A systematic review of antithrombin concentrate use in patients with disseminated intravascular coagulation of severe sepsis

Efficacy of antithrombin administration for patients with sepsis: A systematic review, meta-analysis, and meta-regression

Aims

There have been inconsistent reports regarding the effect of antithrombin on sepsis; furthermore, there are limited reports on how dosage affects therapeutic efficacy. Thus, we aimed to perform a systematic review and meta-analysis of the use of antithrombin for sepsis and a meta-regression analysis of antithrombin dosage.

Methods

We included randomized controlled trials (RCTs) and observational studies of adult patients with sepsis who received antithrombin. Outcomes included all-cause mortality and serious bleeding complications. Statistical analyses and data synthesis were performed using a random-effects model; further, meta-regression and funnel plots were used to explore heterogeneity and biases.

Results

Seven RCTs and six observational studies were included. Most patients in the RCTs and observational studies had severe sepsis and septic-disseminated intravascular coagulation (DIC), respectively. A meta-analysis using RCTs showed no significant differences in mortality between the antithrombin and control groups. However, the meta-analysis of observational studies indicated a trend of decreasing mortality rates with antithrombin administration (odds ratio [OR], 0.79; 95% confidence interval [CI], 0.68-0.92; p = 0.002). Bleeding complications were significantly higher in the antithrombin group than in the control group in both study types (OR, 1.90; 95% CI, 1.52-2.37; p < 0.01). The meta-regression analysis showed no correlation between antithrombin dosage and mortality.

Conclusion

A meta-analysis of RCTs confirmed no survival benefit of antithrombin, whereas that of observational studies, which mostly focused on septic DIC, showed a significant beneficial effect on improving outcomes. Indications of antithrombin should be considered based on its beneficial and harmful effects.

Super Formula for Diagnosing Disseminated Intravascular Coagulation Using Soluble C-Type Lectin-like Receptor 2

The scoring systems for disseminated intravascular coagulation (DIC) criteria require several adequate cutoff values, vary, and are complicated. Accordingly, a simpler and quicker diagnostic method for DIC is needed. Under such circumstances, soluble C-type lectin-like receptor 2 (sCLEC-2) received attention as a biomarker for platelet activation.

MATERIALS AND METHODS

The diagnostic usefulness of sCLEC-2 and several formulas, including sCLEC-2xD-dimer, sCLEC-2/platelet count (sCLEC-2/PLT), and sCLEC-2/PLT × D-dimer (sCLEC-2xD-dimer/PLT), were evaluated among 38 patients with DIC, 39 patients with pre-DIC and 222 patients without DIC or pre-DIC (non-DIC).

RESULTS

Although the plasma level of sCLEC-2 alone was not a strong biomarker for the diagnosis of DIC or pre-DIC, the sCLEC-2xD-dimer/PLT values in patients with DIC were significantly higher than those in patients without DIC, and in a receiver operating characteristic (ROC) analysis for the diagnosis of DIC, sCLEC-2xD-dimer/PLT showed the highest AUC, sensitivity, and odds ratio. This formula is useful for the diagnosis of both pre-DIC and DIC. sCLEC-2xD-dimer/PLT values were significantly higher in non-survivors than in survivors.

CONCLUSION

The sCLEC-2xD-dimer/PLT formula is simple, easy, and highly useful for the diagnosis of DIC and pre-DIC without the use of a scoring system.

Effect of Antithrombin III Administration on the Prognosis of Severe Trauma Patients with Disseminated Intravascular Coagulation

BACKGROUND

We aimed to investigate the effects of antithrombin III administration on the prognosis of severe trauma patients with disseminated intravascular coagulation (DIC).

METHODS

Medical records of a total of 4023 patients who were admitted to the intensive care unit (ICU) at the single regional trauma center from January 2016 to December 2020 were retrospectively analyzed. After the exclusion of young patients (<15 years old), mild trauma (ISS < 16), non DIC, etc., a total of 140 patients were included in the study. These patients were classified into antithrombin III-administered and non-antithrombin III-administered groups. Clinical data, including laboratory findings, trauma- and ICU-related severity scores, prognosis (including length of hospital stay), and need for organ support, were retrospectively collected. We evaluated the characteristics of the two groups, and compared and analyzed the vital signs, laboratory findings, prognosis, and clinical outcomes of each group. With this, we analyzed the effect of antithrombin III administration in severe trauma patients with DIC.

