Rotational thromboelastometry performed during the febrile phase of dengue in predicting progression to critical phase: A prospective case control study

Objectives

Dengue is a global health concern. Early identification of patients whose disease is likely to progress to a critical phase helps reduce mortality.

Methods

A total of 136 patients with fever, a positive dengue NS1 antigen test result, a platelet count >100 × 10⁹/l, and no plasma leakage who were admitted to National Hospital, Sri Lanka had conventional coagulation tests (CCTs); prothrombin time, activated partial thromboplastin time (APTT) and Clauss fibrinogen and ROTEM (rotational thromboelastometry) tests; extrinsic coagulation pathway (EXTEM) and intrinsic coagulation pathway (INTEM) on ROTEM delta performed on the 3^rd day of fever. Patients were followed up and categorized as “cases” if they progressed to critical phase and “controls” if they did not.

Results

A total of 36 cases and 100 controls were recruited. Results of the CCTs were not significant. The three ROTEM delta parameters (clotting time and clot formation time of the EXTEM and clot formation time of INTEM) had cut-off values with acceptable sensitivities and specificities on receiver operating characteristic curve analysis. When combined, these parameters predicted patients whose disease was unlikely to progress to a critical phase (negative predictive value of 84.37%).

Conclusions

ROTEM delta parameters on the 3^rd day of fever predicted progression, whereas CCTs did not. These parameters were generated in approximately 10 minutes, at the point of care. It would be prudent to substantiate these findings in a larger study. The subclinical coagulopathy evidenced by derangements in ROTEM delta with normal Clauss and platelet >100 × 10⁹/l raises the possibility of platelet dysfunction being the cause.