1
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Rodriguez IE, Saben JL, Moore EE, Knudson MM, Moore PK, Pieracci F, Sauaia A, Moore HB. Fibrinolysis Resistance After Injury Is a Risk Factor for a Hospital-Acquired Pneumonia-Like Disease Pattern. Surg Infect (Larchmt) 2024; 25:87-94. [PMID: 38394296 PMCID: PMC10924191 DOI: 10.1089/sur.2023.257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024] Open
Abstract
Background: Pneumonia is associated with increased morbidity and costs in the intensive care unit (ICU). Its early identification is key for optimal outcomes, but early biomarkers are lacking. Studies suggest that fibrinolysis resistance (FR) after major abdominal surgery is linked to an increased risk of infection. Patients and Methods: Patients in a randomized controlled trial for hemorrhagic shock were evaluated for FR. Fibrinolysis resistance was quantified by thrombelastography with exogenous tissue plasminogen activator (tPA-TEG) at 24- and 48-hours post-injury and measuring LY30 (%). A receiver-operating characteristics (ROC) curve analysis was used to identify a cutoff for increased risk of pneumonia, which was then validated in ICU patients at risk for venous thromboembolism (VTE). Multivariable logistic regression was used to control for confounders. Results: Forty-nine patients in the hemorrhagic shock cohort had tPA-TEGs at 24- and 48-hours (median ISS, 27; 7% pneumonia). A composite tPA-TEG LY30 of less than 4% at 24 and 48 hours was found to be the optimal cutoff for increased risk of pneumonia. This cohort had a seven-fold increased rate of pneumonia (4% vs. 28%; p = 0.048). Eighty-eight patients in the VTE cohort had tPA-TEGs at 24 and 48 hours post-ICU admission (median ISS, 28; 6% pneumonia). The tPA-TEG LY30 of less than 4% was associated with a 10-fold increased rate of pneumonia (19% vs. 1.5%; p = 0.002). In patients with traumatic brain injury, the same association was found (33% vs. 3.2%; p = 0.006). Adjusting for confounders, the tPA-TEG persisted as a substantial risk factor for pneumonia (adjusted odds ratio [OR], 35.7; 95% confidence interval [CI], 1.9-682; p = 0.018). Conclusions: Fibrinolysis resistance quantified by tPA-TEG within 48 hours of ICU admission is associated with an increased risk of pneumonia in patients in hemorrhagic shock and those at risk for VTE. Prospective validation of the tPA-TEG LY30 optimal cutoff for pneumonia and further investigation into whether endogenous FR is a cause of an altered immunity is warranted.
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Affiliation(s)
- Ivan E. Rodriguez
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jessica L. Saben
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ernest E. Moore
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Surgery, Ernest E. Shock Trauma Center at Denver Health, Denver, Colorado, USA
| | - M. Margaret Knudson
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Peter K. Moore
- University of Colorado Denver, Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
| | - Fredric Pieracci
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Surgery, Ernest E. Shock Trauma Center at Denver Health, Denver, Colorado, USA
| | - Angela Sauaia
- Department of Surgery, Ernest E. Shock Trauma Center at Denver Health, Denver, Colorado, USA
| | - Hunter B. Moore
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Transplant Institution at Porter, AdventHealth, Denver, Colorado, USA
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2
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Rodriguez IE, Yoeli D, Ferrell T, Jiang JG, Truong R, Nydam TL, Adams MA, Cullen JM, Pomfret EA, Moore HB. Fibrinolysis resistance after liver transplant as a predictor of early infection. Am J Surg 2022; 224:1455-1459. [PMID: 36153270 PMCID: PMC10424327 DOI: 10.1016/j.amjsurg.2022.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 08/27/2022] [Accepted: 09/08/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Infection is a leading cause of morbidity in liver transplant (LT). Considering that the fibrinolytic system is altered in sepsis, we investigated the relationship between fibrinolysis resistance (FR) and post-transplant infection. METHODS Fibrinolysis was quantified using thrombelastography (TEG) with the addition of tPA to quantify FR. FR was defined as LY30 = 0% and stratified as transient if present on POD1 or POD5 (tFR), persistent (pFR) if present on both, or no FR (nFR) if absent. RESULTS 180 LT recipients were prospectively enrolled. 52 (29%) recipients developed infection. 72 had tFR; 37 had pFR; and 71 had nFR. Recipients with pFR had significantly greater incidence of infections (51% vs. 26% tFR vs. 20% nFR, p = 0.002). pFR was independently associated with increased odds of post-transplant infection (adjusted OR 3.39, p = 0.009). CONCLUSIONS Persistent fibrinolysis resistance is associated with increased risk of post-transplant infection.
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Affiliation(s)
- Ivan E Rodriguez
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA.
| | - Dor Yoeli
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
| | - Tanner Ferrell
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
| | - Jessie G Jiang
- University of Colorado School of Medicine, CU Anschutz Fitzsimons Building, 13001 East 17th Place, C290, Aurora, CO, 80045, USA
| | - Ronald Truong
- University of Colorado School of Medicine, CU Anschutz Fitzsimons Building, 13001 East 17th Place, C290, Aurora, CO, 80045, USA
| | - Trevor L Nydam
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
| | - Megan A Adams
- Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, 13123 East 16th Avenue, Aurora, CO, 80045, USA
| | - J Michael Cullen
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
| | - Elizabeth A Pomfret
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
| | - Hunter B Moore
- Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
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3
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Luo C, Hu H, Gong J, Zhou Y, Chen Z, Cai S. The Value of Thromboelastography in the Diagnosis of Sepsis-Induced Coagulopathy. Clin Appl Thromb Hemost 2021; 26:1076029620951847. [PMID: 32870718 PMCID: PMC7469719 DOI: 10.1177/1076029620951847] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Thromboelastography (TEG) is regularly used for monitoring abnormalities of the coagulation system in patients with sepsis. However, it is unclear whether TEG parameters are associated with sepsis-induced coagulopathy (SIC). Thus, we aimed to assess the diagnostic value of TEG for SIC. The medical records of patients who underwent TEG from January 2016 to December 2016 were analyzed retrospectively. The patients were divided into sepsis group and non-sepsis group. Baseline patient characteristics and coagulation function indexes were compared. Receiver–operating characteristic curve analysis was used to determine predictors of SIC. A total of 167 patients were included, of whom 84 had sepsis. The clot formation speed (K) was significantly higher(P < 0.001), and the maximum amplitude (MA) and angle were significantly lower (both P < 0.001) in the sepsis group than that in non-sepsis group. Patients with SIC had higher Sepsis-related Organ Failure Assessment scores than those patients without SIC (P < 0.001). The area under the curve of K for diagnosing SIC was 0.910. The area under the curve of angle and MA for excluding SIC was 0.895 and 0.882, respectively. Thus, TEG parameters have good diagnostic value for SIC.