RESULTS

Of the 140 patients, 61 were treated with antithrombin III. No significant difference was observed in the baseline characteristics between the two groups for initial laboratory results, initial vital signs, or trauma-related severity scores. The improvement of the sequential organ failure assessment (SOFA) score, a prognostic marker, was significantly greater in the administered group (p = 0.009). Additionally, the antithrombin-administered group showed a larger improvement in the SOFA score than the non-administered group (p = 0.002). However, there was no statistical difference between the two groups for the frequency or duration of organ support treatments (renal replacement therapy, mechanical ventilation), mortality, or length of hospital stay.

CONCLUSION

Antithrombin III administration in severe trauma patients with DIC improved SOFA scores and aided in multi-organ dysfunction recovery. Appropriate indications should be studied to maximize the drug's improvement effect in patients with severe trauma in the future.

Antithrombin Therapy: Current State and Future Outlook

Antithrombin (AT) is a natural anticoagulant pivotal in inactivating serine protease enzymes in the coagulation cascade, making it a potent inhibitor of blood clot formation. AT also possesses anti-inflammatory properties by influencing anticoagulation and directly interacting with endothelial cells. Hereditary AT deficiency is one of the most severe inherited thrombophilias, with up to 85% lifetime risk of venous thromboembolism. Acquired AT deficiency arises during heparin therapy or states of hypercoagulability like sepsis and premature infancy. Optimization of AT levels in individuals with AT deficiency is an important treatment consideration, particularly during high-risk situations such as surgery, trauma, pregnancy, and postpartum. Here, we integrate the existing evidence surrounding the approved uses of AT therapy, as well as potential additional patient populations where AT therapy has been considered by the medical community, including any available consensus statements and guidelines. We also describe current knowledge regarding cost-effectiveness of AT concentrate in different contexts. Future work should seek to identify specific patient populations for whom targeted AT therapy is likely to provide the strongest clinical benefit.

Dynamic thromboembolic left ventricular outflow tract obstruction after aggressive procoagulant treatment in hemorrhagic shock: a case report

Background

In cases of hypertrophic obstructive cardiomyopathy (HOCM), the systolic anterior motion of the mitral valve apparatus results in an obstruction of the left ventricular outflow tract (LVOT), which is known as the SAM [systolic anterior motion] phenomenon. Hypothetically, a pathological obstruction of the LVOT of a different etiology would result in a comparable hemodynamic instability, which would be refractory to inotrope therapy, and may be detectable through echocardiography.

Case presentation

We observed a severely impaired left ventricular function due to a combination of a thrombotic LVOT obstruction and distinctive mitral regurgitation in a 56-year-old Caucasian, female patient after massive transfusion with aggressive procoagulant therapy. Initially, the patient had to be resuscitated due to cardiac arrest after a long-distance flight. The resuscitation attempts in combination with lysis therapy due to suspected pulmonary artery embolism were initially successful but resulted in traumatic liver injury, hemorrhagic shock and subsequent acute respiratory distress syndrome (ARDS). Oxygenation was stabilized with veno-venous extracorporeal membrane oxygenation (ECMO), but the hemodynamic situation deteriorated further. Transesophageal echocardiography (TEE) showed a massive, dynamic LVOT obstruction. Two thrombi were attached to the anterior leaflet of the mitral valve, resulting in a predominantly systolic obstruction. Unfortunately, the patient died of multiple-organ failure despite another round of lysis therapy and escalation of the ECMO circuit to a veno-venoarterial cannulation for hemodynamic support.

Conclusion

Massive transfusion with aggressive procoagulant therapy resulted in mitral valve leaflet thrombosis with dynamic, predominantly systolic LVOT obstruction, comparable to the SAM phenomenon. The pathology was only detectable with a TEE investigation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13256-021-02840-3.

Effect of High-dose Antithrombin Supplementation in Patients with Septic Shock and Disseminated Intravascular Coagulation

The efficacy of antithrombin (AT) administration in patients with septic shock and disseminated intravascular coagulation (DIC) was uncertain. This study aimed to investigate whether high-dose AT administration improves outcomes in patients with septic shock and DIC. This observational, prospective cohort study included consecutive adult septic shock patients with DIC who showed AT activity <70% between March 2016 and August 2018. The 28 day mortality of the patients treated with AT and without AT was evaluated by propensity score matching and inverse probability of treatment weighting. Among 142 patients with septic shock and DIC, 45 patients (31.7%) received AT supplementation and 97 did not. The 28 day mortality rate was lower in the AT group, but no statistically significant difference persisted after matching. Multivariable analysis showed that AT supplementation was independently associated with 28 day mortality (odds ratio [OR], 0.342; 95% CI [confidence interval], 0.133-0.876; P = 0.025); however, no such association was observed after matching (OR, 0.480; 95% CI, 0.177-1.301; P = 0.149). High-dose AT administration in septic shock patients with DIC showed the improvement in survival, but the improvement was not observed after matching. Further larger studies are needed to conclusively confirm these findings.

