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Abstract：
Objective: To identify whether coagulation profiles using thromboelastometry are associated with outcomes in pediatric septic shock. The primary outcomes were the development of disseminated intravascular coagulation (DIC) and the severity of the pediatric intensive care unit (PICU) existing scoring systems, while the secondary outcome was hospital mortality. This study aimed to contribute to current findings of the limitations of conventional tests in determining the optimal timing of anticoagulation in sepsis. Design: A prospective, observational study conducted between August 2019 and August 2020. Setting: PICU at a pediatric tertiary hospital in Hanoi, Vietnam. Patients: Fifty-five pediatric patients who met the septic shock criteria were enrolled. Measurements and Main Results: Fifty-five patients with septic shock were recruited. At the time of diagnosis, thromboelastometry revealed normocoagulability, hypercoagulability, and hypocoagulability in 29, 29, and 42% of the patients, respectively (p > 0.05); however, most patients in the overt DIC and non-survival groups progressed to hypocoagulability (82 and 64%, respectively). The overt DIC, PELOD-2 > 8, PRISM-III > 11, and non-survival group had a significant hypocoagulable tendency according to thromboelastometry parameters [prolonged clotting time (CT) and clot formation time (CFT); and reduced α-angle (α), maximum clot firmness (MCF), thrombodynamic potential index (TPI)] compared to the non-overt DIC, PELOD-2 ≤ 8, PRISM-III score ≤ 11 and survival group (p < 0.05). Conventional parameters between the normocoagulable and hypercoagulable groups were not different (p > 0.05). Hypocoagulability was characterized by lower platelet count and fibrinogen level, higher prolonged prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (APTT), and higher D-dimer level than in hypercoagulability (p < 0.05). Hypocoagulable tendency on thromboelastometry had a higher hazard at a PT > 16.1 s [area under the curve (AUC) = 0.747, odds ratio (OR) = 10.5, p = 0.002], INR > 1.4 (AUC = 0.754, OR = 6.9, p = 0.001), fibrinogen <3.3 g/L (AUC = 0.728, OR = 9.9, p = 0.004), and D-dimer > 3,863 ng/mL (AUC = 0.728, OR = 6.7, p = 0.004). Conclusions: Hypocoagulable tendency using thromboelastometry is associated with the severity of septic shock. Conventional coagulation tests may fail to detect hypercoagulability, which is crucial in determining anticoagulation timing.
摘要：
目的：确定使用血栓弹性测定法的凝血曲线是否与小儿脓毒性休克的结局相关。主要结果是弥散性血管内凝血（DIC）的发展和儿科重症监护病房（PICU）现有评分系统的严重程度，而次要结局是住院死亡率.这项研究旨在帮助目前发现常规测试在确定脓毒症抗凝治疗的最佳时机方面的局限性。设计：前瞻性，2019年8月至2020年8月进行的观察性研究。地点：河内一家三级儿科医院的PICU，越南。患者：纳入55例符合感染性休克标准的儿科患者。测量和主要结果：招募了55例脓毒性休克患者。在诊断的时候,血栓弹性分析显示凝血功能正常，高凝状态,29％、29％和42％的患者的低凝状态，分别(p>0.05)；然而，明显DIC和非生存组中的大多数患者进展为低凝状态(82%和64%，分别)。公开的DIC，PELOD-2>8，PRISM-III>11，根据血栓弹性测量参数[凝血时间（CT）和凝块形成时间（CFT）延长，非生存组有明显的低凝趋势；α角（α）减小，最大凝块硬度(MCF),血栓动力学电位指数（TPI）]与非明显的DIC相比，PELOD-2≤8，PRISM-III评分≤11，生存组（p<0.05）。常凝组和高凝组之间的常规参数没有差异（p>0.05）。低凝的特点是血小板计数和纤维蛋白原水平较低，延长凝血酶原时间（PT），国际标准化比率(INR)，活化部分凝血活酶时间（APTT），D-二聚体水平高于高凝状态（p<0.05）。在PT>16.1s[曲线下面积(AUC)=0.747,比值比(OR)=10.5,p=0.002]时,血栓弹性测量的低凝倾向具有更高的风险,INR>1.4（AUC=0.754，OR=6.9，p=0.001），纤维蛋白原<3.3g/L（AUC=0.728，OR=9.9，p=0.004），D-二聚体>3,863ng/mL(AUC=0.728,OR=6.7,p=0.004)。结论：使用血栓弹性测定法的低凝倾向与感染性休克的严重程度相关。常规凝血测试可能无法检测高凝状态，这对于确定抗凝时机至关重要。
