151
|
Thromboelastometric prediction of mortality using the kinetics of clot growth in critically ill septic patients. Blood Coagul Fibrinolysis 2018; 29:533-539. [PMID: 29985193 DOI: 10.1097/mbc.0000000000000757] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
: Sepsis induces alterations in blood coagulation which are associated with mortality. Using rotational thromboelastometry (ROTEM), these states are often characterized by changes in parameters representing terminal clot lysis. However, the ROTEM changes are often subtle, making them difficult to recognize and interpret. The objective of this study is to evaluate a new ROTEM clot velocity parameter representing clot formation kinetics in septic ICU patients. We hypothesized that this time-based parameter was significantly different in critically ill septic survivors vs. nonsurvivors. This retrospective observational study included severe sepsis and septic shock patients having a minimum of two organ dysfunctions by Sequential Organ Failure Assessment criteria (study group), and a control group of healthy adults without infection . ROTEM with EXTEM activation was performed in all groups. The time from maximal clot formation velocity to zero velocity, representing the latter portion of time during active clot formation prior to achieving maximal clot firmness (t-AUCi) was calculated along with other ROTEM parameters and compared between septic survivors, nonsurvivors and healthy controls. A total of 76 septic patients, of which 26.3%, survived, were included in the study group, and 26 healthy control individuals were included in the control group. t-AUCi correlated with terminal clot lysis (P < 0.001), and was significantly prolonged in septic nonsurvivors compared with survivors and healthy controls (P < 0.001). t-AUCi also differentiated nonsurvivors vs. survivors among those patients having similar ROTEM lysis indices. t-AUCi was useful to differentiate critically ill septic patients, and could be useful to identify septic patients with high-risk of ICU mortality.
Collapse
|
152
|
Papageorgiou C, Jourdi G, Adjambri E, Walborn A, Patel P, Fareed J, Elalamy I, Hoppensteadt D, Gerotziafas GT. Disseminated Intravascular Coagulation: An Update on Pathogenesis, Diagnosis, and Therapeutic Strategies. Clin Appl Thromb Hemost 2018; 24:8S-28S. [PMID: 30296833 PMCID: PMC6710154 DOI: 10.1177/1076029618806424] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Disseminated intravascular coagulation (DIC) is an acquired clinicobiological
syndrome characterized by widespread activation of coagulation leading to fibrin
deposition in the vasculature, organ dysfunction, consumption of clotting
factors and platelets, and life-threatening hemorrhage. Disseminated
intravascular coagulation is provoked by several underlying disorders (sepsis,
cancer, trauma, and pregnancy complicated with eclampsia or other calamities).
Treatment of the underlying disease and elimination of the trigger mechanism are
the cornerstone therapeutic approaches. Therapeutic strategies specific for DIC
aim to control activation of blood coagulation and bleeding risk. The clinical
trials using DIC as entry criterion are limited. Large randomized, phase III
clinical trials have investigated the efficacy of antithrombin (AT), activated
protein C (APC), tissue factor pathway inhibitor (TFPI), and thrombomodulin (TM)
in patients with sepsis, but the diagnosis of DIC was not part of the inclusion
criteria. Treatment with APC reduced 28-day mortality of patients with severe
sepsis, including patients retrospectively assigned to a subgroup with
sepsis-associated DIC. Treatment with APC did not have any positive effects in
other patient groups. The APC treatment increased the bleeding risk in patients
with sepsis, which led to the withdrawal of this drug from the market. Treatment
with AT failed to reduce 28-day mortality in patients with severe sepsis, but a
retrospective subgroup analysis suggested possible efficacy in patients with
DIC. Clinical studies with recombinant TFPI or TM have been carried out showing
promising results. The efficacy and safety of other anticoagulants (ie,
unfractionated heparin, low-molecular-weight heparin) or transfusion of platelet
concentrates or clotting factor concentrates have not been objectively
assessed.
Collapse
Affiliation(s)
- Chrysoula Papageorgiou
- Service Anesthésie, Réanimation Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Georges Jourdi
- INSERM UMRS1140, Université Paris Descartes, Paris, France.,Service d'Hématologie Biologique, Hôpital Cochin, Assistance Publique des Hôpitaux de Paris, France
| | - Eusebe Adjambri
- Département d'Hématologie, Faculté de Pharmacie, Université Félix Houphouët Boigny, Abidjan, Côte d'Ivoire
| | - Amanda Walborn
- Department of Pathology, Cardiovascular Institute Loyola University Chicago, Maywood, IL, USA
| | - Priya Patel
- Department of Pathology, Cardiovascular Institute Loyola University Chicago, Maywood, IL, USA
| | - Jawed Fareed
- Department of Pathology, Cardiovascular Institute Loyola University Chicago, Maywood, IL, USA
| | - Ismail Elalamy
- Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique Hoôpitaux de Paris, Paris, France.,Cancer Biology and Therapeutics, Centre de Recherche Saint-Antoine, Institut National de la Santé et de la Recherche Médicale, INSERM U938 and Faculté de Médecine Pierre et Marie Curie (UPMC), Sorbonne Universities, Paris, France
| | - Debra Hoppensteadt
- Department of Pathology, Cardiovascular Institute Loyola University Chicago, Maywood, IL, USA
| | - Grigoris T Gerotziafas
- Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique Hoôpitaux de Paris, Paris, France.,Cancer Biology and Therapeutics, Centre de Recherche Saint-Antoine, Institut National de la Santé et de la Recherche Médicale, INSERM U938 and Faculté de Médecine Pierre et Marie Curie (UPMC), Sorbonne Universities, Paris, France
| |
Collapse
|
153
|
Yatabe T, Inoue S, Sakamoto S, Sumi Y, Nishida O, Hayashida K, Hara Y, Fukuda T, Matsushima A, Matsuda A, Yasuda H, Yamashita K, Egi M. The anticoagulant treatment for sepsis induced disseminated intravascular coagulation; network meta-analysis. Thromb Res 2018; 171:136-142. [PMID: 30312798 DOI: 10.1016/j.thromres.2018.10.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 09/22/2018] [Accepted: 10/05/2018] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The benefits and harm caused by anticoagulant treatments for sepsis induced disseminated intravascular coagulation (DIC) remain unclear. Therefore, we performed a network meta-analysis to assess the effect of available anticoagulant treatments on patient mortality, DIC resolution and the incidence of bleeding complication in patients with septic DIC. MATERIALS AND METHODS We considered all studies from four recent systematic reviews and searched the PubMed, MEDLINE, and Cochrane databases for other studies that investigated anticoagulant treatment for septic DIC using antithrombin, thrombomodulin, heparin, or protease inhibitors in adult critically ill patients. These four anticoagulants and placebo were compared. The primary outcome in this study was patient mortality, and the secondary outcomes were the DIC resolution rate and incidence of bleeding complications. RESULTS The network meta-analysis included 1340 patients from nine studies. There were no significant differences in the risks of mortality and bleeding complications among all direct comparisons and the network meta-analysis. Using a placebo was associated with a significantly lower rate of DIC resolution, compared to antithrombin in the direct comparison (odds ratio [OR]: 0.20, 95% credible interval [95% CrI]: 0.046-0.81) and in the network meta-analysis (OR: 0.20, 95% CrI: 0.043-0.84). CONCLUSIONS Our study revealed no significant differences in the risks for mortality and bleeding complications when a placebo and all four anticoagulants were compared in septic DIC patients. The results also indicated that antithrombin was associated with a five-fold higher likelihood of DIC resolution, compared to placebo.