A Systematic Summary of Systematic Reviews on Anticoagulant Therapy in Sepsis

Many systematic reviews have been published regarding anticoagulant therapy in sepsis, among which there is substantial heterogeneity. This study aimed to provide an overview of existing systematic reviews of randomized controlled trials by using a comprehensive search method. We searched MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews. Of 895 records screened, 19 systematic reviews were included. The target agent was as follows: antithrombin (n = 4), recombinant thrombomodulin (n = 3), heparin (n = 3), recombinant activated protein C (n = 8), and all anticoagulants (n = 1). Antithrombin did not improve mortality in critically ill patients but indicated a beneficial effect in sepsis-induced disseminated intravascular coagulation (DIC), although the certainty of evidence was judged as low. Recombinant thrombomodulin was associated with a trend in reduced mortality in sepsis with coagulopathy with no increased risk of bleeding, although the difference was not statistically significant and the required information size for any declarative judgement insufficient. Although three systematic reviews showed potential survival benefits of unfractionated heparin and low-molecular-weight heparin in patients with sepsis, trials with low risk of bias were lacking, and the overall impact remains unclear. None of the meta-analyses of recombinant activated protein C showed beneficial effects in sepsis. In summary, a beneficial effect was not observed in overall sepsis in poorly characterized patient groups but was observed in sepsis-induced DIC or sepsis with coagulopathy in more specific patient groups. This umbrella review of anticoagulant therapy suggests that characteristics of the target populations resulted in heterogeneity among the systematic reviews.

An open-label, randomized, phase 3 study of the efficacy and safety of antithrombin gamma in patients with sepsis-induced disseminated intravascular coagulation syndrome

Background

A recombinant form of antithrombin (AT), called AT gamma, is being developed as an alternative to AT derived from human plasma. To compare the efficacy and safety of AT gamma to plasma-derived AT (pAT), we conducted a randomized, open-label, multicenter trial in patients with sepsis-induced disseminated intravascular coagulation (DIC).

Methods

Eligible patients, recruited at 30 clinical sites, had been diagnosed with sepsis-induced DIC (by the Japanese Association for Acute Medicine [JAAM] DIC criteria) and AT activity at 70% or below. Patients were randomized 1:1 to either 36 IU/kg/day AT gamma (n = 110) or 30 IU/kg/day pAT (n = 112), both administered intravenously for 5 days. The primary endpoint was recovery from DIC at day 6 or early study withdrawal. DIC recovery was defined as a DIC score of less than four. Secondary endpoints were DIC score, outcome on day 28, sequential organ failure assessment score, acute physiology and chronic health evaluation II score (APACHE II), and plasma AT activity. Adverse events and adverse drug reactions were recorded using MedDRA/J version 16.0.

Results

Baseline patient demographics and clinical features were similar in the two treatment groups. On day 6 (or at withdrawal), DIC recovery had occurred in 62 of 110 (56.4%; 95% confidence interval, 46.6–65.8%) patients in the AT gamma group and 59 of 112 (52.7%; 95% confidence interval, 43.0–62.2%) patients in the pAT group. In both treatment groups, DIC recovery rate values tended to be higher when stratified by baseline AT activity rates. All changes in other secondary endpoints were similar in both treatment groups. Safety was also similar in the two treatment groups. Adverse events occurred in 89 of 108 (82.4%) patients in the AT gamma group and 99 of 113 (87.6%) patients in the pAT group.

Conclusions

Safety and efficacy were similar for 36 IU/kg/day AT gamma and 30 IU/kg/day pAT. These results confirm that AT gamma is an excellent alternative to pAT for improving outcomes for patients with DIC.

Trial registration

ClinicalTrials.gov identifier: NCT01384903; June 2011.

Antithrombin concentrate use in disseminated intravascular coagulation of sepsis: meta-analyses revisited

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.

Antithrombin concentrate use in sepsis-associated disseminated intravascular coagulation: re-evaluation of a 'pendulum effect' drug using a nationwide database

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.

