Management of patients with acute hemorrhage requires addressing the source of bleeding, replenishing blood volume, and addressing any coagulopathy that may be present. Assessing coagulopathy and predicting blood requirements in real-time in patients experiencing ongoing bleeding can pose substantial challenges. In these patients, transfusion concepts based on ratios do not effectively address coagulopathy or reduce mortality. Moreover, ratio-based concepts do not stop bleeding; instead, they just give physicians more time to identify the bleeding source and plan management strategies. In clinical practice, standard laboratory coagulation tests (SLCT) are frequently used to assess various aspects of blood clotting. However, these tests may not always offer a comprehensive understanding of clinically significant coagulopathy and the severity of blood loss. Furthermore, the SLCT have a considerable turnaround time, which may not be ideal for making prompt clinical decisions. In recent years, there has been a growing interest in point-of-care viscoelastic assays like rotational thromboelastometry, which provide real-time, dynamic information about clot formation and dissolution.

• Bleeding
• Critical care
• Haemorrhage
• Intensive care unit
• Rotational thromboelastometry
• Viscoelastic tests

• Calibrated automated thrombogram
• Coagulation tests
• Hemostatic disorders
• Neonatal hemostasis
• Thromboelastography/rotational thromboelastometry
• Viscoelastic coagulation tests

• Infant, Newborn
• Humans
• Hemostasis
• Blood Coagulation Disorders/diagnosis
• Blood Coagulation Disorders/etiology
• Blood Coagulation
• Hemorrhage
• Hemostatics
• Thrombelastography/methods

• esc guidelines
• patient blood management
• patient safety
• patient empowerment

• Humans
• Cardiology
• Hemorrhage
• Risk Assessment/methods
• Blood Transfusion/methods

• neonatal
• developmental hemostasis
• viscoelastic test
• point-of-care tests

• Infant, Newborn
• Humans
• Intensive Care Units, Neonatal
• Blood Coagulation Tests
• Hemostasis
• Blood Coagulation
• Thrombelastography
• Hemostatics/therapeutic use
• Blood Coagulation Disorders/therapy
• Blood Coagulation Disorders/drug therapy

• Clot microstructure
• arterial blood
• critical illness
• venous blood

• National Institute for Social Care and Health Research
• European Social Fund

• cognitive bias
• intensive care unit
• misdiagnosis
• multidisciplinary team
• unclear diagnosis

• Anti-thrombotic therapy
• Biomarkers
• Guidelines
• Non-cardiac surgery
• Peri-operative beta-blockers
• Peri-operative cardiac management
• Peri-operative myocardial injury/infarction
• Peri-operative treatment of arrhythmias
• Post-operative cardiac surveillance
• Pre-operative cardiac risk assessment
• Pre-operative cardiac testing
• Pre-operative coronary artery revascularization
• Pre-operative treatment of valvular disease

• Humans
• Intraoperative Complications
• Postoperative Complications
• Risk Assessment

Data regarding the incidence of a coagulable state following heat stroke as assessed by Sonoclot signature analysis are limited. Our purpose was to appraise coagulopathy using a dynamic test capable of analyzing the entire coagulation cascade and to characterize coagulation in patients with heat stroke prior to transfusion.

The data of 106 patients were collected prospectively from the Critical Care Center of the General Hospital of Guangzhou Military Command. Coagulable state was defined as normal. Both hyper- and hypo-coagulable states were defined as coagulation defects. Hypercoagulability was defined as an activated clotting time (ACT) ≦195s and a clot rate (CR) >23, and hypocoagulability was defined as an ACT ≧119s and a CR < 7. The Sonoclot signature t examination was performed at the time of admission. Conventional tests, such as the prothrombin time (PT) and activated partial thromboplastin time (aPTT), were compared with Sonoclot monitoring to identify coagulation defects.