Collapse
Affiliation(s)
- Tomoaki Yatabe
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi 783-8505, Japan
| | - Shigeaki Inoue
- Department of Emergency and Critical Care Medicine, Tokai University Hachioji Hospital, 1838 Ishikawa-cho, Hachioji, Tokyo 192-0032, Japan
| | - So Sakamoto
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima-ku, Tokyo 177-8521, Japan
| | - Yuka Sumi
- Healthcare New Frontier Promotion Headquarters Office, Kanagawa Prefectural Government, 1Nihon-odori, Naka-ku, Yokohama, Kanagawa 231-8588, Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192, Japan
| | - Kei Hayashida
- Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Yoshitaka Hara
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192, Japan
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara-cho, Okinawa 903-0215, Japan
| | - Asako Matsushima
- Department of Advancing Acute Medicine, Nagoya City University Graduate School of Medical Sciences, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8602, Japan
| | - Akihisa Matsuda
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba 270-1694, Japan
| | - Hideto Yasuda
- Department of Intensive Care Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba 296-8602, Japan
| | - Kazuto Yamashita
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo 650-0017, Japan.
| |
Collapse
|
154
|
Arishima T, Ito T, Yasuda T, Yashima N, Furubeppu H, Kamikokuryo C, Futatsuki T, Madokoro Y, Miyamoto S, Eguchi T, Haraura H, Maruyama I, Kakihana Y. Circulating activated protein C levels are not increased in septic patients treated with recombinant human soluble thrombomodulin. Thromb J 2018; 16:24. [PMID: 30275773 PMCID: PMC6161343 DOI: 10.1186/s12959-018-0178-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 07/24/2018] [Indexed: 01/01/2023] Open
Abstract
Background Recombinant human soluble thrombomodulin (rTM) has been used for the treatment of disseminated intravascular coagulation in Japan, and an international phase III clinical trial for rTM is currently in progress. rTM mainly exerts its anticoagulant effects through an activated protein C (APC)-dependent mechanism, but the circulating APC levels after rTM treatment have not been clarified. This prospective observational study investigated plasma APC levels after rTM treatment. Methods Plasma levels of soluble thrombomodulin, thrombin-antithrombin complex (TAT), protein C, and APC were measured in eight septic patients treated with rTM. APC generation in vitro was assessed in the presence or absence of rTM. Results rTM significantly increased thrombin-mediated APC generation in vitro. In septic patients, soluble thrombomodulin levels were significantly increased during a 30–60-min period of rTM treatment and TAT levels were decreased. However, APC activity was not increased during the treatment period. Conclusions Plasma APC activity is not increased in septic patients treated with rTM. It is possible that APC acts locally and does not circulate systemically. Electronic supplementary material The online version of this article (10.1186/s12959-018-0178-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Takuro Arishima
- 1Emergency and Critical Care Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Takashi Ito
- 1Emergency and Critical Care Center, Kagoshima University Hospital, Kagoshima, Japan.,2Department of Systems Biology in Thromboregulation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8544 Japan
| | - Tomotsugu Yasuda
- 1Emergency and Critical Care Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Nozomi Yashima
- 3Emergency and Intensive Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Hiroaki Furubeppu
- 1Emergency and Critical Care Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Chinatsu Kamikokuryo
- 3Emergency and Intensive Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Takahiro Futatsuki
- 1Emergency and Critical Care Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Yutaro Madokoro
- 1Emergency and Critical Care Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Shotaro Miyamoto
- 1Emergency and Critical Care Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Tomohiro Eguchi
- 1Emergency and Critical Care Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Hiroyuki Haraura
- 1Emergency and Critical Care Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Ikuro Maruyama
- 2Department of Systems Biology in Thromboregulation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8544 Japan
| | - Yasuyuki Kakihana
- 1Emergency and Critical Care Center, Kagoshima University Hospital, Kagoshima, Japan.,3Emergency and Intensive Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| |
Collapse
|
155
|
Iba T, Arakawa M, Ohchi Y, Arai T, Sato K, Wada H, Levy JH. Prediction of Early Death in Patients With Sepsis-Associated Coagulation Disorder Treated With Antithrombin Supplementation. Clin Appl Thromb Hemost 2018; 24:145S-149S. [PMID: 30198317 PMCID: PMC6714842 DOI: 10.1177/1076029618797474] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
For success in clinical trials, eliminating inclusion of patients with irreversible
recovery is important. The purpose of this study was to identify the patient population
who do not survive for more than 3 days. A total of 449 patients with sepsis suspected of
having disseminated intravascular coagulation (DIC) and treated with antithrombin were
examined. The patient characteristics, baseline sequential organ failure assessment (SOFA)
score, DIC score, and hemostatic markers were retrospectively analyzed in relation to
early death (died within 3 days). At the end of day 3, a total of 419 patients had
survived and 30 patients had died. A logistic regression analysis revealed a significant
association between early death and the baseline prothrombin time-international normalized
ratio PT-INR (P <.05) and the total SOFA score (P
<.01). In contrast, neither the platelet count, fibrinogen/fibrin degradation products,
and antithrombin activity nor the DIC score was associated with early death. Although the
accuracy for predicting early death defined by either baseline PT-INR of ≥1.57 or total
SOFA score of more than 13 was not high enough, that of “high-risk of early death (PT-INR
≥ 1.57 and SOFA score ≥ 13)” was 83.5%. Furthermore, the negative predictive of this
category was 96.0%. The baseline SOFA score and PT-INR were associated with early death
among patients with sepsis-associated coagulation disorders. Patients who do not meet the
“high-risk of early death” criteria were likely to survive for more than 3 days and
therefore should be considered for future therapeutic clinical trials.
Collapse
Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Makoto Arakawa
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Yoshifumi Ohchi
- Department of Anesthesiology and Intensive Care, Oita University, Oita, Japan
| | - Takao Arai
- Department of Emergency and Critical Care Medicine, Trauma and Emergency Center, Hachioji Medical Center, Tokyo Medical University, Tokyo, Japan
| | - Koichi Sato
- Department of Surgery, Juntendo Shizuoka Hospital, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Wada
- Department of Molecular Laboratory Medicine, Mie University Graduate School of Medicine, Mie, Japan
| | - Jerrold H Levy
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
156
|
Wang Y, Ouyang Y, Liu B, Ma X, Ding R. Platelet activation and antiplatelet therapy in sepsis: A narrative review. Thromb Res 2018; 166:28-36. [DOI: 10.1016/j.thromres.2018.04.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 04/03/2018] [Accepted: 04/06/2018] [Indexed: 12/31/2022]
|
157
|
The impact of organ dysfunctions on mortality in patients with severe sepsis: A multicenter prospective observational study. J Crit Care 2018; 45:178-183. [DOI: 10.1016/j.jcrc.2018.03.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 02/08/2018] [Accepted: 03/02/2018] [Indexed: 12/29/2022]
|
158
|
Iba T, Arakawa M, Di Nisio M, Gando S, Anan H, Sato K, Ueki Y, Levy JH, Thachil J. Newly Proposed Sepsis-Induced Coagulopathy Precedes International Society on Thrombosis and Haemostasis Overt-Disseminated Intravascular Coagulation and Predicts High Mortality. J Intensive Care Med 2018; 35:643-649. [PMID: 29720054 DOI: 10.1177/0885066618773679] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Disseminated intravascular coagulation (DIC) has been recognized as an urgent and critical condition in patients with sepsis. Therefore, unfamiliar and time-consuming tests or a complex scoring system are not suitable for diagnosis. Sepsis-induced coagulopathy (SIC), a newly proposed category delineated by a few global coagulation tests, has been established as an early warning sign for DIC. The purpose of this study was to elucidate the characteristics of SIC, especially in relation to the score of the International Society on Thrombosis and Haemostasis (ISTH) for overt DIC. METHOD A data set for 332 patients with sepsis who were suspected to have DIC, antithrombin activity <70%, and treated with antithrombin substitution was utilized to examine the relationship between SIC and overt DIC. The performance of SIC calculated at baseline (ie, before treatment) as well as on days 2, 4, or 7 was analyzed in terms of its ability to predict 28-day mortality and overt DIC. RESULTS At baseline, 149 (98.7%) of 151 patients with overt DIC according to the ISTH definition were diagnosed as having SIC. Of the 49, 46 (93.9%) patients who developed overt DIC between days 2 and 4 had received a prior diagnosis of SIC. The sensitivity of baseline SIC for the prediction of death was significantly higher than that of overt DIC (86.8% vs 64.5%, P < .001). The sensitivity of SIC on days 2, 4, and 7 was significantly higher than those of overt DIC (96.1%, 92.3%, and 84.4% vs 67.1%, 57.7%, and 50.0%, P < .001, .001, and .001, respectively), although the specificity of SIC was lower at all time points.