Coagulofibrinolytic Changes in Patients with Post-cardiac Arrest Syndrome

Whole-body ischemia and reperfusion due to cardiac arrest and subsequent return of spontaneous circulation constitute post-cardiac arrest syndrome (PCAS), which consists of four syndromes including systemic ischemia/reperfusion responses and post-cardiac arrest brain injury. The major pathophysiologies underlying systemic ischemia/reperfusion responses are systemic inflammatory response syndrome and increased coagulation, leading to disseminated intravascular coagulation (DIC), which clinically manifests as obstruction of microcirculation and multiple organ dysfunction. In particular, thrombotic occlusion in the brain due to DIC, referred to as the "no-reflow phenomenon," may be deeply involved in post-cardiac arrest brain injury, which is the leading cause of mortality in patients with PCAS. Coagulofibrinolytic changes in patients with PCAS are characterized by tissue factor-dependent coagulation, which is accelerated by impaired anticoagulant mechanisms, including antithrombin, protein C, thrombomodulin, and tissue factor pathway inhibitor. Damage-associated molecular patterns (DAMPs) accelerate not only tissue factor-dependent coagulation but also the factor XII- and factor XI-dependent activation of coagulation. Inflammatory cytokines are also involved in these changes via the expression of tissue factor on endothelial cells and monocytes, the inhibition of anticoagulant systems, and the release of neutrophil elastase from neutrophils activated by inflammatory cytokines. Hyperfibrinolysis in the early phase of PCAS is followed by inadequate endogenous fibrinolysis and fibrinolytic shutdown by plasminogen activator inhibitor-1. Moreover, cell-free DNA, which is also a DAMP, plays a pivotal role in the inhibition of fibrinolysis. DIC diagnosis criteria or fibrinolysis markers, including d-dimer and fibrin/fibrinogen degradation products, which are commonly tested in patients and easily accessible, can be used to predict the mortality or neurological outcome of PCAS patients with high accuracy. A number of studies have explored therapy for this unique pathophysiology since the first report on "no-reflow phenomenon" was published roughly 50 years ago. However, the optimum therapeutic strategy focusing on the coagulofibrinolytic changes in cardiac arrest or PCAS patients has not yet been established. The elucidation of more precise pathomechanisms of coagulofibrinolytic changes in PCAS may aid in the development of novel therapeutic targets, leading to an improvement in the outcomes of PCAS patients.

To What Extent Are the Terminal Stages of Sepsis, Septic Shock, Systemic Inflammatory Response Syndrome, and Multiple Organ Dysfunction Syndrome Actually Driven by a Prion/Amyloid Form of Fibrin?

A well-established development of increasing disease severity leads from sepsis through systemic inflammatory response syndrome, septic shock, multiple organ dysfunction syndrome, and cellular and organismal death. Less commonly discussed are the equally well-established coagulopathies that accompany this. We argue that a lipopolysaccharide-initiated (often disseminated intravascular) coagulation is accompanied by a proteolysis of fibrinogen such that formed fibrin is both inflammatory and resistant to fibrinolysis. In particular, we argue that the form of fibrin generated is amyloid in nature because much of its normal α-helical content is transformed to β-sheets, as occurs with other proteins in established amyloidogenic and prion diseases. We hypothesize that these processes of amyloidogenic clotting and the attendant coagulopathies play a role in the passage along the aforementioned pathways to organismal death, and that their inhibition would be of significant therapeutic value, a claim for which there is considerable emerging evidence.

Anticoagulant Therapy in Sepsis. The Importance of Timing

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.

Platelets and coagulation in infection

Disseminated intravascular coagulation (DIC) is a frequent complication in sepsis that is associated with worse outcomes and higher mortality in patients. In addition to the uncontrolled generation of thrombi throughout the patient's vasculature, DIC often consumes large quantities of clotting factors leaving the patient susceptible to hemorrhaging. Owing to these complications, patients often receive anticoagulants to treat the uncontrolled clotting, often with mixed outcomes. This lack of success with the current array of anticoagulants can be partly explained by the fact that during sepsis clotting is often initiated by the immune system. Systemic inflammation has the capacity to activate and amplify coagulation and, as such, potential therapies for the treatment of sepsis-associated DIC need to address the interaction between inflammation and coagulation. Recent studies have suggested that platelets and neutrophil extracellular traps (NETs) are the key mediators of infection-induced coagulation. This review explores current anticoagulant therapies and discusses the development of future therapies to target platelet and NET-mediated coagulation.