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Affiliation(s)
- Cuizhu Luo
- Department of Critical Care Medicine, 198153Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China.,Department of Critical Care Medicine, Jiang Xi Ping Xiang People's Hospital, Pingxiang Economic and Technological Development District, Ping Xiang, Jiang Xi, China
| | - Hongbin Hu
- Department of Critical Care Medicine, 198153Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Jian Gong
- Department of Critical Care Medicine, The Third People' Hospital of Long Gang Distric, Shenzhen, China
| | - Yun Zhou
- Department of Critical Care Medicine, Jiang Xi Ping Xiang People's Hospital, Pingxiang Economic and Technological Development District, Ping Xiang, Jiang Xi, China
| | - Zhongqing Chen
- Department of Critical Care Medicine, 198153Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Shumin Cai
- Department of Critical Care Medicine, 198153Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
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4
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Larsen JB, Hvas AM. Fibrinolytic Alterations in Sepsis: Biomarkers and Future Treatment Targets. Semin Thromb Hemost 2021; 47:589-600. [PMID: 33878784 DOI: 10.1055/s-0041-1725096] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Sepsis is a life-threatening condition which develops as a dysregulated immune response in the face of infection and which is associated with profound hemostatic disturbances and in the most extreme cases disseminated intravascular coagulation (DIC). In addition, the fibrinolytic system is subject to alterations during infection and sepsis, and impaired fibrinolysis is currently considered a key player in sepsis-related microthrombus formation and DIC. However, we still lack reliable biomarkers to assess fibrinolysis in the clinical setting. Furthermore, drugs targeting the fibrinolytic system have potential value in sepsis patients with severe fibrinolytic disturbances, but these are still being tested in the preclinical stage. The present review provides an overview of key fibrinolytic changes in sepsis, reviews the current literature on potential laboratory markers of altered fibrinolysis in adult sepsis patients, and discusses future perspectives for diagnosis and treatment of fibrinolytic disturbances in sepsis patients.
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Affiliation(s)
- Julie Brogaard Larsen
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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5
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Mitrovic M, Sabljic N, Cvetkovic Z, Pantic N, Zivkovic Dakic A, Bukumiric Z, Libek V, Savic N, Milenkovic B, Virijevic M, Vucinic V, Milosevic I, Pravdic Z, Suvajdzic N, Fareed J, Antic D. Rotational thromboelastometry (ROTEM) profiling of COVID-19 patients. Platelets 2021; 32:690-696. [PMID: 33561381 DOI: 10.1080/09537104.2021.1881949] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
We evaluated coagulation abnormalities via traditional tests and rotational thromboelastometry (ROTEM) in a group of 94 patients with confirmed SARS-CoV-2 infection and different severity of pneumonia (34 moderate, 25 severe, 35 critical) with the hypothesis that ROTEM parameters differed by coronavirus disease 2019 (COVID-19) severity. Shorter than normal clotting time (CT) and higher than normal maximum clot firmness (MCF) in extrinsic rotational thromboelastometry (EXTEM) and fibrinogen rotational thromboelastometry (FIBTEM), shorter than normal EXTEM clot formation time (CFT), and higher than normal α-angle were classified as markers of hypercoagulable state. Increment in the number of patients with ≥2 hypercoagulable parameters, higher EXTEM (P = .0001), FIBTEM MCF (P = .0001) and maximum lysis decrement (P = .002) with increment in disease severity was observed (P = .0001). Significant positive correlations between IL6 and CT EXTEM (P = .003), MCF EXTEM (P = .033), MCF FIBTEM (P = .01), and negative with ML EXTEM (P = .006) were seen. Our findings based on analysis of different disease severity groups confirmed that a hypercoagulable ROTEM pattern characterized by clot formation acceleration, high clot strength, and reduced fibrinolysis was more frequent in advanced disease groups and patients with high IL6. These results supported the need for different thromboprophylaxis approaches for different severity groups.
