoring system, we included patients with a normal value of international normalized ratio ≤ 1.3 and aPTT ≤ 34 s. The primary outcome was 28-day mortality. 893 patients were included and 129 patients with overt DIC were excluded. Of the 764 remaining patients, 414 (54.2%) patients showed normal PT and aPTT (28-day mortality rate, 11.4%). TEG values such as reaction time, kinetic time (K), alpha angle (α), maximum amplitude (MA) and lysis index (LY 30) showed no significant mean difference between the survivor and non-survivor groups. However, hypocoagulable TEG values such as α < 53° (12.0% vs. 23.4%; p = 0.039), and MA < 50 mm (6.3% vs. 21.3%; p = 0.002) were significantly higher in the non-survived group. In multivariate analysis, hypocoagulable state (defined as K > 3 and α < 53 and MA < 50) was independent factors associated with increased risk of death (OR 4.882 [95% CI, 1.698-14.035]; p = 0.003). In conclusion, septic shock patients with normal PT and aPTT can be associated with impaired TEG profile, such as hypocoagulability, associated with increased mortality.

Figure 1

Diagram of TEG. TEG thromboelastography; R reaction time; K kinetic time; MA maximal amplitude; α alpha angle; LY30 percentage of lysis after 30 min.

Figure 2

Flow diagram of the study subjects. TEG thromboelastography; DNR do not resuscitate; ED emergency department; DIC disseminated intravascular coagulation; PT prothrombin time; aPTT activated partial thromboplastin time.

Figure 3

Graphical representation of thromboelastographic tracings and parameters pertaining to the subjects in the survivor (Black dotted line) and non-survivor (Red solid line) groups. R reaction time; K kinetic time; α alpha angle; MA maximal amplitude.