Disseminated intravascular coagulation

Disseminated intravascular coagulation (DIC) is an acquired syndrome characterized by widespread intravascular activation of coagulation that can be caused by infectious insults (such as sepsis) and non-infectious insults (such as trauma). The main pathophysiological mechanisms of DIC are inflammatory cytokine-initiated activation of tissue factor-dependent coagulation, insufficient control of anticoagulant pathways and plasminogen activator inhibitor 1-mediated suppression of fibrinolysis. Together, these changes give rise to endothelial dysfunction and microvascular thrombosis, which can cause organ dysfunction and seriously affect patient prognosis. Recent observations have pointed to an important role for extracellular DNA and DNA-binding proteins, such as histones, in the pathogenesis of DIC. The International Society on Thrombosis and Haemostasis (ISTH) established a DIC diagnostic scoring system consisting of global haemostatic test parameters. This scoring system has now been well validated in diverse clinical settings. The theoretical cornerstone of DIC management is the specific and vigorous treatment of the underlying conditions, and DIC should be simultaneously managed to improve patient outcomes. The ISTH guidance for the treatment of DIC recommends treatment strategies that are based on current evidence. In this Primer, we provide an updated overview of the pathophysiology, diagnosis and management of DIC and discuss the future directions of basic and clinical research in this field.

Sepsis and disseminated intravascular coagulation

Sepsis is frequently complicated by coagulopathy and, in about 35 % of severe cases, by disseminated intravascular coagulation (DIC). In Japan, aggressive treatment of septic DIC is encouraged using antithrombin and recombinant thrombomodulin. The macrophages, monocytes, and neutrophils are a source of TF and participate in the direct activation of the coagulation cascade in the early phases of sepsis. And activated factor X (FXa), which is involved in hemostasis, thrombogenesis, inflammation, and cellular immune responses, induces TF expression in human peripheral monocytes and, conversely, that inhibition of FXa activity reduces TF expression. Both inflammation and coagulation play an important role in DIC due to sepsis. In addition to inflammatory cytokines (TNF-α, IL-1 and so on), HMGB1 has recently been shown to mediate the lethal late phase of sepsis and caused coagulopathy. TM not only binds HMGB1 but also aids the proteolytic cleavage of HMGB1 by thrombin. There have been many reports of the efficacy of recombinant TM and antithrombin for treatment of septic DIC from Japan. Further investigation of the efficacy of recombinant TM and AT in countries other than Japan, as well as the monitoring of medical costs incurred during hospitalization, will help validate the use of TM and AT for treatment of septic DIC.

[Experience in treating portal thromboses in patients with chronic myeloproliferative diseases]

Patients with myeloproliferative diseases (MPD) are noted to be at high risk for portal thromboses. This problem gives rise to disability if it is untimely treated or resistant to therapy. The paper gives the experience of the Outpatient Department of the Hematology Research Center, Ministry of Health of the Russian Federation, in using antithrombin III in MPD patients (3 patients with primary myelofibrosis, 3 with essential thrombocythemia) and acute and subacute portal vein thromboses resistant to therapy with direct anticoagulants. In all 5 cases, the use of antithrombin III in combination with low-molecular-weight heparin showed a positive clinical effect as rapid relief of pain syndrome and comparatively early (3-week to 1.5-2-month) recanalization of thrombosed vessels. Three clinical cases are described in detail.

Shock, acute disseminated intravascular coagulation, and microvascular thrombosis: is 'shock liver' the unrecognized provocateur of ischemic limb necrosis?

For unknown reasons, a small minority of critically ill patients with septic or cardiogenic shock, multiorgan failure, and disseminated intravascular coagulation develop symmetrical acral (distal extremity) limb loss due to microvascular thrombosis ('limb gangrene with pulses'). Case reports have described preceding 'shock liver' in some critically ill patients who developed such a picture of ischemic limb necrosis. This suggests that profoundly disturbed procoagulant-anticoagulant balance featuring uncontrolled generation of thrombin-resulting from failure of the protein C and antithrombin natural anticoagulant systems due to insufficient hepatic synthesis of these crucial proteins-could explain the microvascular thrombosis and associated limb loss. We hypothesize that shock liver is the key predisposing risk factor underlying ischemic limb necrosis in the majority of patients who develop this complication in the setting of acute disseminated intravascular coagulation complicating septic or cardiogenic shock. As shock liver precedes onset of limb ischemia by several days, therapeutic intervention may be possible.