Collapse
Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Hongo Bunkyo-ku, Tokyo, Japan
| | - Makoto Arakawa
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Hongo Bunkyo-ku, Tokyo, Japan
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University G.D'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Tokyo, Japan
| | - Hideaki Anan
- Emergency Medical Center, Fujisawa City Hospital, Tokyo, Japan
| | - Koichi Sato
- Department of Surgery, Juntendo Shizuoka Hospital, Juntendo University Graduate School of Medicine, Hongo Bunkyo-ku, Tokyo, Japan
| | - Yutaka Ueki
- Department of Acute Critical Care and Disaster Medicine, Tokyo Medical and Dental University, Bunkyō, Tokyo, Japan
| | - Jerrold H Levy
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, United Kingdom
| |
Collapse
|
159
|
Iba T, Arakawa M, Levy JH, Yamakawa K, Koami H, Hifumi T, Sato K. Sepsis-Induced Coagulopathy and Japanese Association for Acute Medicine DIC in Coagulopathic Patients with Decreased Antithrombin and Treated by Antithrombin. Clin Appl Thromb Hemost 2018; 24:1020-1026. [PMID: 29695178 PMCID: PMC6714750 DOI: 10.1177/1076029618770273] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) in patients with sepsis represents a critical condition. Thus, a simple and rapid diagnosis is required. The purpose of this study was to compare the performances of a recently developed Sepsis-Induced Coagulopathy (SIC) with the Japanese Association for Acute Medicine (JAAM) DIC. Four hundred nine patients with sepsis having coagulopathy and antithrombin activity of less than 70% and treated with antithrombin were retrospectively analyzed, and the SIC and JAAM-DIC criteria on days 1 (before treatment), 2, 4, and 7 were compared. The prevalence of JAAM-DIC on day 1 was significantly higher than that of SIC (91.4% vs 81.8%, P = .003), but there were no differences on days 2, 4, and 7. The mortality rates in the SIC and JAAM-DIC groups were both 23.3%. The specificity to 28-day mortality on day 1 was higher in the SIC group (15.8% vs 9.2%, P = .013). There were no differences in sensitivity on days 1, 2, 4, and 7. Mortality was significantly different between SIC-positive and SIC-negative groups on days 2, 4, and 7 (P < .01, respectively), while significant differences were seen between JAAM-DIC-positive and JAAM-DIC-negative groups only on days 4 and 7 (P < .05, .01, respectively). In summary, the SIC characteristics were similar to the JAAM-DIC group, and the classifications were comparable in terms of mortality prediction. The SIC scoring system is simple, easy to use, and adaptable to the new sepsis definitions and offers an important approach to evaluating patients in emergency and critical care settings.
Collapse
Affiliation(s)
- Toshiaki Iba
- 1 Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Makoto Arakawa
- 1 Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Jerrold H Levy
- 2 Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC, USA
| | - Kazuma Yamakawa
- 3 Department of Emergency and Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Hiroyuki Koami
- 4 Department of Emergency and Critical Care Medicine, Saga University, Saga, Japan
| | - Toru Hifumi
- 5 Emergency Medical Center, Kagawa University Hospital, Kagawa, Japan
| | - Koichi Sato
- 6 Department of Surgery, Juntendo Shizuoka Hospital, Juntendo University Graduate School of Medicine, Tokyo, Japan
| |
Collapse
|
160
|
Iba T, Di Nisio M, Thachil J, Wada H, Asakura H, Sato K, Saitoh D. A Proposal of the Modification of Japanese Society on Thrombosis and Hemostasis (JSTH) Disseminated Intravascular Coagulation (DIC) Diagnostic Criteria for Sepsis-Associated DIC. Clin Appl Thromb Hemost 2018; 24:439-445. [PMID: 28747069 PMCID: PMC6714647 DOI: 10.1177/1076029617720069] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Sepsis-associated disseminated intravascular coagulation (DIC) carries a high risk of death. Thus, a simple tool to quickly establish DIC diagnosis is required. The purpose of this study was to introduce the simple and reliable tool for the prediction of outcome in patients with sepsis complicated by coagulopathy. We investigated the performance of simplified Japanese Society on Thrombosis and Hemostasis (JSTH) DIC diagnostic criteria. In this study, we conducted a retrospective, multicenter survey in 107 general emergency and critical care centers in secondary and tertiary care hospitals. A total of 918 patients with sepsis-associated coagulopathy who underwent antithrombin supplementation were examined. The relationships between patient mortality and each of the baseline (ie, before treatment) JSTH-DIC diagnostic criteria were examined. A reduced platelet count, increased prothrombin time (PT) ratio, and lower antithrombin activity were correlated with 28-day mortality, while fibrinogen and fibrin degradation product (FDP) level were not. Thus, the number of points assigned to FDP levels was reduced from 3 to 1 (above 20 μg/mL). The simplified JSTH diagnostic criteria combining platelet count, PT ratio, antithrombin activity, and FDP level (reduction in the maximum score) strongly predicted 28-day mortality and allowed us to diagnose a larger/similar number of patients with DIC as compared to the original JSTH-DIC. The simplified JSTH-DIC diagnostic criteria show a similar performance to JSTH-DIC criteria in patients with septic coagulopathy. The lower number of laboratory markers used in the simplified JSTH-DIC score may increase its applicability and routine use in emergency and critical care setting.
Collapse
Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate
School of Medicine, Tokyo, Japan
| | - Marcello Di Nisio
- Department of Ageing Sciences, University G D’Annunzio of Chieti-Pescara,
Chieti, Italy
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, United
Kingdom
| | - Hideo Wada
- Department of Molecular Laboratory Medicine, Mie University Graduate School
of Medicine, Mie, Japan
| | - Hidesaku Asakura
- Third Department of Internal Medicine, Kanazawa University Graduate School
of Medical Science, Kanazawa, Japan
| | - Koichi Sato
- Department of Surgery, Juntendo Shizuoka Hospital, Juntendo University
Graduate School of Medicine, Tokyo, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical
College, Tokorozawa, Japan
| |
Collapse
|
161
|
Masuda T, Shoko T, Deguchi Y. Clinical Investigation of Coagulation Markers for Early Detection of Sepsis-Induced Disseminated Intravascular Coagulation: A Single-Center, Prospective Observational Study. Clin Appl Thromb Hemost 2018; 24:1082-1087. [PMID: 29552913 PMCID: PMC6714757 DOI: 10.1177/1076029618762473] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Disseminated intravascular coagulation (DIC) often complicates sepsis, and its early treatment is crucial for improving patient outcomes. Coagulation markers may enable earlier diagnosis of DIC. The purpose of this study was to evaluate whether the risk of DIC onset can be predicted using coagulation markers. Patients who showed symptoms of systemic inflammatory response syndrome ≥2 and the quick Sequential Organ Failure Assessment score ≥2 points were investigated. All blood samples collected from the time of hospital admission to 7 days postadmission were investigated. Patients were classified according to time of DIC onset (1) no DIC group (not DIC developed), (2) pre-DIC group (DIC onset >24 hours after admission), (3) DIC group (DIC onset at time of the admission) and according to cutoff values of coagulation markers, High group and Low group. Statistical differences were analyzed by log-rank test, Kruskal-Wallis rank test, and Friedman test. A total of 107 patients were enrolled in the study. Soluble fibrin (SF), plasminogen activator inhibitor (PAI)-1, and d-dimer levels were significantly increased even under pre-DIC conditions. Japanese Association for Acute Medicine (JAAM) DIC scores increased significantly over time in the High SF group (≥31.0 µg/mL) and High PAI-1 group (≥49.0 ng/mL), while JAAM DIC scores in the Low SF group remained ≤3 until day 7. We proposed the cutoff values of SF as 31 µg/mL to detect early phase of DIC. Soluble fibrin might be useful not only to predict DIC but also to exclude a diagnosis of DIC.
