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LETTER TO THE EDITOR
Year : 2021  |  Volume : 3  |  Issue : 1  |  Page : 17

Do TEG Parameters Like Maximum Amplitude, Reaction Time Predict Sepsis-Induced Coagulopathy and Mortality?


Department of Critical Care Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission31-Oct-2021
Date of Acceptance24-Nov-2021
Date of Web Publication10-Dec-2021

Correspondence Address:
Dr. Syed Nabeel Muzaffar
Department of Critical Care Medicine, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
India
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DOI: 10.4103/JTCCM-D-21-00024

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How to cite this article:
Muzaffar SN. Do TEG Parameters Like Maximum Amplitude, Reaction Time Predict Sepsis-Induced Coagulopathy and Mortality?. J Transl Crit Care Med 2021;3:17

How to cite this URL:
Muzaffar SN. Do TEG Parameters Like Maximum Amplitude, Reaction Time Predict Sepsis-Induced Coagulopathy and Mortality?. J Transl Crit Care Med [serial online] 2021 [cited 2022 Jan 21];3:17. Available from: http://www.tccmjournal.com/text.asp?2021/3/1/17/332241



Dear Editor,

I read with great interest the article published by Li et al. in your esteemed journal in September 2021, entitled “TEG parameters maximum amplitude, reaction time predicts sepsis-induced coagulopathy and mortality: A prospective, observational study.”[1] The authors have done a great job to explore the spectrum of coagulopathy in sepsis by thromboelastography (TEG), in which they have found an association between deranged maximum amplitude (MA)/reaction time (R) ratio and poor outcome in sepsis. This study aptly emphasizes the possible advantages of a comprehensive test like TEG over conventional coagulation assays (CCAs). TEG analyzes the whole coagulation cascade in a holistic way unlike CCAs, which depicts only the initial phase of clotting cascade.[2] However, there are a few points which we would like to emphasize upon:

  1. Although the concept of MA/R is novel and has shown a good association with the outcome of patients in this study, rationale behind choosing MA/R ratio needs further explanation. MA depends upon platelet count and R depends upon clotting factors. However, fibrinogen levels are not considered in this ratio, which is mainly depicted by the alpha angle, and has an importance influence on kinetics of clot formation. In addition, deranged fibrinogen levels also play an important role in sepsis-induced coagulopathy[3]
  2. Normal baseline values for TEG in healthy controls have not yet been validated and may vary between different populations. Studies are required to establish the baseline values and then decide test cutoffs accordingly. The rationale behind deciding cutoffs for MA/R and formation of three groups (MA/R0, MA/R1, and MA/R2) are not clear from the methodology
  3. Majority of patients were elderly and had abdominal infections. It would have been interesting to know how many of them had surgical etiology of infection as source control is an essential step influencing outcome of patients in surgical cases
  4. Most of the patients in this study were in septic shock and had higher intensive care unit (ICU) mortality of around 50% (and around 67% hospital mortality) as compared to mortality rates mentioned in the literature,[4],[5] which may depend upon many factors such as time to ICU admission (although not high in this study) and usual standard of care provided. Hence, it is difficult to associate MA/R to the disease process per se
  5. Blood component therapy and its influence on MA/R kinetics are not clear from the study
  6. Besides sepsis, patients with cirrhosis may also not bleed despite having an apparently deranged coagulation profile. This may be due to the underlying pathophysiological change of balanced coagulopathy.[6] Thus, TEG also has an important role in managing coagulopathy in patients with cirrhosis also
  7. Incidence of sepsis and its further differentiation into bacterial versus fungal sepsis may also influence the study results. Thus, applicability of the study results may not be similar in different etiologies of sepsis


To conclude, TEG is popular in the fields of cardiac surgery and trauma, and its exploration in the management of cirrhosis and sepsis would help in maximizing its utility in these areas. Further large-scale research is required looking into different TEG parameters rigorously and thereby utilizing a promising tool like TEG holistically for the diagnosis and management of sepsis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Li X, Wang L, Liang Y, Li L, Li X, Zhang Z, et al. TEG parameters maximum amplitude, reaction time predicts sepsis-induced coagulopathy and mortality: A prospective, observational study. J Transl Crit Care Med 2021;3:5.  Back to cited text no. 1
    
2.
Afzal A, Syed NM. Thromboelastography and thromboelastometry in patients with sepsis – A mini-review. J Anesth Intensive Care Med 2017;3:555603.  Back to cited text no. 2
    
3.
Simmons J, Pittet JF. The coagulopathy of acute sepsis. Curr Opin Anaesthesiol 2015;28:227-36.  Back to cited text no. 3
    
4.
Vincent JL, Jones G, David S, Olariu E, Cadwell KK. Frequency and mortality of septic shock in Europe and North America: A systematic review and meta-analysis. Crit Care 2019;23:196.  Back to cited text no. 4
    
5.
Auriemma CL, Zhuo H, Delucchi K, Deiss T, Liu T, Jauregui A, et al. Acute respiratory distress syndrome-attributable mortality in critically ill patients with sepsis. Intensive Care Med 2020;46:1222-31.  Back to cited text no. 5
    
6.
Tripodi A, Mannucci PM. The coagulopathy of chronic liver disease. N Engl J Med 2011;365:147-56.  Back to cited text no. 6
    




 

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