Supportive management strategies for disseminated intravascular coagulation. An international consensus

The cornerstone of the management of disseminated intravascular coagulation (DIC) is the treatment of the underlying condition triggering the coagulopathy. However, a number of uncertainties remain over the optimal supportive treatment. The aim of this study was to provide evidence and expert-based recommendations on the optimal supportive haemostatic and antithrombotic treatment strategies for patients with DIC. A working group defined five relevant clinical scenarios. Published studies were systematically searched in the MEDLINE and EMBASE databases (up to May 2014). Seven internationally recognised experts were asked to independently provide clinical advice. A two-phase blinded data collection technique was used to reach consensus. Only three randomised controlled trials (RCTs) on the supportive management of DIC were identified. The RCTs (overall less than 100 patients) investigated the use of fresh frozen plasma and platelet transfusion and found no differences in survival between the intervention and control groups. The experts' approach was heterogeneous, although there was consensus that supportive management should vary according to the underlying cause, clinical manifestations and severity of blood test abnormalities. Platelet transfusion should be given to maintain platelet count > 50×10⁹/l in case of bleeding while a lower threshold of 20 to 30×10⁹/l may be used in DIC without bleeding. Thromboprophylaxis with low-molecular-weight heparin is advised until bleeding ensues or platelet count drops below 30×10⁹/l. In conclusion, in the absence of solid evidence from RCTs, an individualised supportive management of DIC is advisable based on the type of underlying disease, presence of bleeding or thrombotic complications and laboratory tests results.

Antithrombin: anti-inflammatory properties and clinical applications

Many humoral and cellular components participate in bidirectional communication between the coagulation and inflammation pathways. Natural anticoagulant proteins, including antithrombin (AT), tissue factor pathway inhibitor, and protein C, suppress proinflammatory mediators. Conversely, inflammation blunts anticoagulant activity and, when uncontrolled, promotes systemic inflammation-induced coagulation, such as those that occur in disseminated intravascular coagulation and severe sepsis. This review discusses the mechanisms of action and clinical use of AT concentrate in critically ill patients and in the settings of perioperative anticoagulation management for surgery and obstetrics. AT is a serine protease inhibitor with broad anticoagulant activity and potent anti-inflammatory properties. In clinical conditions associated with hereditary or acquired AT deficiency, administration of AT concentrate has been shown to restore proper haemostasis and attenuate inflammation. Of note, AT modulates inflammatory responses not only by inhibiting thrombin and other clotting factors that induce cytokine activity and leukocyte-endothelial cell interaction, but also by coagulation-independent effects, including direct interaction with cellular mediators of inflammation. An increasing body of evidence suggests that AT concentrate may be a potential therapeutic agent in certain clinical settings associated with inflammation. In addition to the well-known anticoagulation properties of AT for the treatment of hereditary AT deficiency, AT also possesses noteworthy anti-inflammatory properties that could be valuable in treating acquired AT deficiency, which often result in thrombotic states associated with an inflammatory component.

Supplemental dose of antithrombin use in disseminated intravascular coagulation patients after abdominal sepsis

The effectiveness of supplemental dose antithrombin administration (1,500 to 3,000 IU/ day) for patients with sepsis-associated disseminated intravascular coagulation (DIC), especially sepsis due to abdominal origin, remains uncertain. This was a retrospective cohort study of patients with mechanically ventilated septic shock and DIC after emergency surgery for perforation of the lower intestinal tract using a nationwide administrative database, Japanese Diagnosis Procedure Combination inpatient database. A total of 2,164 patients treated at 612 hospitals during the 33-month study period between 2010 and 2013 were divided into an antithrombin group (n=1,021) and a control group (n=1,143), from which 518 propensity score-matched pairs were generated. Although there was no significant 28-day mortality difference between the two groups in the unmatched groups (control vs antithrombin: 25.7 vs 22.9 %; difference, 2.8 %; 95 % confidence interval [CI], -0.8-6.4), a significant difference existed between the two groups in propensity-score weighted groups (26.3 vs 21.7 %; difference, 4.6 %; 95 % CI, 2.0-7.1) and propensity-score matched groups (27.6 vs 19.9 %; difference, 7.7 %; 95 % CI, 2.5-12.9). Logistic regression analyses showed a significant association between antithrombin use and lower 28-day mortality in propensity-matched groups (odds ratio, 0.65; 95 % CI, 0.49-0.87). Analysis using the hospital antithrombin-prescribing rate as an instrumental variable showed that receipt of antithrombin was associated with a 6.5 % (95 % CI, 0.05-13.0) reduction in 28-day mortality. Supplemental dose of antithrombin administration may be associated with reduced 28-day mortality in sepsis-associated DIC patients after emergency laparotomy for intestinal perforation.