Collapse
Affiliation(s)
- Takamitsu Masuda
- 1 Emergency and Critical Care Center, Tokyo Women's Medical University, Arakawa-ku, Tokyo, Japan
| | - Tomohisa Shoko
- 1 Emergency and Critical Care Center, Tokyo Women's Medical University, Arakawa-ku, Tokyo, Japan
| | - Yoshizumi Deguchi
- 1 Emergency and Critical Care Center, Tokyo Women's Medical University, Arakawa-ku, Tokyo, Japan
| |
Collapse
|
162
|
Hayakawa M, Yamakawa K, Kudo D, Ono K. Optimal Antithrombin Activity Threshold for Initiating Antithrombin Supplementation in Patients With Sepsis-Induced Disseminated Intravascular Coagulation: A Multicenter Retrospective Observational Study. Clin Appl Thromb Hemost 2018. [PMID: 29514467 PMCID: PMC6714723 DOI: 10.1177/1076029618757346] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Low-dose antithrombin supplementation therapy (1500 IU/d for 3 days) improves outcomes in patients with sepsis-induced disseminated intravascular coagulation (DIC). This retrospective study evaluated the optimal antithrombin activity threshold to initiate supplementation, and the effects of supplementation therapy in 1033 patients with sepsis-induced DIC whose antithrombin activity levels were measured upon admission to 42 intensive care units across Japan. Of the 509 patients who had received antithrombin supplementation therapy, in-hospital mortality was significantly reduced only in patients with very low antithrombin activity (≤43%; bottom quartile; adjusted hazard ratio: 0.603; 95% confidence interval: 0.368-0.988; P = .045). Similar associations were not observed in patients with low, moderate, or normal antithrombin activity levels. Supplementation therapy did not correlate with the incidence of bleeding requiring transfusion. The adjusted hazard ratios for in-hospital mortality increased gradually with antithrombin activity only when initial activity levels were very low to normal but plateaued thereafter. We conclude that antithrombin supplementation therapy in patients with sepsis-induced DIC and very low antithrombin activity may improve survival without increasing the risk of bleeding.
Collapse
Affiliation(s)
- Mineji Hayakawa
- 1 Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Kazuma Yamakawa
- 2 Department of Emergency Medicine, Osaka General Medical Center, Osaka, Japan
| | - Daisuke Kudo
- 3 Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kota Ono
- 4 Clinical Research and Medical Innovation Center, Hokkaido University Hospital, Sapporo, Japan
| |
Collapse
|
163
|
Laursen MA, Larsen JB, Hvas AM. Platelet function in disseminated intravascular coagulation: A systematic review. Platelets 2018. [DOI: 10.1080/09537104.2018.1442567] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Mathies Appel Laursen
- Centre for Haemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus N, Denmark
| | - Julie Brogaard Larsen
- Centre for Haemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus N, Denmark
| | - Anne-Mette Hvas
- Centre for Haemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
164
|
Wiedermann CJ. Antithrombin concentrate use in disseminated intravascular coagulation of sepsis: meta-analyses revisited. J Thromb Haemost 2018; 16:455-457. [PMID: 29316235 DOI: 10.1111/jth.13950] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Indexed: 11/29/2022]
Abstract
Recently, two meta-analyses examined the effect of antithrombin on mortality in patients with sepsis and disseminated intravascular coagulation (DIC) with diverging results. In the meta-analysis observing no significant survival effect of antithrombin, the results of a large trial were included under the assumption that all 2314 participants of the trial had sepsis and DIC, which according to post hoc analyses was not the case. To the other meta-analysis reporting beneficial effect, the same trial contributed only those 229 patients that had confirmed sepsis-induced DIC. Replacing the mixed sepsis patient group with and without DIC with the group of sepsis patients with confirmed DIC provides evidence for a beneficial intervention effect of antithrombin also in the meta-analysis that reported no beneficial effect of antithrombin on mortality. This revised result does not change the overall conclusion that the quantity and quality of evidence supporting the use of antithrombin in sepsis patients with DIC is low.
Collapse
Affiliation(s)
- C J Wiedermann
- UMIT - The Health and Life Sciences University, Hall, Tyrol, Austria
| |
Collapse
|
165
|
Tagami T. Antithrombin concentrate use in sepsis-associated disseminated intravascular coagulation: re-evaluation of a 'pendulum effect' drug using a nationwide database. J Thromb Haemost 2018; 16:458-461. [PMID: 29316251 DOI: 10.1111/jth.13948] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Indexed: 01/21/2023]
Abstract
There are four systematic reviews and meta-analyses of trials of antithrombin use for sepsis or critically ill patients published to date with conflicting results. The two studies that showed positive results used data only from septic patients who were also diagnosed with disseminated intravascular coagulation (DIC), whereas the two studies showing negative results included data from all septic and/or critically ill patients in their analyses. We believe that the underlying diseases of the study population must be as homogeneous as possible when evaluating treatment efficacy for sepsis-associated DIC. We published two large-scale antithrombin studies of sepsis-associated DIC using a Japanese nationwide database. The above-mentioned DIC studies reported significant associations between antithrombin use and better 28-day mortality in both populations (DIC-associated with severe pneumonia, n = 9075; and with severe abdominal sepsis, n = 2164). Now is the time to initiate multinational antithrombin trials exclusively among sepsis-associated DIC patients.
Collapse
Affiliation(s)
- T Tagami
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
166
|
Umemura Y, Yamakawa K. Optimal patient selection for anticoagulant therapy in sepsis: an evidence-based proposal from Japan. J Thromb Haemost 2018; 16:462-464. [PMID: 29316171 DOI: 10.1111/jth.13946] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Indexed: 02/01/2023]
Abstract
Selecting an appropriate target population is essential to maximize survival benefits of anticoagulant therapy against sepsis. Our meta-analysis of three populations with sepsis and nationwide observational study in Japan showed that anticoagulants improved mortality only in sepsis-induced disseminated intravascular coagulation (DIC) but not in non-DIC. This divergent effect was physiologically explained by host-protective immune responses of local thrombosis, which are mandatory in the early stage of sepsis. Meanwhile, the lack of definitive evidence for survival benefit provided by several trials of sepsis-induced DIC indicated that this condition was probably not the best target of anticoagulants. Our multicenter cohort study including only patients with sepsis-induced DIC showed a survival benefit from recombinant thrombomodulin only in patients with high disease severity. Thus, we believe that the population with sepsis and DIC and high disease severity is the optimal target for anticoagulant therapy. Anticoagulant therapy without appropriate target selection should be avoided because of the increased risk of bleeding with no survival benefit.
Collapse
Affiliation(s)
- Y Umemura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - K Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| |
Collapse
|
167
|
Umemura Y, Yamakawa K, Hayakawa M, Kudo D, Fujimi S. Concomitant Versus Individual Administration of Antithrombin and Thrombomodulin for Sepsis-Induced Disseminated Intravascular Coagulation: A Nationwide Japanese Registry Study. Clin Appl Thromb Hemost 2018; 24:734-740. [PMID: 29471674 PMCID: PMC6714866 DOI: 10.1177/1076029618755948] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Antithrombin and recombinant human thrombomodulin (rhTM) are individually reported to improve survival in sepsis-induced disseminated intravascular coagulation (DIC). However, continuing controversy exists as to which agent is superior and whether concomitant therapy is superior to individual administration. Methods: This post hoc analysis included adult patients with sepsis-induced DIC from a nationwide multicenter registry database in Japan. We categorized patients into 4 groups: patients who received (1) individual administration of antithrombin, (2) individual administration of rhTM, (3) both, and (4) neither. In-hospital mortality was compared between every 2 groups among the 4 groups by Cox proportional hazards model adjusted with propensity scores. Results: In total, 1432 patients with sepsis-induced DIC were included. Although both antithrombin and rhTM were associated better outcome compared with no anticoagulants, mortality benefits were similar between each individual anticoagulant. Similarly, no significant difference in mortality was detected between individual administrations and concomitant therapy. Conclusion: Antithrombin and rhTM might have comparable efficacy in reducing mortality in patients with sepsis; however, concomitant therapy appeared to offer no additional survival benefit.
