HUBUNGAN COAGULATION INDEX TROMBOELASTOGRAFI (CI TEG) DENGAN KEMATIAN PADA PASIEN COVID-19

Yunan Nadhif Fanani, Dr. dr. Usi Sukorini, M.Kes., Sp.PK(K); dr. Ira Puspitawati, M.Kes., Sp.PK(K)

2023 | Tesis | S2 Kedokteran Klinik

Latar belakang: Pada bulan Maret 2020 WHO mengumumkan bahwa SARS-CoV-2  penyebab COVID-19 dinyatakan sebagai pandemi global. Pandemi COVID-19 dengan jumlah kasus terkonfirmasi dan kematian yang tinggi merupakan beban di seluruh negara-negara di dunia. Gejala klinis bervariasi mulai dari asimtomatik, hingga manifestasi klinis berat, koagulopati, kegagalan multi-organ dan berujung pada kematian. Hiperkoagulabilitas ataupun hipokoagulabilitas berkaitan dengan kematian pasien COVID-19. Tromboelastografi (TEG) merupakan penilaian status koagulasi secara menyeluruh dibanding parameter koagulasi rutin. Salah satu parameter TEG adalah coagulation index (CI). 

Tujuan: Mengetahui hubungan CI TEG dengan kematian pada pasien COVID-19  yang dirawat di RSUP Dr. Sardjito.

Metode: Penelitian dilakukan dengan kohort prospektif pada pasien COVID-19 yang dirawat di RSUP Dr. Sardjito. Inception cohort adalah pasien yang dirawat 24 jam pertama di ICU. Data diambil berdasarkan hasil PCR di laboratorium biomolekuler di Instalasi Laboratorium Terpadu. Kriteria inklusi yaitu pasien terkonfirmasi COVID-19, usia > 18 tahun. Pemeriksaan laboratorium yang dilakukan meliputi TEG, hemostasis rutin dan darah lengkap. Data dasar,  komorbid kematian sebagai keluaran dicatat. Data ditampilkan dalam rerata±simpang baku median (minimal–maksimal). Data kategorik disajikan dalam proporsi, dan hubungan antara CI TEG dan kematian dianalisis dengan risk relative. p kurang dari 0,05 dianggap signifikan secara statistik. Data dianalisis menggunakan perangkat lunak IBM SPSS Statistics versi 23.

Hasil: Sebanyak 75 subjek yang dianalisis dalam penelitian ini dengan 33 pasien (44%) mengalami keluaran meninggal. Jumlah leukosit, jumlah netrofil, D dimer, dan CI TEG secara signifikan berbeda pada kelompok keluaran meninggal dibanding hidup ( p kurang dari 0,05). Analisis bivariat terhadap kematian, untuk obesitas RR: 1,93 (p=0,013 95% CI: 1,14–3,24), CI TEG < -3,  RR: 2,05(p=0,002 95% CI: 1,29 – 3,24). Dilakukan analisis multivariat CI TEG < -3  sebagai faktor risiko kematian belum memiliki kemaknaan secara statistik dengan risiko relatif 4,14 (p=0,059; 95%CI : 0,36 – 47,01)

Simpulan: Coagulation index tromboelastografi (CI TEG) < -3, memiliki kecenderungan risiko kematian 2,05 kali lebih tinggi dibandingkan dengan CI TEG > = -3  pasien COVID-19 derajat berat yang dirawat di ICU.  Pada saat bersama dengan faktor lain (penyakit jantung, obesitas, pemanjangan PT/aPTT serta peningkatan D dimer) hubungan CI TEG < -3 terhadap kematian tidak signifikan.

Kata kunci: COVID-19, hipokoagulasi, coagulation index, Tromboelastografi 

Background: In March 2020 WHO announced that SARS-CoV-2 that causes COVID-19 was declared a global pandemic. The COVID-19 pandemic with a high number of confirmed cases and deaths was a burden to all countries in the world. The clinical symptoms varied from asymptomatic to severe clinical manifestations, the coagulopathy, multi-organ failure and lead to the death. the hypercoagulability or hypocoagulability ware related to the death of COVID-19 patients. The Thromboelastography (TEG) was a more comprehensive assessment of coagulation state than routine coagulation test. the coagulation index (CI) was one of the  TEG parameters. 

Objective: The aim of this study was to determine the correlation CI TEG and mortality in COVID-19 patients who were admitted at RSUP Dr. Sardjito.

Methods : It was a prospective cohort study in confirmed COVID-19 patients, who were hospitalized at RSUP dr Sardjito. The inception cohort were patients admitted for the first 24 hours in the ICU. The data were taken based on PCR results in the biomolecular laboratory. The inclusion criteria were patients with confirmed COVID-19,  more than 18 years old. The TEG, screening of hemostasis test,  complete blood count, baseline characteristic data, comorbidities and outcome mortality were recorded. The data were presented descriptively, presented  in mean±SD, median (minimum–maximum). The Categorical data were presented in proportions, and the association between CI TEG and mortality was analyzed by risk relative. p value less than 0.05 is considered statistically significant. The data were analyzed using IBM SPSS Statistic software version 23.

Results: Seventy-five  subjects were analyzed in this study and 33 (44%) patients had died as a outcome. The leukocyte count, neutrophil count, D dimers, and CI TEG were significantly different in the non-survive compared to survive group (p less than 0.05). the univariate analysis of mortality, for obesity RR: 1.93 (p=0.013 95% CI : 1.14–3.24), CI TEG < -3, RR: 2.05(p=0.002 95% CI : 1, 29 – 3.24).and the multivariate analysis was performed CI TEG < -3 as a risk factor for death but no statistically significance. RR 4.14 (p=0.059; 95%CI : 0.36 – 47.01).

Conclusion: the coagulation index thromboelastography (CI TEG) < -3 had a 2.05 times higher risk of mortality compared to CI TEG >= -3 in severe COVID-19 patients admitted to the ICU.  When CI TEG < -3 combined with other factors (ie:heart disease, obesity, prolongation of PT/aPTT and increased D dimer level) the correlation of CI TEG < -3 to mortality was not significant.

Keywords: COVID-19, hypocoagulation, coagulation index, thromboelastography

Kata Kunci : COVID-19, hipokoagulasi, coagulation index, Tromboelastografi