The average age of the 106 patients was 23.2±2.5 years. There were 102 males (96.3%) and 4 females (3.7%). Thirty-four patients (32.1%) were hypercoagulable and 44 patients (41.5%) were hypocoagulable at the time of admission; 28 patients (26.4%) had no evidence of a coagulopathy. Patients with hypocoagulability, unlike patients with hypercoagulability, had a higher sequential Organ Failure Assessment score, indicating a more severe multiple organ dysfunction score. Mortality was 5.9% in patients with hypercoagulability compared with 3.5% in patients with normal coagulation, and 18.1% in patients with a hypocoagulable state (P < 0.05). ACT was a predictor of mortality, while the CR and platelet function did not show statistical significance.

This study determined the clinical outcomes and prognostic value of coagulability in patients with heat stroke, as defined by Sonoclot signature analysis at the time of admission.

• coagulopathy
• heat stroke
• prognosis

• COVID-19
• Cerebral small vessel disease
• Coagulopathy
• Microparticles
• Stroke

• COVID-19/complications
• COVID-19/diagnostic imaging
• COVID-19/pathology
• COVID-19/virology
• Cell-Derived Microparticles/metabolism
• Cerebral Small Vessel Diseases/etiology
• Humans
• Risk Factors
• SARS-CoV-2/physiology
• Thrombosis/etiology

• Diabetic ketoacidosis (DKA)
• fractal dimension
• gel point
• haemorheology

• acute traumatic coagulopathy
• fibrinogen
• hypofibrinogenemia
• massive hemorrhage protocol
• transfusion medicine

• cerebral small vessel disease
• diet
• microparticles
• microthrombosis
• neurodegeneration

Liver produces most of the blood coagulation factors, so it is not surprising to see a deranged coagulation profile in patients receiving liver transplants. Besides standard laboratory methods to evaluate coagulation profile, point-of-care assays are being used regularly since their results are rapidly available. However, sparse information is available on the comparability of point-of-care coagulation assays with laboratory coagulation assays in this special setting. In this study, our aim is to observe the changing hemostatic profile during different stages of liver transplant surgery using laboratory-based tests and thromboelastography (TEG).

Fifty patients undergoing living donor liver transplantation surgery were selected. Coagulation tests (prothrombin time [PT], activated partial thromboplastin time [APTT], platelet count, and fibrinogen) and TEG were performed at various intervals during liver transplant surgeries – before induction of anesthesia, 2 h into dissection phase, 30 min into anhepatic phase, 30 min after reperfusion of homograft, postoperative – at closure of surgery, 12 h postoperative, and 24 h postoperative. Statistical analysis and Pearson correlation were performed between laboratory-based coagulation tests and TEG, and their pattern through various stages of the surgery analyzed.

Platelet count and fibrinogen have a significant positive correlation with TEG in almost all phases of liver transplant. PT and APTT have a positive correlation with TEG until uptake of new liver and predominantly negative correlation after that. However, this correlation is significant only before induction of anesthesia and anhepatic phase.

TEG can be used to estimate platelet count and fibrinogen concentrations in all phases but PT and APTT only before induction and anhepatic phase of liver transplant surgery. The decision regarding transfusion of blood products should be based on a combination of the clinical assessment of surgeon and anesthesia personnel combined with results from laboratory and TEG.

• Fresh frozen plasma (FFP)
• Hepatocellular carcinoma (HCC)
• Perioperative morbidity

• anaesthesia in oncology
• bleeding disorders & coagulopathies
• gastrointestinal tumours

• Adolescent
• Adult
• Antineoplastic Combined Chemotherapy Protocols
• Blood Transfusion
• Combined Modality Therapy
• Cytoreduction Surgical Procedures
• Humans
• Hyperthermia, Induced
• Middle Aged
• Prospective Studies
• Randomized Controlled Trials as Topic
• Thrombelastography
• Young Adult

• The Youth Science Foundation of Beijing Shijitan Hospital Affiliated with Capital Medical University

• Aged
• Aged, 80 and over
• Anticoagulants/adverse effects
• Aspirin/adverse effects
• Cohort Studies
• Critical Illness
• Drug Therapy, Combination
• Electronic Health Records
• Female
• Hemorrhage/chemically induced
• Hemorrhage/epidemiology
• Hemorrhage/etiology
• Humans
• Incidence
• Intensive Care Units
• Male
• Middle Aged
• New York/epidemiology
• Platelet Aggregation Inhibitors/adverse effects
• Retrospective Studies
• Risk Factors