Collapse
Affiliation(s)
- Yutaka Umemura
- 1 Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Yamadaoka, Suita, Osaka, Japan
| | - Kazuma Yamakawa
- 2 Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Mineji Hayakawa
- 3 Emergency and Critical Care Center, Hokkaido University Hospital, Kita-ku, Sapporo, Hokkaido, Japan
| | - Daisuke Kudo
- 4 Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai, Miyagi, Japan
| | - Satoshi Fujimi
- 2 Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| |
Collapse
|
168
|
Nishida O, Ogura H, Egi M, Fujishima S, Hayashi Y, Iba T, Imaizumi H, Inoue S, Kakihana Y, Kotani J, Kushimoto S, Masuda Y, Matsuda N, Matsushima A, Nakada TA, Nakagawa S, Nunomiya S, Sadahiro T, Shime N, Yatabe T, Hara Y, Hayashida K, Kondo Y, Sumi Y, Yasuda H, Aoyama K, Azuhata T, Doi K, Doi M, Fujimura N, Fuke R, Fukuda T, Goto K, Hasegawa R, Hashimoto S, Hatakeyama J, Hayakawa M, Hifumi T, Higashibeppu N, Hirai K, Hirose T, Ide K, Kaizuka Y, Kan’o T, Kawasaki T, Kuroda H, Matsuda A, Matsumoto S, Nagae M, Onodera M, Ohnuma T, Oshima K, Saito N, Sakamoto S, Sakuraya M, Sasano M, Sato N, Sawamura A, Shimizu K, Shirai K, Takei T, Takeuchi M, Takimoto K, Taniguchi T, Tatsumi H, Tsuruta R, Yama N, Yamakawa K, Yamashita C, Yamashita K, Yoshida T, Tanaka H, Oda S. The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016). J Intensive Care 2018; 6:7. [PMID: 29435330 PMCID: PMC5797365 DOI: 10.1186/s40560-017-0270-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 12/11/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND PURPOSE The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 and published in the Journal of JSICM, [2017; Volume 24 (supplement 2)] 10.3918/jsicm.24S0001 and Journal of Japanese Association for Acute Medicine [2017; Volume 28, (supplement 1)] http://onlinelibrary.wiley.com/doi/10.1002/jja2.2017.28.issue-S1/issuetoc.This abridged English edition of the J-SSCG 2016 was produced with permission from the Japanese Association of Acute Medicine and the Japanese Society for Intensive Care Medicine. METHODS Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ) and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (> 66.6%) majority vote of each of the 19 committee members. RESULTS A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation, and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty-seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for five CQs. CONCLUSIONS Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.
Collapse
Affiliation(s)
- Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192 Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Moritoki Egi
- Department of anesthesiology, Kobe University Hospital, Kobe, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiro Hayashi
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hitoshi Imaizumi
- Department of Anesthesiology and Critical Care Medicine, Tokyo Medical University School of Medicine, Tokyo, Japan
| | - Shigeaki Inoue
- Department of Emergency and Critical Care Medicine, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Yasuyuki Kakihana
- Department of Emergency and Intensive Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Joji Kotani
- Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshiki Masuda
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Naoyuki Matsuda
- Department of Emergency & Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Asako Matsushima
- Department of Advancing Acute Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Taka-aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Satoshi Nakagawa
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Shin Nunomiya
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Tomohito Sadahiro
- Department of Emergency and Critical Care Medicine, Tokyo Women’s Medical University Yachiyo Medical Center, Tokyo, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Institute of Biomedical & Health Sciences, Hiroshima University, Higashihiroshima, Japan
| | - Tomoaki Yatabe
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kochi, Japan
| | - Yoshitaka Hara
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192 Japan
| | - Kei Hayashida
- Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Yutaka Kondo
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Yuka Sumi
- Healthcare New Frontier Promotion Headquarters Office, Kanagawa Prefectural Government, Yokohama, Japan
| | - Hideto Yasuda
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Kazuyoshi Aoyama
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Canada
- Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Takeo Azuhata
- Division of Emergency and Critical Care Medicine, Departmen of Acute Medicine, Nihon university school of Medicine, Tokyo, Japan
| | - Kent Doi
- Department of Acute Medicine, The University of Tokyo, Tokyo, Japan
| | - Matsuyuki Doi
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Naoyuki Fujimura
- Department of Anesthesiology, St. Mary’s Hospital, Westminster, UK
| | - Ryota Fuke
- Division of Infectious Diseases and Infection Control, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Japan
| | - Tatsuma Fukuda
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Koji Goto
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Oita University, Oita, Japan
| | - Ryuichi Hasegawa
- Department of Emergency and Intensive Care Medicine, Mito Clinical Education and Training Center, Tsukuba University Hospital, Mito Kyodo General Hospital, Mito, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Tsukuba, Japan
| | - Junji Hatakeyama
- Department of Intensive Care Medicine, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Mineji Hayakawa
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| | - Toru Hifumi
- Emergency Medical Center, Kagawa University Hospital, Miki, Japan
| | - Naoki Higashibeppu
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Kobe City Hospital Organization, Kobe, Japan
| | - Katsuki Hirai
- Department of Pediatrics, Kumamoto Red cross Hospital, Kumamoto, Japan
| | - Tomoya Hirose
- Emergency and Critical Care Medical Center, Osaka Police Hospital, Osaka, Japan
| | - Kentaro Ide
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yasuo Kaizuka
- Department of Emergency & ICU, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Tomomichi Kan’o
- Department of Emergency & Critical Care Medicine Kitasato University, Tokyo, Japan
| | - Tatsuya Kawasaki
- Department of Pediatric Critical Care, Shizuoka Children’s Hospital, Shizuoka, Japan
| | - Hiromitsu Kuroda
- Department of Anesthesia, Obihiro Kosei Hospital, Obihiro, Japan
| | - Akihisa Matsuda
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital, Inzai, Japan
| | - Shotaro Matsumoto
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Masaharu Nagae
- Department of anesthesiology, Kobe University Hospital, Kobe, Japan
| | - Mutsuo Onodera
- Department of Emergency and Critical Care Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Tetsu Ohnuma
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, USA
| | - Kiyohiro Oshima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Nobuyuki Saito
- Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, Inzai, Japan
| | - So Sakamoto
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hatsukaichi, Japan
| | - Mikio Sasano
- Department of Intensive Care Medicine, Nakagami Hospital, Uruma, Japan
| | - Norio Sato
- Department of Aeromedical Services for Emergency and Trauma Care, Ehime University Graduate School of Medicine, Matsuyama, Japan
| | - Atsushi Sawamura
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kentaro Shimizu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kunihiro Shirai
- Department of Emergency and Critical Care Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Tetsuhiro Takei
- Department of Emergency and Critical Care Medicine, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan
| | - Kohei Takimoto
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Takumi Taniguchi
- Department of Anesthesiology and Intensive Care Medicine, Kanazawa University, Kanazawa, Japan
| | - Hiroomi Tatsumi
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Naoya Yama
- Department of Diagnostic Radiology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Chizuru Yamashita
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192 Japan
| | - Kazuto Yamashita
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Yoshida
- Intensive Care Unit, Osaka University Hospital, Osaka, Japan
| | - Hiroshi Tanaka
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Shigeto Oda
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| |
Collapse
|
169
|
Iba T, Levy JH. Inflammation and thrombosis: roles of neutrophils, platelets and endothelial cells and their interactions in thrombus formation during sepsis. J Thromb Haemost 2018; 16:231-241. [PMID: 29193703 DOI: 10.1111/jth.13911] [Citation(s) in RCA: 288] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Indexed: 12/12/2022]
Abstract
The inflammatory response and the activation of coagulation are two important responses in a host's defense against infection. These mechanisms do not work independently, but cooperate in a complex and synchronous manner. Recent research has also shed light on the critical role of thrombus formation, which prevents the dissemination of microorganisms. The cellular components of blood vessels, i.e. leukocytes, platelets, erythrocytes, and vascular endothelial cells, play significant roles in the development of thrombi in combination with activation of the coagulation system. In addition to the cellular components, alarmins such as histones and high-mobility group box 1, microparticles and secreted granule proteins are all important for clot formation. In this summary, we review the pathophysiology of sepsis-induced coagulopathy and the role of cellular components and critical factors released from damaged cells. In addition, we review important therapeutic approaches that have been developed, are under investigation and are currently available in certain countries, including antithrombin, recombinant thrombomodulin, anti-Toll-like receptor 4 therapy, anti-damage associated molecular pattern therapy, and hemoadsorption with a polymyxin B-immobilized fiber column.