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Affiliation(s)
- Mirjana Mitrovic
- Clinic of Hematology, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nikica Sabljic
- Clinic of Hematology, Clinical Center of Serbia, Belgrade, Serbia
| | - Zorica Cvetkovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinical Hospital Center Zemun, Zemun, , Serbia
| | - Nikola Pantic
- Clinic of Hematology, Clinical Center of Serbia, Belgrade, Serbia
| | | | - Zoran Bukumiric
- Institute for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vesna Libek
- Clinical Hospital Center Zemun, Zemun, , Serbia
| | - Nebojsa Savic
- Clinic of Vascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Branislava Milenkovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic of Pulmology, Clinical Center of Serbia, Belgrade, Serbia
| | - Marijana Virijevic
- Clinic of Hematology, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Violeta Vucinic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic of Pulmology, Clinical Center of Serbia, Belgrade, Serbia
| | - Ivana Milosevic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Infectious and Tropical Disease, Clinical Center of Serbia, Belgrade, Serbia
| | - Zlatko Pravdic
- Clinic of Hematology, Clinical Center of Serbia, Belgrade, Serbia
| | - Nada Suvajdzic
- Clinic of Hematology, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jawed Fareed
- Departments of Pathology and Pharmacology, Loyola University Center, Maywood, Illinois, USA
| | - Darko Antic
- Clinic of Hematology, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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6
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Hypercoagulability and coronavirus disease 2019-associated hypoxemic respiratory failure: Mechanisms and emerging management paradigms. J Trauma Acute Care Surg 2020; 89:e177-e181. [PMID: 32890338 PMCID: PMC7687878 DOI: 10.1097/ta.0000000000002938] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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7
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Covid-19-Associated Coagulopathy: Biomarkers of Thrombin Generation and Fibrinolysis Leading the Outcome. J Clin Med 2020; 9:jcm9113487. [PMID: 33126772 PMCID: PMC7692774 DOI: 10.3390/jcm9113487] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 12/15/2022] Open
Abstract
Background: Coronavirus Disease 2019 (COVID-19)-associated coagulopathy is characterized by a prothrombotic state not yet comprehensively studied. We investigated the coagulation pattern of patients with COVID-19 acute respiratory distress syndrome (ARDS), comparing patients who survived to those who did not. Methods: In this prospective cohort study on 20 COVID-19 ARDS patients, the following biomarkers were measured: thrombin generation (prothrombin fragment 1 + 2 (PF 1 + 2)), fibrinolysis activation (tissue plasminogen activator (tPA)) and inhibition (plasminogen activator inhibitor 2 (PAI-2)), fibrin synthesis (fibrinopeptide A) and fibrinolysis magnitude (plasmin–antiplasmin complex (PAP) and D-dimers). Measurements were done upon intensive care unit (ICU) admission and after 10–14 days. Results: There was increased thrombin generation; modest or null release of t-PA; and increased levels of PAI-2, fibrinopeptide A, PAP and D-dimers. At baseline, nonsurvivors had a significantly (p = 0.014) higher PAI-2/PAP ratio than survivors (109, interquartile range (IQR) 18.1–216, vs. 8.7, IQR 2.9–12.6). At follow-up, thrombin generation was significantly (p = 0.025) reduced in survivors (PF 1 + 2 from 396 pg/mL, IQR 185–585 to 237 pg/mL, IQR 120–393), whereas it increased in nonsurvivors. Fibrinolysis inhibition at follow-up remained stable in survivors and increased in nonsurvivors, leading to a significant (p = 0.026) difference in PAI-2 levels (161 pg/mL, IQR 50–334, vs. 1088 pg/mL, IQR 177–1565). Conclusion: Severe patterns of COVID-19 ARDS are characterized by a thrombin burst and the consequent coagulation activation. Mechanisms of fibrinolysis regulation appear unbalanced toward fibrinolysis inhibition. This pattern ameliorates in survivors, whereas it worsens in nonsurvivors.
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8
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The prognostic value of routine coagulation tests for patients with heat stroke. Am J Emerg Med 2020; 44:366-372. [PMID: 32389399 DOI: 10.1016/j.ajem.2020.04.062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 04/16/2020] [Accepted: 04/17/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To evaluate the prognostic value of routine coagulation tests for patients with heat stroke. METHODS This was a multi-center retrospective study. Patients who arrived at the hospital <24 h after the onset of Heat Stroke (HS) were included. The routine coagulation variables were detected within 24 h after the onset, including the lowest platelet count (PLC). RESULTS 60-day mortality rate was 20.9%. The median Prothrombin Time-International Normalized Ratio (PT-INR) of the non-surviving patients was significantly higher than that of the survivors (P < 0.01). The median Activated Partial Thromboplastin Time (APTT) in non-surviving patients was significantly higher than in the surviving patients (P < 0.01). A Cox regression analysis revealed that 60-day mortality was associated with PT-INR (P = 0.032) and APTT (P = 0.004). The optimal PT-INR point for predicting 60-day mortality rate was 1.7. The optimal APTT point for predicting 60-day mortality was 51.45. Patients with increased PT-INR (≥1.7) levels had, overall, a significantly reduced survival time (P < 0.01). Patients with elevated APTT (≥51.45) also had a decrease in survival time (P < 0.01). The prognostic scoring, with increased PT-INR (≥1.7) and prolonged APTT (≥51.45) at one point each, was also demonstrated to be useful in predicting 60-day mortality. Patients whose temperature fell to 38.9 °C within 30 min had significantly lower levels of PT-INR and APTT within 24 h than those who took longer to cool down. CONCLUSIONS A prolonged APTT and elevated PT-INR within 24 h are independent prognostic factors of 60-day mortality in HS.
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9
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Luo C, Zhuang B, Chen Z. Thromboelastography Parameters as Predictors for Long-Term Survival in Critically Ill Patients. Clin Appl Thromb Hemost 2020; 25:1076029619876028. [PMID: 31549520 PMCID: PMC6829951 DOI: 10.1177/1076029619876028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Thromboelastography (TEG) is used for monitoring abnormal blood coagulation in critically
ill patients. However, the correlation between TEG parameters and long-term survival in
these patients is unknown. We aimed to quantify the effect of TEG on long-term survival of
critically ill patients. Critically ill patients undergoing TEG were retrospectively
examined. Baseline patient characteristics and coagulation function indexes were compared.
Cox regression, receiver–operating characteristic curve analysis, and Kaplan-Meier
survival estimate curve were performed. We included 167 critically ill patients. Clot
formation speed (K) and reaction time (R) were higher, whereas maximum amplitude (MA) and
angle were lower in the mortality group than in the survival group (P
< .01). All TEG parameters were risk factors for 2-year survival in critically ill
patients (P < .01). The area under the curve of MA for predicting
2-year survival was 0.756 (95% confidence interval: 0.670-0.841). The Kaplan-Meier
survival estimate curve analysis showed that MA predicted 2-year survival of critically
ill patients(P < .01). Maximum amplitude can effectively predict
2-year survival of critically ill patients, indicating the influence of the coagulation
system on these patients.