• KL2 TR002379 NCATS NIH HHS

• Anesthesia
• cardiac surgery
• cardiovascular risk factors
• guideline
• preoperative evaluation
• shared decision-making

• Biomarker
• Burns
• Clot microstructure
• Coagulation
• Thermal injury

How to cite this article: Govil D, Pal D. Point-of-care Testing of Coagulation in Intensive Care Unit: Role of Thromboelastography. Indian J Crit Care Med 2019;23(Suppl 3):S202–S206.

• Analytical variability
• Coagulation
• Global hemostatic assay
• Point-of-care testing
• TEG

• Female
• Humans
• Liver Transplantation/methods
• Middle Aged
• Thrombelastography/methods

• T32 GM008721 NIGMS NIH HHS

Transfusion therapy is associated with increased morbidity, mortality and costs. Conventional coagulation tests (CCT) are weak bleeding predictors, poorly reflecting coagulation in vivo. Thromboelastometry (ROTEM) provides early identification of coagulation disorders and can guide transfusion therapy by goals, reducing blood components transfusion.

The aim of this study is to describe coagulation profile of critically ill patients using ROTEM and evaluate the association between CCT and thromboelastometry.

This is a retrospective, observational study conducted in medical-surgical intensive care unit (ICU). Adult patients (≥18 years) admitted to ICU between November 2012 and December 2014, in whom ROTEM analyses were performed for bleeding management were included in this study. The first ROTEM and CCT after ICU admission were recorded simultaneously. Additionally, we collected data on blood components transfusion and hemostatic agents immediately after laboratory tests results.

The study included 531 patients. Most ROTEM tests showed normal coagulation profile [INTEM (54.8%), EXTEM (54.1%) and FIBTEM (53.3%)] with divergent results in relation to CCT: low platelet count (51.8% in INTEM and 55.9% in EXTEM); prolonged aPTT (69.9% in INTEM and 63.7% in EXTEM) and higher INR (23.8% in INTEM and 27.4% in EXTEM). However 16,7% of patients with normocoagulability in ROTEM received platelet concentrates and 10% fresh frozen plasma.

The predominant ROTEM profile observed in this sample of critically ill patients was normal. In contrast, CCT suggested coagulopathy leading to a possibly unnecessary allogenic blood component transfusion. ROTEM test may avoid inappropriate allogeneic blood products transfusion in these patients.

• Aged
• Blood Transfusion
• Critical Care
• Critical Illness
• Female
• Hemorrhage/diagnosis
• Hemorrhage/therapy
• Hemostatics/therapeutic use
• Humans
• Male
• Middle Aged
• Retrospective Studies
• Thrombelastography

• thrombelastography, paediatric intensive care unit, haemostasis, observer variation

• Biomarkers
• Coagulation
• ROTEM
• Sepsis

• Anemia
• Patient blood management
• Patient outcome

• 10/104/06 Department of Health

Computer simulations can come in handy to train medical personnel with necessary skills to face the clinical scenarios involving various coagulopathies. Now a days, point of care (POC) devices such as thromboelastography, Sonoclot analyzer and newly approved rotational thromboelastometry (ROTEM) with faster results to assess coagulopathies are available on bedside of patients. ROTEM is emerging as a quick, portable, and well-validated device to evaluate coagulopathy in critical care and perioperative setup. A novel platelet-aggregometry integrated module enables simultaneous analysis of platelets as well as coagulation tests on the same screen. The entire gamut of POC signature curves obtained with different coagulation defects can be learned with graphical simulations. These simulations can be a valuable strategy to elucidate latent conditions, for which simulation interventions can then be designed to mimic different clinical scenarios.