Collapse
Affiliation(s)
- T Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - J H Levy
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
170
|
Hayakawa M, Ono K. A summary of the Japan septic disseminated intravascular coagulation study. Acute Med Surg 2018; 5:123-128. [PMID: 29657722 PMCID: PMC5891114 DOI: 10.1002/ams2.326] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 11/13/2017] [Indexed: 12/30/2022] Open
Abstract
Over the past few decades, the large, international, randomized controlled trials of anticoagulant therapies for patients with sepsis have not yielded any improvement in mortality rates. However, in Japan, anticoagulant therapies are administered for sepsis patients with disseminated intravascular coagulation (DIC), but not for sepsis patients without DIC. Furthermore, epidemiological data regarding sepsis in Japan are scarce. Therefore, a nationwide multicenter retrospective observational study, the Japan Septic Disseminated Intravascular Coagulation (JSEPTIC DIC) study, was undertaken. The JSEPTIC DIC study enrolled 42 intensive care units and included 3,195 patients with sepsis. The results of the JSEPTIC DIC study indicated the following: (i) anticoagulant therapy may be effective in sepsis-induced DIC patients at high risk for death, (ii) recombinant human soluble thrombomodulin administration and antithrombin supplementation are associated with survival benefits in patients with sepsis-induced DIC.
Collapse
Affiliation(s)
- Mineji Hayakawa
- Emergency and Critical Care Center Hokkaido University Hospital Sapporo Japan
| | - Kota Ono
- Clinical Research and Medical Innovation Center Hokkaido University Hospital Sapporo Japan
| |
Collapse
|
171
|
Kudo D, Hayakawa M, Ono K, Yamakawa K. Impact of non-anticoagulant therapy on patients with sepsis-induced disseminated intravascular coagulation: A multicenter, case-control study. Thromb Res 2018; 163:22-29. [PMID: 29329022 DOI: 10.1016/j.thromres.2017.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 12/12/2017] [Accepted: 12/29/2017] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Anticoagulant therapy for patients with sepsis is not recommended in the latest Surviving Sepsis Campaign guidelines, and non-anticoagulant therapy is the global standard treatment approach at present. We aimed at elucidating the effect of non-anticoagulant therapy on patients with sepsis-induced disseminated intravascular coagulation (DIC), as evidence on this topic has remained inconclusive. MATERIALS AND METHODS Data from 3195 consecutive adult patients admitted to 42 intensive care units for the treatment of severe sepsis were retrospectively analyzed via propensity score analyses with and without multiple imputation. The primary outcome was in-hospital all-cause mortality. RESULTS Among 1784 patients with sepsis-induced DIC, 745 (41.8%) were not treated with anticoagulants. The inverse probability of treatment-weighted (with and without multiple imputation) and quintile-stratified propensity score analyses (without multiple imputation) indicated a significant association between non-anticoagulant therapy and higher in-hospital all-cause mortality (odds ratio [95% confidence interval]: 1.59 [1.19-2.12], 1.32 [1.02-1.81], and 1.32 [1.03-1.69], respectively). However, quintile-stratified propensity score analyses with multiple imputation and propensity score matching analysis with and without multiple imputation did not show this association. Survival duration was not significantly different between patients in the propensity score-matched non-anticoagulant therapy group and those in the anticoagulant therapy group (Cox regression analysis with and without multiple imputation: hazard ratio [95% confidence interval]: 1.26 [1.00-1.60] and 1.22 [0.93-1.59], respectively). CONCLUSIONS It remains controversial if non-anticoagulant therapy is harmful, equivalent, or beneficial compared with anticoagulant therapy in the treatment of patients with sepsis-induced DIC.
Collapse
Affiliation(s)
- Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan.
| | - Mineji Hayakawa
- Emergency and Critical Care Center, Hokkaido University Hospital, 5 Kita8jonishi, Kita-ku, Sapporo 060-0808, Japan.
| | - Kota Ono
- Clinical Research and Medical Innovation Center, Hokkaido University Hospital, 5 Kita8jonishi, Kita-ku, Sapporo 060-0808, Japan.
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi-ku, Osaka 558-0056, Japan
| |
Collapse
|
172
|
Nishida O, Ogura H, Egi M, Fujishima S, Hayashi Y, Iba T, Imaizumi H, Inoue S, Kakihana Y, Kotani J, Kushimoto S, Masuda Y, Matsuda N, Matsushima A, Nakada T, Nakagawa S, Nunomiya S, Sadahiro T, Shime N, Yatabe T, Hara Y, Hayashida K, Kondo Y, Sumi Y, Yasuda H, Aoyama K, Azuhata T, Doi K, Doi M, Fujimura N, Fuke R, Fukuda T, Goto K, Hasegawa R, Hashimoto S, Hatakeyama J, Hayakawa M, Hifumi T, Higashibeppu N, Hirai K, Hirose T, Ide K, Kaizuka Y, Kan'o T, Kawasaki T, Kuroda H, Matsuda A, Matsumoto S, Nagae M, Onodera M, Ohnuma T, Oshima K, Saito N, Sakamoto S, Sakuraya M, Sasano M, Sato N, Sawamura A, Shimizu K, Shirai K, Takei T, Takeuchi M, Takimoto K, Taniguchi T, Tatsumi H, Tsuruta R, Yama N, Yamakawa K, Yamashita C, Yamashita K, Yoshida T, Tanaka H, Oda S. The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016). Acute Med Surg 2018; 5:3-89. [PMID: 29445505 PMCID: PMC5797842 DOI: 10.1002/ams2.322] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 10/11/2017] [Indexed: 11/11/2022] Open
Abstract
Background and Purpose The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 in Japanese. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. Methods Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ), and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (>66.6%) majority vote of each of the 19 committee members. Results A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for 5 CQs. Conclusions Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.
Collapse
|
173
|
Hayakawa M. Management of disseminated intravascular coagulation: current insights on antithrombin and thrombomodulin treatments. Open Access Emerg Med 2017; 10:25-29. [PMID: 29343993 PMCID: PMC5749552 DOI: 10.2147/oaem.s135909] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Sepsis and septic shock are frequently complicated by disseminated intravascular coagulation (DIC), which decreases the survival rate of patients with sepsis. In the past, large international randomized controlled trials (RCTs) using physiological anticoagulants for sepsis-induced DIC were not performed; however, RCTs have been conducted for sepsis and/or septic shock. In these trials, physiological anticoagulants did not show any beneficial effects compared with placebo for the treatment of sepsis and/or septic shock. In Japan, DIC treatments using antithrombin (AT) and/or recombinant human soluble thrombomodulin (rhTM) are common for patients with sepsis-induced DIC. Recently, large propensity score analyses demonstrated that AT and rhTM improved survival in patients with sepsis-induced DIC. Furthermore, post hoc analyses and meta-analyses that selected patients with sepsis-induced DIC from the previous large international RCTs indicated that physiological anticoagulants improved survival without increasing the associated sepsis-induced DIC bleeding. DIC treatments, such as AT and rhTM, may demonstrate beneficial effects when they are targeted at patients with sepsis-induced DIC only.
