Coagulation in acutely ill patients with severe chronic liver disease: insights from thromboelastography

2017-04

Lloyd-Donald, Patryck

Vasudevan, Abhinav

Angus, Peter W

Gow, Paul J

Mårtensson, Johan

Glassford, Neil J

Eastwood, Glenn M

Hart, Graeme K

Bellomo, Rinaldo

Hepatic cirrhosis

Global coagulation assays

Thromboelastography

Coagulopathy

Journal Article

0000-0002-1650-8939

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10.1016/j.jcrc.2016.10.030

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.

link

Journal of Critical Care 2017; 38: 215-224

Journal of Critical Care