• Anemia
• Blood loss
• Blood transfusion
• Hemostasis
• Patient blood management

• Direct oral anticoagulant
• Major orthopedic surgery
• Neuraxial anesthesia
• Perioperative management
• Postoperative management

• aspirin
• blood platelets
• clopidogrel
• cytochrome P-450 enzyme system
• platelet aggregation inhibitors
• platelet function tests

• Critical care
• Delayed graft function
• Hemodynamic monitoring
• Hepatic artery thrombosis
• Immunosuppression
• Intensive care unit
• Orthotopic liver transplantation
• Primary nonfunction

• Biomarkers/blood
• Clinical Trials as Topic/standards
• Government Regulation
• Humans
• United States
• United States Food and Drug Administration
• Validation Studies as Topic

• Haemorrhagic disorders
• blood component transfusion
• critical illness
• interventional radiology
• transfusion medicine

Coagulation is a dynamic process and the understanding of the blood coagulation system has evolved over the recent years in anaesthetic practice. Although the traditional classification of the coagulation system into extrinsic and intrinsic pathway is still valid, the newer insights into coagulation provide more authentic description of the same. Normal coagulation pathway represents a balance between the pro coagulant pathway that is responsible for clot formation and the mechanisms that inhibit the same beyond the injury site. Imbalance of the coagulation system may occur in the perioperative period or during critical illness, which may be secondary to numerous factors leading to a tendency of either thrombosis or bleeding. A systematic search of literature on PubMed with MeSH terms ‘coagulation system, haemostasis and anaesthesia revealed twenty eight related clinical trials and review articles in last 10 years. Since the balance of the coagulation system may tilt towards bleeding and thrombosis in many situations, it is mandatory for the clinicians to understand physiologic basis of haemostasis in order to diagnose and manage the abnormalities of the coagulation process and to interpret the diagnostic tests done for the same.

• Anaesthesia
• Coagulation system
• haemostasis

There is wide variation in the management of coagulation and blood transfusion practice in liver transplantation. The use of blood products intraoperatively is declining and transfusion free transplantations take place ever more frequently. Allogenic blood products have been shown to increase morbidity and mortality. Primary haemostasis, coagulation and fibrinolysis are altered by liver disease. This, combined with intraoperative disturbances of coagulation, increases the risk of bleeding. Meanwhile, the rebalancing of coagulation homeostasis can put patients at risk of hypercoagulability and thrombosis. The application of the principles of patient blood management to transplantation can reduce the risk of transfusion. This includes: preoperative recognition and treatment of anaemia, reduction of perioperative blood loss and the use of restrictive haemoglobin based transfusion triggers. The use of point of care coagulation monitoring using whole blood viscoelastic testing provides a picture of the complete coagulation process by which to guide and direct coagulation management. Pharmacological methods to reduce blood loss include the use of anti-fibrinolytic drugs to reduce fibrinolysis, and rarely, the use of recombinant factor VIIa. Factor concentrates are increasingly used; fibrinogen concentrates to improve clot strength and stability, and prothrombin complex concentrates to improve thrombin generation. Non-pharmacological methods to reduce blood loss include surgical utilisation of the piggyback technique and maintenance of a low central venous pressure. The use of intraoperative cell salvage and normovolaemic haemodilution reduces allogenic blood transfusion. Further research into methods of decreasing blood loss and alternatives to blood transfusion remains necessary to continue to improve outcomes after transplantation.

• Liver disease
• Transplantation
• Coagulation
• Transfusion
• Patient blood management
• Thromboelastography
• Cell salvage

• Blood Coagulation
• Blood Transfusion
• Elasticity
• End Stage Liver Disease/therapy
• Humans
• Liver Transplantation
• Platelet Transfusion
• Postoperative Complications
• Risk Factors
• Thrombelastography
• Treatment Outcome
• Viscosity

• Anemia/diagnosis
• Anemia/therapy
• Blood Coagulation/physiology
• Blood Loss, Surgical/prevention & control
• Blood Transfusion/methods
• Blood Transfusion/standards
• Disease Management
• Humans
• Patient-Centered Care/methods
• Patient-Centered Care/standards
• Quality Improvement/standards
• Quality Improvement/trends