Collapse
Affiliation(s)
- Mineji Hayakawa
- Emergency and Critical Care Center, Hokkaido University Hospital, Sapporo, Japan
| |
Collapse
|
174
|
Screening itself for disseminated intravascular coagulation may reduce mortality in sepsis: A nationwide multicenter registry in Japan. Thromb Res 2017; 161:60-66. [PMID: 29202320 DOI: 10.1016/j.thromres.2017.11.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 11/13/2017] [Accepted: 11/24/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Screening of patients with sepsis for disseminated intravascular coagulation (DIC) has been recommended in several guidelines. However, DIC screening is still not widely accepted as an essential component of sepsis management, partly because of a lack of evidence that DIC screening has an effect on mortality. We investigated whether DIC screening was associated with a survival benefit in patients with sepsis. DESIGN Post hoc analysis of a nationwide multicenter retrospective cohort study. SETTING 42 intensive care units in Japan. PARTICIPANTS 2663 adult patients diagnosed as having severe sepsis: 1893 (71.1%) patients were considered candidates for and 770 (28.9%) patients were not considered candidates for International Society of Thrombosis and Hemostasis (ISTH) overt DIC screening on ICU day 1. MAIN OUTCOME MEASURES The primary outcome measure was all-cause in-hospital mortality. Patients were stratified according to whether DIC screening was performed at the time of ICU admission (day 1) to investigate the survival effect associated with DIC screening. We also evaluated survival benefit by classifying patients according to whether DIC screening was performed on day 1 and repeated on day 3. Effects of screening on mortality were assessed using Cox proportional hazards models adjusted by the inverse probability of treatment weighting (IPTW) method using propensity scoring. RESULTS After adjustment for imbalances, ISTH overt DIC screening on day 1 was associated with significantly lower mortality (IPTW-adjusted HR: 0.836; 95% confidence interval [CI]: 0.711-0.984), and this association became even stronger when ISTH overt DIC screening was repeated on day 3 (IPTW-adjusted HR: 0.727; 95% CI: 0.597-0.884). Besides, we observed an almost comparable effect on mortality associated with DIC screening using the Japanese Association for Acute Medicine criteria. CONCLUSION DIC screening was associated with a reduction in mortality in patients with sepsis. This association could be even stronger by repeating DIC screening.
Collapse
|
175
|
Iba T, Nisio MD, Levy JH, Kitamura N, Thachil J. New criteria for sepsis-induced coagulopathy (SIC) following the revised sepsis definition: a retrospective analysis of a nationwide survey. BMJ Open 2017; 7:e017046. [PMID: 28963294 PMCID: PMC5623518 DOI: 10.1136/bmjopen-2017-017046] [Citation(s) in RCA: 234] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Recent clinical studies have shown that anticoagulant therapy might be effective only in specific at-risk subgroups of patients with sepsis and coagulation dysfunction. The definition of sepsis was recently modified, and as such, old scoring systems may no longer be appropriate for the diagnosis of sepsis-associated coagulopathy. The aim of this study was to evaluate prognostic factors in patients diagnosed with sepsis and coagulopathy according to the new sepsis definition and assess their accuracy in comparison with existing models. DESIGN Retrospective analysis of the nationwide survey for recombinant human soluble thrombomodulin. SETTING General emergency and critical care centres in secondary and tertiary care hospitals. PARTICIPANTS We evaluated the prognostic value of the newly proposed diagnostic criteria for sepsis-induced coagulopathy (SIC). A total of 1498 Japanese patients with sepsis and coagulopathy complications who were treated with recombinant thrombomodulin were analysed in this study. MAIN OUTCOME MEASURES The platelet count, prothrombin time (PT) ratio, fibrinogen/fibrin degradation products, systemic inflammatory response syndrome score and Sequential Organ Failure Assessment (SOFA) score obtained just before the start of treatment were examined in relation to the 28-day mortality rate. RESULTS The platelet count, PT ratio and total SOFA were independent predictors of a fatal outcome in a logistic regression model. A SIC score was defined using the three above-mentioned variables with a positivity threshold of 4 points or more. The SIC score predicted higher 28-day mortality rate compared with the current Japanese Association for Acute Medicine-disseminated intravascular coagulation score (38.4%vs34.7%). CONCLUSION The SIC score is based on readily available parameters, is easy to calculate and has a high predictive value for 28-day mortality. Future studies are warranted to evaluate whether the SIC score may guide the decision to initiate anticoagulant therapy.
Collapse
Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University G D’Annunzio of Chieti-Pescara, Chieti, Italy
| | - Jerrold H Levy
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Naoya Kitamura
- Department of Recomodulin Strategy Planning, Division of Pharmaceuticals Sales, Asahi Kasei Pharma Corporation, Tokyo, Japan
| | | |
Collapse
|
176
|
Thachil J, Iba T. The application of anticoagulant therapy to sepsis. J Intensive Care 2017; 5:32. [PMID: 28572981 PMCID: PMC5450244 DOI: 10.1186/s40560-017-0230-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 05/24/2017] [Indexed: 11/23/2022] Open
Abstract
Since the withdrawal of recombinant-activated protein C, the anticoagulant therapy for sepsis was taken no notice. For instance, the international sepsis guidelines did not share a space for this therapy. However, we can see the signs of change recently. The Surviving Sepsis Campaign Guidelines 2016 introduced the development of recombinant thrombomodulin, and the European Society of Intensive Care Medicine released comments on this subject. However, since small but important discrepancy was recognized between the standpoints of Japan (more aggressive) and other countries (rather conservative), we intend to discuss on this point.
Collapse
Affiliation(s)
- Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421 Japan
| |
Collapse
|
177
|
Should all patients with sepsis receive anticoagulation? Yes. Intensive Care Med 2017; 43:452-454. [PMID: 28194512 DOI: 10.1007/s00134-016-4621-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 11/01/2016] [Indexed: 12/29/2022]
|
178
|
Zaragoza JJ, Espinoza-Villafuerte MV. Current approach to disseminated intravascular coagulation related to sepsis - organ failure type. World J Hematol 2017; 6:11-16. [DOI: 10.5315/wjh.v6.i1.11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/18/2016] [Accepted: 12/19/2016] [Indexed: 02/05/2023] Open
Abstract
Disseminated intravascular coagulation (DIC) is a syndrome characterized by the systemic activation of blood clotting, which generates large amount of intravascular thrombin and fibrin. Various diseases may cause acceleration of the clotting cascade, inactivate the endogenous anticoagulants and modify fibrinolysis, having thus the formation of micro thrombi in the systemic circulation. The abnormalities in the hemostatic system in patients with DIC result from the sum of pathways that generate both hypercoagulability and augmented fibrinolysis. When the hypercoagulability state prevails, the main manifestation is organic failure. This subtype of DIC is often referred as “organ impairment” type, frequently seen in patients suffering from severe sepsis. To identify the underlying infection, early initiation of culture-based antimicrobial treatment, and to resolve any infection source promptly are keystone actions of DIC related to sepsis prevention and treatment. These should be combined with specific treatment related to each DIC subtype. In the context of septic shock, DIC is associated to increased severity, greater number and seriousness of organ failures, more frequent side-effects from treatment itself, and worse outcomes. Therefore, we ought to review the information available in the literature about approach and management of DIC in severe sepsis.
