Hemoglobin Concentration Impacts Viscoelastic Hemostatic Assays in ICU Admitted Patients

Authors

David J. Roh, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.
Tiffany R. Chang, Department of Neurology and Neurosurgery, McGovern Medical School at UTHealth, Houston, TX.
Aditya Kumar, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.Follow
Devin Burke, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.
Glenda Torres, Department of Neurology and Neurosurgery, McGovern Medical School at UTHealth, Houston, TX.
Katherine Xu, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.
Winni Yang, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.
Azzurra Cottarelli, Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.
Ernest Moore, Department of Surgery, University of Colorado Denver, Aurora, CO.
Angela Sauaia, Department of Surgery, University of Colorado Denver, Aurora, CO.
Kirk Hansen, Department of Biochemistry and Molecular Genetics, University of Colorado Denver, Aurora, CO.
Angela Velazquez, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.
Amelia Boehme, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.
Athina Vrosgou, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.
Shivani Ghoshal, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.
Soojin Park, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.
Sachin Agarwal, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.
Jan Claassen, Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.
E Sander Connolly, Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.
Gebhard Wagener, Department of Anesthesiology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.
Richard O. Francis, Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.
Eldad Hod, Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.

Document Type

Article

Abstract

OBJECTIVES: Low hemoglobin concentration impairs clinical hemostasis across several diseases. It is unclear whether hemoglobin impacts laboratory functional coagulation assessments. We evaluated the relationship of hemoglobin concentration on viscoelastic hemostatic assays in intracerebral hemorrhage (ICH) and perioperative patients admitted to an ICU. DESIGN: Observational cohort study and separate in vitro laboratory study. SETTING: Multicenter tertiary referral ICUs. PATIENTS: Two acute ICH cohorts receiving distinct testing modalities: rotational thromboelastometry (ROTEM) and thromboelastography (TEG), and a third surgical ICU cohort receiving ROTEM were evaluated to assess the generalizability of findings across disease processes and testing platforms. A separate in vitro ROTEM laboratory study was performed utilizing ICH patient blood samples. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Relationships between baseline hemoglobin and ROTEM/TEG results were separately assessed across patient cohorts using Spearman correlations and linear regression models. A separate in vitro study assessed ROTEM tracing changes after serial hemoglobin modifications from ICH patient blood samples. In both our ROTEM (n = 34) and TEG (n = 239) ICH cohorts, hemoglobin concentrations directly correlated with coagulation kinetics (ROTEM r: 0.46; p = 0.01; TEG r: 0.49; p < 0.0001) and inversely correlated with clot strength (ROTEM r: -0.52, p = 0.002; TEG r: -0.40, p < 0.0001). Similar relationships were identified in perioperative ICU admitted patients (n = 121). We continued to identify these relationships in linear regression models. When manipulating ICH patient blood samples to achieve lower hemoglobin concentrations in vitro, we similarly identified that lower hemoglobin concentrations resulted in progressively faster coagulation kinetics and greater clot strength on ROTEM tracings. CONCLUSIONS: Lower hemoglobin concentrations have a consistent, measurable impact on ROTEM/TEG testing in ICU admitted patients, which appear to be artifactual. It is possible that patients with low hemoglobin may appear to have normal viscoelastic parameters when, in fact, they have a mild hypocoagulable state. Further work is required to determine if these tests should be corrected for a patient's hemoglobin concentration.

Medical Subject Headings

Humans; Blood Coagulation Disorders (diagnosis); Cerebral Hemorrhage (diagnosis, therapy); Hemoglobins (analysis); Hemostasis; Hemostatics; Thrombelastography (methods); Intensive Care Units

Publication Date

2-1-2023

Publication Title

Critical care medicine

E-ISSN

1530-0293

Volume

51

Issue

2

First Page

267

Last Page

278

PubMed ID

36661453

Digital Object Identifier (DOI)

10.1097/CCM.0000000000005700

Recommended Citation

Roh, David J.; Chang, Tiffany R.; Kumar, Aditya; Burke, Devin; Torres, Glenda; Xu, Katherine; Yang, Winni; Cottarelli, Azzurra; Moore, Ernest; Sauaia, Angela; Hansen, Kirk; Velazquez, Angela; Boehme, Amelia; Vrosgou, Athina; Ghoshal, Shivani; Park, Soojin; Agarwal, Sachin; Claassen, Jan; Connolly, E Sander; Wagener, Gebhard; Francis, Richard O.; and Hod, Eldad, "Hemoglobin Concentration Impacts Viscoelastic Hemostatic Assays in ICU Admitted Patients" (2023). Neurology. 1671.
https://scholar.barrowneuro.org/neurology/1671