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Affiliation(s)
- Cuizhu Luo
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China.,Department of Critical Care Medicine, JiangXi PingXiang People's Hospital, PingXiang, JiangXi, China
| | - Bingjie Zhuang
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Zhongqing Chen
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
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10
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Zheng R, Pan H, Wang JF, Yu XS, Chen ZQ, Pan JY. The association of coagulation indicators with in-hospital mortality and 1-year mortality of patients with sepsis at ICU admissions: A retrospective cohort study. Clin Chim Acta 2020; 504:109-118. [PMID: 32044332 DOI: 10.1016/j.cca.2020.02.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 02/01/2020] [Accepted: 02/06/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Coagulation activation is the host's response to pathogens during sepsis and is considered to be one of the reasons for tissue damage and multiple organ failure. This study is designed to evaluate whether the alterations of coagulation indicators are related to in-hospital mortality and 1-year mortality of patients with sepsis. METHOD Data of all 2258 patients were extracted from the database Multiparameter Intelligent Monitoring in Intensive Care III (MIMIC III). The relationship between the in-hospital mortality of patients with sepsis and coagulation indicators was analyzed with a receiver operating characteristic (ROC) curve analysis and logistic regression model. Effects of coagulation indicators on patients' 1-year mortality were determined by using a Cox hazard regression model, and clinical experience or quintiles were used to classify the activated partial thromboplastin time (APTT) to determine the cutoff values to explore segmentation effects. RESULT International normalized ratio (INR) was positively associated with hospital mortality of patients with sepsis after adjusting confounders with an odds ratio (OR) of 1.86 [95% confidence interval (CI), 1.37-2.52], and a hazard ratio (HR) of 1.465[95%CI(1.24-1.74)] for 1-year mortality, respectively. 1-year mortality of patients with sepsis demonstrated a U-shaped relationship with APTT, ranging from 25 to 37, indicating the lowest risk. The adjusted HR (95% CI) values for 1-year mortality of septic patients with risk values <25 and >37 were 1.493 (1.02, 2.19) and 1.379 (1.06, 1.79), respectively. CONCLUSION Increased INR in critically ill septic patients is related to greater in-hospital mortality and 1-year mortality. A U-shaped relationship was found between APTT and 1-year mortality of patients with sepsis.
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Affiliation(s)
- Rui Zheng
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Hao Pan
- Department of Orthopedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Jun-Feng Wang
- Department of Intensive Care Unit, Yiwu Hospital Affiliated to Wenzhou Medical University, Yiwu 322000, China
| | - Xue-Shu Yu
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Zhi-Qiang Chen
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Jing-Ye Pan
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China.
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11
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Boscolo A, Spiezia L, Campello E, Consolaro EM, Ori C, Simioni P. The prognostic role of ThromboDynamic Index in patients with severe sepsis. Intern Emerg Med 2020; 15:163-168. [PMID: 31267438 DOI: 10.1007/s11739-019-02137-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 06/25/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Annalisa Boscolo
- UOC Anaesthesia and Intensive Care Unit, Department of Medicine-DIMED, Padova University Hospital, Padua, Italy
| | - Luca Spiezia
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine-DIMED, Padova University Hospital, 105, Via Ospedale Civile, 35100, Padua, Italy
| | - Elena Campello
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine-DIMED, Padova University Hospital, 105, Via Ospedale Civile, 35100, Padua, Italy
| | - Elisabetta Maria Consolaro
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine-DIMED, Padova University Hospital, 105, Via Ospedale Civile, 35100, Padua, Italy
| | - Carlo Ori
- UOC Anaesthesia and Intensive Care Unit, Department of Medicine-DIMED, Padova University Hospital, Padua, Italy
| | - Paolo Simioni
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine-DIMED, Padova University Hospital, 105, Via Ospedale Civile, 35100, Padua, Italy.
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12
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Moore HB, Moore EE, Neal MD, Sheppard FR, Kornblith LZ, Draxler DF, Walsh M, Medcalf RL, Cohen MJ, Cotton BA, Thomas SG, Leeper CM, Gaines BA, Sauaia A. Fibrinolysis Shutdown in Trauma: Historical Review and Clinical Implications. Anesth Analg 2019; 129:762-773. [PMID: 31425218 PMCID: PMC7340109 DOI: 10.1213/ane.0000000000004234] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite over a half-century of recognizing fibrinolytic abnormalities after trauma, we remain in our infancy in understanding the underlying mechanisms causing these changes, resulting in ineffective treatment strategies. With the increased utilization of viscoelastic hemostatic assays (VHAs) to measure fibrinolysis in trauma, more questions than answers are emerging. Although it seems certain that low fibrinolytic activity measured by VHA is common after injury and associated with increased mortality, we now recognize subphenotypes within this population and that specific cohorts arise depending on the specific time from injury when samples are collected. Future studies should focus on these subtleties and distinctions, as hypofibrinolysis, acute shutdown, and persistent shutdown appear to represent distinct, unique clinical phenotypes, with different pathophysiology, and warranting different treatment strategies.