Collapse
|
179
|
Iba T. Bleeding complications of anticoagulant therapy in sepsis-induced disseminated intravascular coagulation. Crit Care 2016; 20:307. [PMID: 27677585 PMCID: PMC5039791 DOI: 10.1186/s13054-016-1464-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
|
180
|
Iba T, Thachil J. Is protein C zymogen really ineffective for ALL cases of sepsis including septic DIC? Intensive Care Med 2016; 43:152-153. [PMID: 27822595 DOI: 10.1007/s00134-016-4615-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| |
Collapse
|
181
|
Umemura Y, Yamakawa K. Efficacy and safety of anticoagulant therapy in three specific populations with sepsis: a meta-analysis of randomized controlled trials: reply. J Thromb Haemost 2016; 14:2310-2311. [PMID: 27537607 DOI: 10.1111/jth.13473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Y Umemura
- Department of Emergency and Critical Care, Osaka General Medical Center, Osaka, Japan
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - K Yamakawa
- Department of Emergency and Critical Care, Osaka General Medical Center, Osaka, Japan
| |
Collapse
|
182
|
Wada H, Matsumoto T, Aota T, Imai H, Suzuki K, Katayama N. Efficacy and safety of anticoagulant therapy in three specific populations with sepsis: a meta-analysis of randomized controlled trials: comment. J Thromb Haemost 2016; 14:2308-2309. [PMID: 27331770 DOI: 10.1111/jth.13394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 06/19/2016] [Indexed: 11/27/2022]
Affiliation(s)
- H Wada
- Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, Tsu, Japan
| | - T Matsumoto
- Department of Hematology and Oncology, Mie University School of Medicine, Mie, Japan
| | - T Aota
- Blood Transfusion Service, Mie University Hospital, Tsu, Japan
| | - H Imai
- Emergency Critical Care Center, Mie University Hospital, Tsu, Japan
| | - K Suzuki
- Emergency Critical Care Center, Mie University Hospital, Tsu, Japan
| | - N Katayama
- Blood Transfusion Service, Mie University Hospital, Tsu, Japan
| |
Collapse
|
183
|
Iba T, Di Nisio M, Thachil J, Wada H, Asakura H, Sato K, Kitamura N, Saitoh D. Revision of the Japanese Association for Acute Medicine (JAAM) disseminated intravascular coagulation (DIC) diagnostic criteria using antithrombin activity. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:287. [PMID: 27629997 PMCID: PMC5024432 DOI: 10.1186/s13054-016-1468-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 08/26/2016] [Indexed: 12/21/2022]
Abstract
Background With advances in the treatment of sepsis, the systemic inflammatory response syndrome (SIRS) has been losing its prognostic power. Since the SIRS category is no longer used for the diagnosis of sepsis, the disseminated intravascular coagulation (DIC) diagnostic criteria released by Japanese Association for Acute Medicine (JAAM) should be modified. Thus, the purpose of this study was to examine the appropriateness of replacing the SIRS score with antithrombin activity in JAAM-DIC diagnostic criteria. Methods We analyzed data from 819 septic patients who had received recombinant thrombomodulin. The relationships between the 28-day mortality rate and baseline laboratory and clinical parameters were examined using univariate and multivariate analyses, and the impact of replacing the SIRS criteria with antithrombin activity was evaluated. Results The SIRS score, prothrombin time ratio, and antithrombin activity were associated with the 28-day mortality rate (P values = 0.013, 0.018, and 0.003, respectively, by multivariate analysis). A modified version of the JAAM-DIC diagnostic criteria using an antithrombin activity <70 % was capable of diagnosing the identical number (n = 706) and a similar severity of patients (mortality, 34.6 % versus 34.8 %). Conclusion Since anticoagulant therapy is expected to be more effective in patients with more severe coagulation disorders, the modified version of the JAAM-DIC diagnostic criteria might be useful for discriminating patients with sepsis who are good candidates for anticoagulant therapy.
Collapse
Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Marcello Di Nisio
- Department of Medical, Oral and Biotechnological Sciences, University G D'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Oxford Road, Manchester, UK
| | - Hideo Wada
- Department of Molecular Laboratory Medicine, Mie University Graduate School of Medicine, 2-174, Tsu, Mie, Japan
| | - Hidesaku Asakura
- Third Department of Internal Medicine, Kanazawa University, Graduate School of Medical Science, 13-1, Kanazawa, Japan
| | - Koichi Sato
- Department of Surgery, Juntendo Shizuoka Hospital, Juntendo University Graduate School of Medicine, 1129, Izunokuni-shi, Shizuoka, Japan
| | - Naoya Kitamura
- Recomodulin Strategy Planning Department, Pharmaceuticals Sales Division, Asahi Kasei Pharma Corporation, 1-105, Kanda, Tokyo, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Saitama, Japan
| |
Collapse
|
184
|
Yamakawa K, Umemura Y, Hayakawa M, Kudo D, Sanui M, Takahashi H, Yoshikawa Y, Hamasaki T, Fujimi S. Benefit profile of anticoagulant therapy in sepsis: a nationwide multicentre registry in Japan. Crit Care 2016; 20:229. [PMID: 27472991 PMCID: PMC4966726 DOI: 10.1186/s13054-016-1415-1] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 07/20/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Little evidence supports anticoagulant therapy as effective adjuvant therapy to reduce mortality overall in sepsis. However, several studies suggest that anticoagulant therapy may reduce mortality in specific patients. This study aimed to identify a subset of patients with high benefit profiles for anticoagulant therapy against sepsis. METHODS This post hoc subgroup analysis of a nationwide multicentre retrospective registry was conducted in 42 intensive care units in Japan. Consecutive adult patients with sepsis were included. Treatment effects of anticoagulants, e.g. antithrombin, recombinant thrombomodulin, heparin, and protease inhibitors, were evaluated by stratifying patients according to disseminated intravascular coagulation (DIC) and Sequential Organ Failure Assessment (SOFA) score. Intervention effects of anticoagulant therapy on in-hospital mortality and bleeding complications were analysed using Cox regression analysis stratified by propensity scores. RESULTS Participants comprised 2663 consecutive patients with sepsis; 1247 patients received anticoagulants and 1416 received none. After adjustment for imbalances, anticoagulant administration was significantly associated with reduced mortality only in subsets of patients diagnosed with DIC, whereas similar mortality rates were observed in non-DIC subsets with anticoagulant therapy. Favourable associations between anticoagulant therapy and mortality were observed only in the high-risk subset (SOFA score 13-17; adjusted hazard ratio 0.601; 95 % confidence interval 0.451, 0.800) but not in the subsets of patients with sepsis with low to moderate risk. Although the differences were not statistically significant, there was a consistent tendency towards an increase in bleeding-related transfusions in all SOFA score subsets. CONCLUSIONS The analysis of this large database indicates anticoagulant therapy may be associated with a survival benefit in patients with sepsis-induced coagulopathy and/or very severe disease. TRIAL REGISTRATION University Hospital Medical Information Network Clinical Trial Registry (UMIN-CTR ID: UMIN000012543 ). Registered on 10 December 2013.
Collapse
Affiliation(s)
- Kazuma Yamakawa
- Department of Emergency and Critical Care, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan.
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Mineji Hayakawa
- Emergency and Critical Care Center, Hokkaido University Hospital, Kita 15 Nishi 7 Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Hiroki Takahashi
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yoshiaki Yoshikawa
- Department of Emergency and Critical Care, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Toshimitsu Hamasaki
- Office of Biostatistics and Data Management, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, 565-8565, Japan
| | - Satoshi Fujimi
- Department of Emergency and Critical Care, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| |
Collapse
|
185
|
Antithrombin supplementation and risk of bleeding in patients with sepsis-associated disseminated intravascular coagulation. Thromb Res 2016; 145:46-50. [PMID: 27479532 DOI: 10.1016/j.thromres.2016.07.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 07/22/2016] [Accepted: 07/26/2016] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Although antithrombin is commonly used for the treatment of sepsis-associated disseminated intravascular coagulation (DIC) in Japan, the factors influencing the incidence of bleeding complications have not been sufficiently studied. The purpose of this survey was to identify the factors that predict clinically relevant bleeding in patients receiving antithrombin for DIC. METHODS We analyzed data from 1026 sepsis-associated DIC patients with a baseline antithrombin activity ≤70% who underwent antithrombin supplementation at two dosages (1500IU/day or 3000IU/day) for three consecutive days. The patients' demographic characteristics, parameters before and after the treatment, and co-administered anticoagulants were analyzed in relation to the bleeding events. RESULTS Overall, 55 patients (5.36%) experienced bleeding events (major bleeding: 1.75%). Logistic regression analysis revealed that sustained DIC>7days was significantly associated with bleeding (odds ratio: 2.761, P=0.001). In contrast, the higher dose of antithrombin or the co-administration of recombinant thrombomodulin or heparins were not associated with bleeding events. CONCLUSION A higher dose of antithrombin or the concomitant use of other anticoagulants were not associated with bleeding events. On the other hand, sustained DIC lasting more than one week was associated with an increased risk of bleeding in patients with sepsis-associated DIC.
Collapse
|
186
|
Iba T, Thachil J. Is antithrombin III for sepsis-associated disseminated intravascular coagulation really ineffective? Intensive Care Med 2016; 42:1193-4. [PMID: 27143022 DOI: 10.1007/s00134-016-4288-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 02/21/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| |
Collapse
|