Anticoagulant modulation of inflammation in severe sepsis

Inflammation and coagulation are so tightly linked that the cytokine storm which accompanies the development of sepsis initiates thrombin activation and the development of an intravascular coagulopathy. This review examines the interaction between the inflammatory and coagulation cascades, as well as the role of endogenous anticoagulants in regulating this interaction and dampening the activity of both pathways. Clinical trials attempting to improve outcomes in patients with severe sepsis by inhibiting thrombin generation with heparin and or endogenous anticoagulants are reviewed. In general, these trials have failed to demonstrate that anticoagulant therapy is associated with improvement in mortality or morbidity. While it is possible that selective patients who are severely ill with a high expected mortality may be shown to benefit from such therapy, at the present time none of these anticoagulants are neither approved nor can they be recommended for the treatment of sepsis.

Observational study to compare antithrombin and thrombomodulin for disseminated intravascular coagulation

BACKGROUND

There have been no studies comparing the effects of antithrombin (AT-III) and recombinant human soluble thrombomodulin (rhs-TM) on outcomes in patients with disseminated intravascular coagulation (DIC) associated with infectious diseases.

OBJECTIVE

The aim of this observational study is to compare AT-III and rhs-TM in terms of outcomes such as mortality, length of hospitalization, and medical costs in patients with DIC associated with infectious diseases based on a Japanese administrative database.

SETTING

A total of 7,535 patients with DIC associated with infectious diseases in 886 hospitals from 2010 to 2012 in Japan. Methods We collected patients' data from the administrative database to compare clinical and medical economic outcomes of patients with DIC. Patients were divided into two groups according to treatment of DIC: AT-III (n = 3,601) and rhs-TM (n = 3,934).

MAIN OUTCOMES MEASURE

In-hospital mortality (within 14 days, within 28 days, and overall mortality), length of stay (LOS), and medical costs during hospitalization.

RESULTS

Multilevel logistic regression analysis showed that there were no significant differences with regard to in-hospital mortality between AT-III and rhs-TM within 14 days (odds ratio (OR) of rhs-TM 0.97, 95 % confidence interval (CI) 0.85-1.11, p = 0.744), within 28 days (OR 1.00, 95 % CI 0.89-1.13, p = 0.919), and overall (OR 0.95, 95 % CI 0.85-1.07, p = 0.470). However, multilevel linear regression analysis revealed that use of rhs-TM significantly decreased LOS and medical costs during hospitalization. The coefficient for LOS was -2.92 days (95 % CI -4.79 to -1.04 days; p = 0.002) whereas that for medical costs during hospitalization was -798.3 Euro (95 % CI -1,515.7 to -81.0 Euro; p = 0.029).

CONCLUSION

This study demonstrated no significant difference in in-hospital mortality between AT-III and rhs-TM. However, use of rhs-TM was significantly associated with decreased LOS and medical costs during hospitalization in patients with DIC associated with infectious diseases.

[Adjuvant treatment of sepsis: what is known?]

BACKGROUND

Recent decades have been characterized by a large number of trials for registration of new drugs or indication approvals in the field of sepsis. Modern anti-inflammatory drugs or interventions are intended to correct the overwhelming dysregulation of inflammatory and coagulation pathways seen particularly in the early phase of sepsis. Immunostimulatory therapies are also being studied in order to correct immunoparalysis, which develops later in the course of sepsis as a compensatory mechanism.

CURRENT STUDY RESULTS

Recombinant activated protein C, drotrecogin α, was conditionally approved and later withdrawn from the market by the producer because the initially observed beneficial effect could not be confirmed. The efficacy and safety of antithrombin, which, like drotrecogin α, also modulates inflammation and coagulation as an endogenous anticoagulant could not be confirmed when used for treating sepsis. As sepsis leads to disseminated intravascular coagulation which may be counteracted by antithrombin, new guidelines recommend antithrombin as a treatment option in this subgroup of sepsis patients. Intravenous administration of immunoglobulin, enteral administration of immunomodulating substances as immunonutrition, and the substitution of selenium, all showed some effectiveness in small heterogeneous studies, but their efficacy was not confirmed in large high-quality trials. Intensive glycemic control, which was temporarily recommended for acutely ill patients, increased the risk for adverse hypoglycemia in several clinical trials so that blood glucose target levels have been redefined and guidelines now no longer ask for normalization of blood glucose values with insulin.

CONCLUSION AND OUTLOOK

None of the new drugs, however, has successfully become established as a new standard of care. In the future, studies of novel sepsis therapies may succeed better if suitable biomarkers allow for patient selection, reflecting key pathophysiologic mechanisms that are targeted by the innovative drugs.