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Affiliation(s)
- Hunter B. Moore
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Ernest E. Moore
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Matthew D. Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Lucy Z. Kornblith
- Department of Surgery, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Dominik F. Draxler
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Mark Walsh
- Department of Surgery, Memorial Hospital Trauma Center, Springfield, Illinois
- Department of Emergency Medicine, Memorial Hospital Trauma Center, Springfield, Illinois
| | - Robert L. Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Mitch J. Cohen
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Bryan A. Cotton
- Department of Surgery, Center for Translational Injury Research, The McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Scott G. Thomas
- Department of Surgery, Memorial Hospital Trauma Center, Springfield, Illinois
- Department of Emergency Medicine, Memorial Hospital Trauma Center, Springfield, Illinois
| | - Christine M. Leeper
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Barbara A. Gaines
- Department of Surgery, Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Angela Sauaia
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- Division of Health Systems, Management, and Policy, University of Colorado School of Public Health, Aurora, Colorado
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13
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Iba T, Levy JH, Raj A, Warkentin TE. Advance in the Management of Sepsis-Induced Coagulopathy and Disseminated Intravascular Coagulation. J Clin Med 2019; 8:E728. [PMID: 31121897 PMCID: PMC6572234 DOI: 10.3390/jcm8050728] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 05/17/2019] [Accepted: 05/20/2019] [Indexed: 12/18/2022] Open
Abstract
Coagulopathy commonly occurs in sepsis as a critical host response to infection that can progress to disseminated intravascular coagulation (DIC) with an increased mortality. Recent studies have further defined factors responsible for the thromboinflammatory response and intravascular thrombosis, including neutrophil extracellular traps, extracellular vesicles, damage-associated molecular patterns, and endothelial glycocalyx shedding. Diagnosing DIC facilitates sepsis management, and is associated with improved outcomes. Although the International Society on Thrombosis and Haemostasis (ISTH) has proposed criteria for diagnosing overt DIC, these criteria are not suitable for early detection. Accordingly, the ISTH DIC Scientific Standardization Committee has proposed a new category termed "sepsis-induced coagulopathy (SIC)" to facilitate earlier diagnosis of DIC and potentially more rapid interventions in these critically ill patients. Therapy of SIC includes both treatment of the underlying infection and correcting the coagulopathy, with most therapeutic approaches focusing on anticoagulant therapy. Recently, a phase III trial of recombinant thrombomodulin was performed in coagulopathic patients. Although the 28-day mortality was improved by 2.6% (absolute difference), it did not reach statistical significance. However, in patients who met entry criteria for SIC at baseline, the mortality difference was approximately 5% without increased risk of bleeding. In this review, we discuss current advances in managing SIC and DIC.
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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.
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC 27705, USA.
| | - Aditya Raj
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo 113-8421, Japan.
- Imperial College London, South Kensington, London SW7 2AZ, UK.
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, and Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON L8S4L8, Canada.
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14
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Blasi A, Calvo A, Prado V, Reverter E, Reverter JC, Hernández-Tejero M, Aziz F, Amoros A, Cardenas A, Fernández J. Coagulation Failure in Patients With Acute-on-Chronic Liver Failure and Decompensated Cirrhosis: Beyond the International Normalized Ratio. Hepatology 2018; 68:2325-2337. [PMID: 29790188 DOI: 10.1002/hep.30103] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/14/2018] [Indexed: 12/22/2022]
Abstract
Balanced hemostasis with hypocoagulable and hypercoagulable features may occur in acute-on-chronic liver failure (ACLF). The characteristics and prognostic impact of the coagulation profile in ACLF are unknown. Consecutive patients with ACLF (n = 36) and acute decompensation (AD; n = 24) were included. Blood samples for thromboelastometry (TE) were obtained at admission and 72 hours thereafter. The coagulation profile was evaluated in patients with and without ACLF and in those with and without systemic inflammatory response syndrome. The impact of the coagulation profile on transfusion requirements, bleeding events, and short-term survival was assessed. At admission, patients with ACLF showed more hypocoagulable characteristics compared to AD subjects, with prolonged time to initial fibrin formation and clot formation time and decreased maximum clot firmness and alpha-angle values. TE parameters worsened at 72 hours in ACLF but improved in patients with AD. Prevalence of a hypocoagulable profile (three or more TE parameters outside range) was significantly higher in patients with ACLF either at admission (61% versus 29% in AD; P = 0.03) or during follow-up. Hypocoagulability correlated with systemic inflammation and was associated with higher 28-day (45% versus 16%; P = 0.02) and 90-day (52% versus 19%; P = 0.01) mortality rates but not with transfusion requirements or bleeding. Prolonged time to initial fibrin formation (extrinsic TE assay >80 seconds) and Model for End-Stage Liver Disease score at baseline were independent predictors of 28-day mortality. Conclusion: Patients with ACLF frequently show hypocoagulable features with prolonged time to initial fibrin formation and clot formation time and reduced clot firmness; these alterations worsen after admission, correlate with systemic inflammation, and translate into higher short-term mortality; hypofibrinolysis could contribute to organ failure in ACLF.
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Affiliation(s)
- Annabel Blasi
- Anesthesiology Department, Hospital Clínic, and University of Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) y Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD)
| | - Andrea Calvo
- Anesthesiology Department, Hospital Clínic, and University of Barcelona, Spain
| | - Verónica Prado
- Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona
| | - Enric Reverter
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) y Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD).,Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona
| | | | - María Hernández-Tejero
- Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona
| | - Fátima Aziz
- Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona
| | - Alex Amoros
- European Foundation for the Study of Chronic Liver Failure
| | - Andres Cardenas
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) y Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD).,GI/Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona, Barcelona, Spain
| | - Javier Fernández
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) y Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD).,Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, and University of Barcelona.,European Foundation for the Study of Chronic Liver Failure
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15
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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.
