Thromboelastography Predicts Thromboembolism in Critically Ill Coagulopathic Patients. Harahsheh Y, Duff OC, Ho KM. Crit Care Med. 2019 Jun; 47(6):826-832.
The utilization of thromboelastography to direct the resuscitative efforts of trauma patients with blood component products had been proven to be helpful in acute management as well as with resource preservation. The focus has always been on assessment of different parameters of clot formation to direct therapy, however, Harasheh et al., focused on the predictive capabilities of thromboelastography to determine the occurrence of thromboembolism in critically ill coagulopathic patients.
Approximately 20-30% of patients admitted to the ICU have abnormal coagulation profiles ( INR > 1.5, aPTT > 40s ) or thrombocytopenia ( < 150 x 109 L) and as such VTE prophylaxis is withheld which may preclude these patients to VTE development. This prospective cohort study, aimed to assess whether whole blood in vitro clot strength as determined by the maximum amplitude (MA) can predict the development of thromboembolism in critically ill patients with acquired coagulopathy as well as the need for blood transfusion within 24H of enrollment. 215 patients met inclusion criteria for the study where a blood sample was obtained within 48H of Med-Surg ICU admission for thromboelastography. Despite the presence of an abnormal coagulation profile the majority of patients had a normal MA 54-72mm ( n=124) or an increased in vitro clot strength MA >72mm (n=39). Of the 215 patients, 34 developed symptomatic thromboembolism; 23 venous and 11 arterial. The incidence of thromboembolism was increased in patients who had a normal MA (n=14) or increased MA (n=17) as compared to those who had a reduced MA (n=3). The strength of the maximum amplitude had a moderate ability to discriminate between patients with and without subsequent thromboembolism (area under the receiver-operating characteristic curve 0.738; 95% CI, 0.641-0.834; p,0.001). An increase in MA was significantly associated with a higher risk of thromboembolism in both the adjusted and unadjusted risk analyses. In terms of need for blood transfusion, patients with a higher MA (n=5) received less blood transfusions compared to those with a normal (n=42) or reduced MA (n=36).
In critically ill patients with an abnormal coagulation profile the decision of when and in whom to initiate VTE prophylaxis is difficult. This study demonstrated that with the use of thromboelastography especially with an increased MA there is a higher risk of developing a thromboembolism and a lower risk of bleeding thereby less need for transfusion in this cohort of patients. It may have also broadened the utilization of thromboelastography to aid in when to initiate VTE prophylaxis in coagulopathic critically ill patients without active bleeding.
Fluid Overload Associates With Major Adverse Kidney Events in Critically Ill Patients With Acute Kidney Injury Requiring Continuous Renal Replacement Therapy. Woodward CW, Lambert J, Ortiz-Soriano V, Li Y, Ruiz-Conejo M, Bissell B, Kelly A, Adams P, Yessayan L, Morris PE, Neyra JA. Crit Care Med. 2019 Sep;47(9):e753-e760. .
Fluid overload (FO) has been found to be associated with increased mortality, increased ventilator dependence, and reduced renal recovery in Acute Kidney Injury (AKI) critically ill patients due to a state of impaired homeostasis secondary to impaired renal function and/or iatrogenic excessive fluid administration. The focus of this retrospective cohort study was to evaluate the association between FO at the start of Continuous Renal Replacement Therapy (CRRT) and Major Adverse Kidney Effects (MAKE) in critically ill patients with AKI.
Patients admitted to the ICU that developed an AKI requiring CRRT were eligible for the study. The FO was estimated based on a formula by Goldstein et al., which was calculated from fluid status data extrapolated from ICU admission to the time of CRRT initiation. FO was examined as both a continuous variable as well as a categorical variable: FO < 10%; FO >10%. The primary outcome was MAKE (mortality, dependence on RRT, or inability to recover > 50% of kidney function based on GFR). 481 patients were included in the study where 243 were < 10% FO and 238 were >10% FO. Patients with less than 10% FO were less likely to need blood transfusion, had a higher Charlson Comorbidity Index (CCI) and were started earlier on CRRT from time of ICU admission compared to those with >10% FO. Data assessment demonstrated a lower prevalence of MAKE in patients with FO <10% compared to those with FO > 10%(71.6% vs. 79.4%; p= 0.047). There was also a significant correlation between FO from time of ICU admission to initiation of CRRT (rs= 0.213; p < 0.001). Multivariable analysis revealed a 58% increased adjusted odds of MAKE in patients with FO greater than 10% (p = 0.046). Clinical factors that impacted on MAKE were older age, higher CCI, lack of diuretic use and longer time to initiation of CRRT. In-house mortality was decreased in patients with a FO <10% as compared to those with FO >10% ( 54.7% vs. 66.0%; p = 0.012). As CCI, age and use of diuretics were found to be associated with MAKE, an interaction analysis performed demonstrated that even though diuretic use by itself decreased the prevalence of MAKE this effect was increased as the CCI increased.
FO remains a significant risk factor to adverse events in critically ill patients with AKI requiring CRRT. This study demonstrated that in patients with FO > 10% at the time of CRRT initiation there was an independent association with MAKE, hospital mortality and fewer ventilator-free days. It also demonstrated a protective effect of diuretic use, which was amplified as Charlson score increased. FO is a risk factor that is modifiable and as such fluid status should be carefully managed in the critically ill in hopes of preventing the potential adverse effects of FO in AKI patients who may require CRRT.