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Early Prediction of Coagulopathy in Acquired Bleeding Disorders - Revisited Using Rotational Thromboelastometry

OBJECTIVES: This study was done to establish a correlation between rotational thromboelastometryparameters and standard coagulation profile in the context of acquired bleeding disorders. 
BACKGROUND: Acquired bleeding disorders are a major cause of mortality, both in the developed and developing countries. An acute haemorrhage should be managed immediately with blood products, factor concentrates or antifibrinolytics. Investigations to detect coagulopathies typically include baseline screening tests like prothrombin time, activated partial thromboplastin time, platelet count and fibrinogen level. These tests have a long turnaround time which frequently lead to a blinded approach towards blood product support leading to under or over transfusion. In contrast, rotational thromboelastometry (ROTEM) which assesses haemostasis from the start of clot formation to fibrinolysis gives earliest results within ten minutes. 
AIMS AND OBJECTIVES: 
To compare the diagnostic ability of Rotational Thromboelastometry (ROTEM) with the standard coagulation profile to detect coagulation defects in acquired bleeding disorders. 
METHODS: 
A total of 138 subjects - 70 patients who presented with acquired bleeding disordersand 68 subjects diagnosed to be normal on the basis of a complete coagulation work up were included as the cases and controlsrespectively. All samples were subjected to standard coagulation profile by automated methods and ROTEM analysis which included Clotting Time, Clot Formation Time, Alpha Angle, Maximum Clot Firmness and Maximum Lysis. 
RESULTS: 
The Maximum Clot Firmness shows a very good correlation with serum fibrinogen levels (k value - 0.807; p<0.000; Sensitivity - 88%; Specificity - 92%), and good correlation with platelet count (k value - 0.793; p< 0.000; Sensitivity - 86%, Specificity-92%), whereas Clot Formation Time showed moderate correlation with activated partial thromboplastin time, platelet count and fibrinogen levels.Alpha angle had a moderate correlation with platelet count and fibrinogen.Clotting time had a poor correlation with prothrombin time and activated partial thromboplastin time. 
DISCUSSION AND CONCLUSION: 
The achievement of haemostasis is a crucial factor for determining patient outcomes in acquired bleeding disorders. The gold standard test to diagnose coagulopathy is the standard coagulation profile. Rotational thromboelastometry correlates well with standard coagulation parameters. This test which is performed on whole blood showed interpretable results within 10 minutes, whereas standard coagulation profile required an average of 45minutes. In view of the good correlation to the standard coagulation profile, it appears that Rotational Thromboelastometryresults can be safely used to implement early transfusion therapy for haemorrhage.