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16
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Tipoe TL, Wu WKK, Chung L, Gong M, Dong M, Liu T, Roever L, Ho J, Wong MCS, Chan MTV, Tse G, Wu JCY, Wong SH. Plasminogen Activator Inhibitor 1 for Predicting Sepsis Severity and Mortality Outcomes: A Systematic Review and Meta-Analysis. Front Immunol 2018; 9:1218. [PMID: 29967603 PMCID: PMC6015919 DOI: 10.3389/fimmu.2018.01218] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/15/2018] [Indexed: 01/24/2023] Open
Abstract
Objectives Plasminogen activator inhibitor-1 (PAI-1), a crucial regulator of fibrinolysis, is increased in sepsis, but its values in predicting disease severity or mortality outcomes have been controversial. Therefore, we conducted a systematic review and meta-analysis of its predictive values in sepsis. Methods PubMed and Embase were searched until August 18, 2017 for studies that evaluated the relationships between PAI-1 levels and disease severity or mortality in sepsis. Results A total of 112 and 251 entries were retrieved from the databases, of which 18 studies were included in the final meta-analysis. A total of 4,467 patients (36% male, mean age: 62 years, mean follow-up duration: 36 days) were analyzed. PAI-1 levels were significantly higher in non-survivors than survivors [odds ratios (OR): 3.93, 95% confidence interval (CI): 2.31-6.67, P < 0.0001] and in patients with severe sepsis than in those less severe sepsis (OR: 3.26, 95% CI: 1.37-7.75, P = 0.008). Conclusion PAI-1 is a significant predictor of disease severity and all-cause mortality in sepsis. Although the predictive values of PAI-1 reached statistical significance, the clinical utility of PAI-1 in predicting outcomes will require carefully designed prospective trials.
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Affiliation(s)
- Timothy L Tipoe
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - William K K Wu
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Lilianna Chung
- Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Mengqi Gong
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Mei Dong
- Department of Clinical Research, Federal University of Uberlândia, Uberlândia, Brazil
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Leonardo Roever
- Department of Clinical Research, Federal University of Uberlândia, Uberlândia, Brazil
| | - Jeffery Ho
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Martin C S Wong
- JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Matthew T V Chan
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Justin C Y Wu
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Sunny H Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
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17
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The effect of sepsis and septic shock on the viscoelastic properties of clot quality and mass using rotational thromboelastometry: A prospective observational study. J Crit Care 2017; 44:7-11. [PMID: 28988002 DOI: 10.1016/j.jcrc.2017.09.183] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 09/25/2017] [Accepted: 09/30/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE The study purpose was to define changes in coagulation across the sepsis spectrum using rotational thromboelastometry (ROTEM). METHODS Sepsis patients were recruited on admission to the Emergency Department and Intensive Care Units of a large teaching hospital in Wales. ROTEM markers of clot development and fibrinolysis were determined, as well as standard coagulation markers. A healthy control group matched for age and gender was also recruited (n=44). RESULTS 100 patients were recruited (50 sepsis, 20 severe sepsis and 30 septic shock). Maximum clot firmness was significantly higher in the sepsis (p<0.001) and severe sepsis (p=0.012) groups than the healthy control (71.6±4.5 and 70.4±4.1 vs 64.4 respectively). In septic shock there was prolonged clot development; however, maximum clot firmness remained normal. Fibrinolytic function was significantly impaired in septic shock, which was also significantly associated with 28-day mortality (p<0.001). CONCLUSIONS ROTEM indicated significantly enhanced clot structural development in sepsis and severe sepsis, which could be indicative of a hypercoagulable phase. In septic shock, despite there being a prolongation of clotting pathways and impaired fibrinolysis, clot mass was comparably normal, suggestive of the development of a clot with healthy characteristics.
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18
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Lukas P, Durila M, Jonas J, Vymazal T. Evaluation of Thromboelastometry in Sepsis in Correlation With Bleeding During Invasive Procedures. Clin Appl Thromb Hemost 2017; 24:993-997. [PMID: 28950719 PMCID: PMC6714732 DOI: 10.1177/1076029617731624] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Prolongation of prothrombin time (PT) is often encountered in patients with sepsis. On the other hand, thromboelastometry as a global coagulation test might yield normal results. The aim of our study was to evaluate whether prolonged PT in the presence of normal thromboelastometry parameters is associated with severe bleeding in patients with sepsis undergoing invasive procedures. In patients with sepsis undergoing low-risk bleeding invasive procedures (central venous catheter placement, dialysis catheter insertion, drain insertion, and so on) or high-risk bleeding invasive procedures (surgical tracheostomy, surgical laparotomy, thoracotomy, and so on), coagulation was assessed by thromboelastometry using EXTEM test (test for evaluation of the extrinsic pathway of coagulation, contains activator of extrinsic pathway) and with PT. For period of years 2013 to 2016, we assessed occurrence of severe bleeding during those procedures and 24 hours later in patients with prolonged PT and normal thromboelastometry results. This retrospective study was performed at Department of Anaesthesiology and Intensive Care Medicine of Motol University Hospital in Prague. Data from 76 patients with sepsis were analyzed. Median value of international normalized ratio (INR) was 1.59 (min—1.3 and max—2.56), and median value of prothrombin ratio (PR) was 1.5 (min—1.23 and max—2.55) with normal thromboelastometry finding. Despite prolonged INR/PR, no severe bleeding was observed during invasive procedures. Our data show that sepsis may be accompanied by normal thromboelastometry results, despite prolonged values of PT, and invasive procedures were performed without severe bleeding. This approach to coagulation assessment in sepsis may reduce administration of fresh frozen plasma to the patients. The study was registered at Clinical Trials.gov with assigned number NCT02971111.
