Hipokoagulasi sebagai prediktor kejadian Overt Disseminated Intravascular Coagulation (DIC) pasien COVID-19 di ruang perawatan intensif

YUNAN NADHIF FANANI, Dr. dr. Usi Sukorini, M. Kes., Sp.PK (K) ; dr. Ira Puspitawati, M.Kes., Sp.PK (K)

2024 | Tesis-Spesialis | S2 Ilmu Patologi Klinik

Latar belakang: Pandemi COVID-19 merupakan burden diseases di seluruh dunia. COVID-19 associated coagulopathy (CAC) merupakan salah satu manifestasi klinis yang berat pada COVID-19. Luaran klinis CAC bervariatif mulai ringan, disseminated intravascular coagulation (DIC), kegagalan organ hingga kematian. Status koagulasi pada pasien COVID-19 dapat diketahui melalui coagulation index tromboelastografi (CI TEG). Belum diketahui apakah CI TEG <-3, dapat berisiko 1,6 kali terjadinya overt DIC. 

Tujuan: Mengetahui apakah hipokoagulasi (CI TEG< -3) dapat memprediksi risiko kejadian overt DIC pada pasien COVID-19 derajat berat di RSUP Dr. Sardjito Yogyakarta.

Metode: Penelitian cross-sectional retrospective study dengan subyek pasien COVID-19 di ruang intensif di RSUP Dr. Sardjito. Data diambil berdasarkan hasil RT PCR di Instalasi Laboratorium Terpadu. Kriteria inklusi pasien terkonfirmasi COVID-19, usia>18tahun. dilakukan pemeriksaan CI TEG, jika CI TEG <-3 sebagai hipokoagulasi. Data jumlah trombosit, prothrombin time, fibrinogen, D-dimer dilacak dan dicatat. Dilakukan penghitungan skor DIC berdasar ISTH, untuk menentukan luaran overt atau non overt DIC. Data ditampilkan dalam rerata±simpang baku, median(minimal–maksimal) atau proporsi. Perbedaan rerata diuji menggunakan independent sample t-test atau Mann Whitney U test. Perbedaan proporsi menggunakan Fisher’s exact test. Dilakukan uji multivariat regresi logistik. Analisis data menggunakan IBM SPSS Statistic versi 23. Nilai p kurang dari 0,05 dianggap signifikan secara statistik.

Hasil: Sebanyak 41 sample dari 38 subyek dianalisis dalam penelitian ini, 11(26,8%) mengalami luaran overt DIC. Umur,jenis kelamin, penyakit komorbid, tidak berbeda secara signifikan antara kelompok overt DIC dan non overt DIC. Proporsi CI TEG, prothrombin time, D-dimer, fibrinogen, berbeda secara signifikan antara kelompok overt DIC dan non overt DIC (p kurang dari 0,05). Hasil analisis hipokoagulasi dengan CI TEG <-3 memiliki peluang 19,2 kali (95% CI 1,99 – 184,1 ; p=0,011 ) sebagai faktor risiko kejadian overt DIC. 

Simpulan: Hipokoagulasi CI TEG< –3 memiliki prevalensi risiko terjadinya overt DIC 19,2 kali lebih tinggi, dan merupakan faktor risiko independen untuk peluang terjadinya overt DIC pada pasien COVID-19 derajat berat di RSUP Dr. Sardjito Yogyakarta.

Background: The COVID-19 pandemic was a worldwide burden disease. COVID-19 associated coagulopathy (CAC) was one of the severe clinical manifestations of COVID-19. The clinical outcomes of CAC varied, from mild, disseminated intravascular coagulation (DIC), organ failure to mortality. The coagulation in COVID-19 patients could be assessed using the coagulation index thromboelastography (CI TEG). It has not yet known whether hypocoagulation was a risk factor for overt DIC.

Objective: To determine whether hypocoagulation (CI TEG < -3) can predicted the risk of overt DIC in severe COVID-19 patients at Dr. Sardjito Hospital Yogyakarta.

Methods: it was a cross-sectional retrospective study with subjects of COVID-19 patients in the intensive care unit at Dr. Sardjito Hospital. The data were taken based on the results of RT-PCR at the Integrated Laboratory Installation. The inclusion criteria were patients with confirmed COVID-19, over 18 years of age. CI TEG examination was performed. CI TEG <-3 as hypocoagulation. Platelet count, prothrombin time, fibrinogen, D-dimer were tracked and recorded. The DIC score was calculated based on ISTH, to determined the outcome of overt DIC or non overt DIC. The data were presented as mean ± standard deviation, median (minimum-maximum) and percentage, proportion. Independent sample t-test or Mann Whitney U test was used to test the difference in means. Fisher's exact test was used to test the difference in proportions. Multivariate logistic regression test was performed. Data were analyzed using IBM SPSS Statistic version 23. p value less then 0.05 was considered statistically significant.

Results: A total of 41 samples of 38 subjects were analyzed in this study, eleven samples (26.8%) had overt DIC outcomes. Age, gender, comorbid diseases, were not significantly different between the overt DIC and non overt DIC groups. The proportion of CI TEG, PT, D-dimer, fibrinogen, were significantly different between the overt DIC and non overt DIC groups (p less then 0.05). The result of the analysis was hypocoagulation CI TEG <-3 had 19.2 times the prevalence of overt DIC (PR=19.2; 95% CI 1.99–184.1; p=0.011).

Conclusion: CI TEG hypocoagulation < –3 has a 19.2 times higher prevalence of risk of overt DIC, and it was an independent risk factor for the chance of overt DIC in severe COVID-19 patients at Dr. Sardjito Hospital Yogyakarta

Kata Kunci : COVID-19, Tromboelastografi, disseminated intravascular coagulation