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Affiliation(s)
- Pavel Lukas
- 1 Second Faculty of Medicine, Department of Anaesthesiology and Intensive Care Medicine, Charles University, Motol University Hospital, Prague, Czech Republic, Europe
| | - Miroslav Durila
- 1 Second Faculty of Medicine, Department of Anaesthesiology and Intensive Care Medicine, Charles University, Motol University Hospital, Prague, Czech Republic, Europe
| | - Jakub Jonas
- 1 Second Faculty of Medicine, Department of Anaesthesiology and Intensive Care Medicine, Charles University, Motol University Hospital, Prague, Czech Republic, Europe
| | - Tomas Vymazal
- 1 Second Faculty of Medicine, Department of Anaesthesiology and Intensive Care Medicine, Charles University, Motol University Hospital, Prague, Czech Republic, Europe
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19
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Benediktsson S, Frigyesi A, Kander T. Routine coagulation tests on ICU admission are associated with mortality in sepsis: an observational study. Acta Anaesthesiol Scand 2017; 61:790-796. [PMID: 28681428 DOI: 10.1111/aas.12918] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 05/02/2017] [Accepted: 05/15/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Low platelet count on admission to an intensive care unit (ICU) is associated with increased mortality and is thus included in some severity scoring systems such as the simplified acute physiologic score 3 (SAPS 3); however it is unclear whether other routine coagulation tests also predict mortality. The purpose of this retrospective single-centre study was to investigate whether activated partial thromboplastin time (APTT) or prothrombin time - international normalized ratio (PT-INR) measured on admission to the ICU in patients with severe sepsis or septic shock may be associated with mortality independent of SAPS 3 score. METHODS All patients admitted to a tertiary general ICU from 2007 to 2014 diagnosed with severe sepsis or septic shock were eligible. Results from APTT and PT-INR within 1.5 h of admission as well as SAPS 3 were used as independent variables in a Cox regression. RESULTS Of total 5485 ICU admissions during the study period we identified 647 unique patients with severe sepsis or septic shock. APTT and PT-INR were found to correlate significantly with mortality with a hazard ratio (HR) of 1.014 [95% confidence interval of HR (1.006-1.023)] for APTT and 1.422 (1.117-1.811) for PT-INR. HR for SAPS 3 was 1.036 (1.028-1.044). CONCLUSION Activated partial thromboplastin time prolongation and raised PT-INR on ICU admission in patients with severe sepsis or septic shock is associated with increased mortality independent of SAPS 3 score. This indicates that APTT prolongation and PT-INR increase represents morbidity that is not accounted for in SAPS 3.
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Affiliation(s)
- S. Benediktsson
- Department of Intensive and Perioperative Care; Skåne University Hospital; Lund Sweden
- Department of Clinical Sciences; Section for Anaesthesiology and Intensive Care; Lund University; Lund Sweden
| | - A. Frigyesi
- Department of Intensive and Perioperative Care; Skåne University Hospital; Lund Sweden
- Department of Clinical Sciences; Section for Anaesthesiology and Intensive Care; Lund University; Lund Sweden
| | - T. Kander
- Department of Intensive and Perioperative Care; Skåne University Hospital; Lund Sweden
- Department of Clinical Sciences; Section for Anaesthesiology and Intensive Care; Lund University; Lund Sweden
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20
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Scarlatescu E, Tomescu D, Arama SS. Anticoagulant Therapy in Sepsis. The Importance of Timing. ACTA ACUST UNITED AC 2017; 3:63-69. [PMID: 29967873 PMCID: PMC5769917 DOI: 10.1515/jccm-2017-0011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 03/24/2017] [Indexed: 11/25/2022]
Abstract
Sepsis associated coagulopathy is due to the inflammation-induced activation of coagulation pathways concomitant with dysfunction of anticoagulant and fibrinolytic systems, leading to different degrees of haemostasis dysregulation. This response is initially beneficial, contributing to antimicrobial defence, but when control is lost coagulation activation leads to widespread microvascular thrombosis and subsequent organ failure. Large clinical trials of sepsis-related anticoagulant therapies failed to show survival benefits, but posthoc analysis of databases and several smaller studies showed beneficial effects of anticoagulants in subgroups of patients with early sepsis-induced disseminated intravascular coagulation. A reasonable explanation could be the difference in timing of anticoagulant therapy and patient heterogeneity associated with large trials. Proper selection of patients and adequate timing are required for treatment to be successful. The time when coagulation activation changes from advantageous to detrimental represents the right moment for the administration of coagulation-targeted therapy. In this way, the defence function of the haemostatic system is preserved, and the harmful effects of overwhelming coagulation activation are avoided.
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Affiliation(s)
- Ecaterina Scarlatescu
- Department of Anesthesiology and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania
| | - Dana Tomescu
- Department of Anesthesiology and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania.,University of Medicine and Pharmacy, "Carol Davila", Bucharest, Romania
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21
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Scarlatescu E, Tomescu D, Arama SS. Sepsis-Associated Coagulopathy. ACTA ACUST UNITED AC 2016; 2:156-163. [PMID: 29967855 DOI: 10.1515/jccm-2016-0024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 09/29/2016] [Indexed: 11/15/2022]
Abstract
Systemic inflammatory activation in sepsis often leads to coagulation activation, but the relationship is bilateral, as coagulation also modulates the inflammatory response. This close associate has significant consequences for the pathogenesis of microvascular thrombosis and organ dysfunction in sepsis. While coagulation activation can be beneficial for immune defense, it can also be detrimental once it becomes widespread and uncontrolled. The knowledge of the pathophysiologic mechanisms involved in the interaction between infection and coagulation may lead to the better timing for the administration of targeted antithrombotic therapies in septic patients. This brief review highlights the pathophysiologic pathways leading to the prothrombotic state in sepsis and the mechanisms that play a role in the interaction between infection and coagulation.
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Affiliation(s)
- Ecaterina Scarlatescu
- Department of Anesthesiology and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania
| | - Dana Tomescu
- Department of Anesthesiology and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania
- University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
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22
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Assessment of Haemostasis in Disseminated Intravascular Coagulation by Use of Point-of-Care Assays and Routine Coagulation Tests, in Critically Ill Patients; A Prospective Observational Study. PLoS One 2016; 11:e0151202. [PMID: 26959974 PMCID: PMC4784845 DOI: 10.1371/journal.pone.0151202] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 02/23/2016] [Indexed: 01/06/2023] Open
Abstract
Background Disseminated intravascular coagulopathy (DIC) relates to the consumption of coagulation factors and platelets with bleeding and micro thrombosis events. Aim The aim of this study was to compare haemostasis parameters in critically ill patients with DIC versus patients without DIC, and in survivors versus non-survivors over time. Correlations between the DIC-score, the degree of organ failure and the haemostasis were assessed. Method Patients admitted to the intensive care unit with a condition known to be associated with DIC and with an expected length of stay of >3 days were included. Routine laboratory tests, prothrombin time, activated partial thromboplastin time, platelet count, fibrinogen concentration and D-dimer were measured. Coagulation and platelet function were assessed with two point-of-care devices; Multiplate and ROTEM. DIC scores were calculated according to the International Society on Thrombosis and Haemostasis and Japanese Association for Acute Medicine. Results Blood was sampled on days 0–1, 2–3 and 4–10 from 136 patients with mixed diagnoses during 290 sampling events. The point-of-care assays indicated a hypocoagulative response (decreased platelet aggregation and reduced clot strength) in patients with DIC and, over time, in non-survivors compared to survivors. Patients with DIC as well as non-survivors had decreased fibrinolysis as shown by ROTEM. DIC scores were higher in non-survivors than in survivors. Conclusions Patients with DIC displayed signs of a hypocoagulative response and impaired fibrinolysis, which was also evident over time in non-survivors. Patients with DIC had a higher mortality rate than non-DIC patients, and DIC scores were higher in non-survivors than in survivors.
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23
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Prakash S, Wiersema UF, Bihari S, Roxby D. Discordance between ROTEM® clotting time and conventional tests during unfractionated heparin–based anticoagulation in intensive care patients on extracorporeal membrane oxygenation. Anaesth Intensive Care 2016; 44:85-92. [DOI: 10.1177/0310057x1604400113] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We hypothesised that ROTEM® (Basel, Switzerland) INTEM® (ROTEM, Basel, Switzerland) clotting time (CT) would have good agreement with activated partial thromboplastin time (aPTT) in determining whether a dose adjustment should be made to the unfractionated heparin (UFH) infusion in patients on extracorporeal membrane oxygenation. All patients treated with extracorporeal membrane oxygenation over a five-year period were included for data analysis. Retrospective analysis was performed of prospectively collected data points, wherein aPTT, activated CT and ROTEM was performed simultaneously to monitor UFH–based anticoagulation. Two hundred data points were available for analysis. Turnaround time was shortest for activated CT followed by ROTEM and aPTT. Despite achieving therapeutic aPTT targets, the majority (>50%) of INTEM CT results were within normal limits. The aPTT and INTEM CT results correlated weakly (r=0.31, 95% confidence interval [0.17, 0.43]) and there was no agreement between the directional changes of aPTT and INTEM CT results on successive days (χ2 = 2.33, P=0.17). Due to relative insensitivity, INTEM CT–guided UFH titration was estimated to result in a 289% increase in incidence of up-titration, over aPTT–guided titration. The INTEM CT results (r=0.36, 95% confidence interval [0.23, 0.48]) correlated weakly with UFH infusion rates. The UFH infusion rate only explained 13% variability in INTEM CT values. While haemorrhagic complications were frequent, no major clotting complications were encountered. Our results demonstrated that aPTT and INTEM CT do not provide equivalent information to guide UFH infusion rate titration during extracorporeal membrane oxygenation. Our study suggests caution regarding the use of ROTEM for guiding UFH–based anticoagulation as it may lead to excessive UFH exposure.
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Affiliation(s)
- S. Prakash
- Department of Intensive Care, Flinders Medical Centre, Bedford Park, South Australia
| | - U. F. Wiersema
- Department of Intensive Care, Flinders Medical Centre, Bedford Park, South Australia
| | - S. Bihari
- Department of Intensive Care, Flinders Medical Centre, Bedford Park, South Australia
| | - D. Roxby
- SA Pathology Transfusion Medicine, Flinders Medical Centre, Bedford Park, South Australia
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24
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Markers of endothelial damage and coagulation impairment in patients with severe sepsis resuscitated with hydroxyethyl starch 130/0.42 vs Ringer acetate. J Crit Care 2015; 32:16-20. [PMID: 26810483 DOI: 10.1016/j.jcrc.2015.11.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 11/10/2015] [Accepted: 11/26/2015] [Indexed: 01/14/2023]
Abstract
PURPOSE The Scandinavian Starch for Severe Sepsis/Septic Shock (6S) trial showed increased mortality in patients resuscitated with hydroxyethyl starch 130/0.42 (HES) vs Ringer acetate. Different effects of the fluids on the endothelium may have contributed to the observed outcome. We aimed to investigate associations between HES vs Ringer and changes in plasma biomarkers reflecting endothelial damage and coagulation impairment. MATERIALS AND METHODS Six biomarkers, including soluble thrombomodulin (sTM) and plasminogen activator inhibitor 1 (PAI-1), were assessed in a subgroup of 208 patients from the 6S trial. We analyzed differences in plasma concentration in the 2 intervention groups using linear or logistic regression models. RESULTS The increase in plasma sTM was lower in the HES group (-1.8 ng/mL; 95% confidence interval, -2.9 to -0.7; P = .002). The change was not statistically significant associated with mortality whereas increase in plasminogen activator inhibitor 1 was (odds ratio for 1-unit increase, 1.04; 95% confidence interval, 1.01-1.08; P = .01). CONCLUSIONS Resuscitation with HES vs Ringer decreased early endothelial damage. Although this finding should be interpreted with caution, it indicates that the increased mortality observed with HES in the 6S trial may not be explained by endothelial damage and it emphasizes the challenge of using surrogate markers as outcome.
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Larsson A, Tynngård N, Kander T, Bonnevier J, Schött U. Comparison of point-of-care hemostatic assays, routine coagulation tests, and outcome scores in critically ill patients. J Crit Care 2015; 30:1032-8. [DOI: 10.1016/j.jcrc.2015.06.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 05/29/2015] [Accepted: 06/14/2015] [Indexed: 10/23/2022]
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