Efficacy and bleeding risk of antithrombin supplementation in septic disseminated intravascular coagulation: a secondary survey

Introduction

In a previous report, we demonstrated a favorable trend for supplementation with antithrombin (AT) concentrate at a dosage of 3,000 IU/day over 1,500 IU/day for the treatment of sepsis-associated disseminated intravascular coagulation (DIC) in patients with an AT activity of 70% or less. Since the survival difference did not reach statistical significance, we planned to examine the effects in a larger number of cases with severer disease.

Methods

We performed a non-randomized multi-institutional survey. In total, 307 septic DIC patients who had AT activity less than 40% and who had undergone AT substitution at a dose of either 1,500 IU/day or 3,000 IU/day for three consecutive days were analyzed. Of these, 259 patients received 1,500 IU/day (AT1500 group) and 48 patients received 3,000 IU/day (AT3000 group). The primary efficacy endpoints were recovery from DIC by day 7 and an all-cause mortality on day 28. Adverse bleeding events were also examined. A logistic regression analysis was conducted by using age, sex, body weight, initial AT activity, DIC score, platelet count, coadministration of heparin, recombinant thrombomodulin, suspected source of infection, surgery, and supplemented AT dose.

Results

Supplementation significantly decreased the DIC score in the AT3000 group, leading to the superior resolution of DIC, compared with the results in the AT1500 group (66.7% versus 45.2%, P = 0.007). In addition, the AT3000 group exhibited a better survival than the AT1500 group (77.1% versus 56.4%, P = 0.010). Bleeding events were observed in 6.96% (severe bleeding: 3.04%) in the AT1500 group and 6.52% (severe bleeding, 4.35%) in the AT3000 group (P = 1.000; severe bleeding, P = 0.648). A logistic regression analysis revealed that the use of AT3000 (odds ratio (OR), 2.419; P = 0.025), a higher initial platelet count (OR, 1.054; P = 0.027), and patient age (OR, 0.977; P = 0.045) were significantly correlated with an improved survival.

Conclusions

The AT3000 group exhibited significantly improved rates of survival and recovery from DIC without an increased risk of bleeding, compared with the AT1500 group, among the patients with sepsis-associated DIC and an AT activity of less than 40%.

Antithrombin and mortality in severe pneumonia patients with sepsis-associated disseminated intravascular coagulation: an observational nationwide study

BACKGROUND

The association between antithrombin use and mortality in patients with sepsis-associated disseminated intravascular coagulation (DIC) remains controversial.

OBJECTIVES

To examine the hypothesis that antithrombin could be effective in the treatment of patients with sepsis-associated DIC following severe pneumonia.

METHODS

Propensity score and instrumental variable analyses were performed by use of a nationwide administrative database, the Japanese Diagnosis Procedure Combination inpatient database. The main outcome was 28-day mortality.

RESULTS

Severe pneumonia patients diagnosed with sepsis-associated DIC (n = 9075) were categorized into antithrombin (n = 2663) and control (n = 6412) groups. Propensity score matching created a matched cohort of 2194 pairs of patients with and without antithrombin use. Mortality differences were found between the two groups (antithrombin vs. control: unmatched, 40.8% vs. 45.7%; propensity-matched, 40.6% vs. 44.2%; inverse probability-weighted, 41.1% vs. 45.1%). Multiple logistic regression analyses showed an association between antithrombin use and 28-day mortality (unmatched with propensity score adjusted, adjusted odds ratio [OR] 0.87, 95% confidence interval [CI] 0.78-0.97; propensity-matched, adjusted OR 0.85, 95% CI 0.75-0.97; inverse probability-weighted, adjusted OR 0.85, 95% CI 0.79-0.90). An analysis with the hospital antithrombin-prescribing rate as an instrumental variable showed that receipt of antithrombin was associated with a 9.9% (95% CI 3.5-16.3) reduction in 28-day mortality.

CONCLUSIONS

This retrospective, large, nationwide database study demonstrates that antithrombin administration may be associated with reduced 28-day mortality in patients with severe pneumonia and sepsis-associated DIC. A large, multinational randomized trial is required.

Anticoagulant therapy for sepsis-associated disseminated intravascular coagulation: the view from Japan

The current management of disseminated intravascular coagulation (DIC) is based on aggressive treatment of the underlying condition and resuscitation with appropriate blood products. Anticoagulant therapy has appeared and disappeared in the different guidelines and important documents detailing the treatment of DIC. For example, Surviving Sepsis Campaign (SSC) guidelines, the 'global standard' for the management of severe sepsis, had recombinant activated protein C highly recommended in the original version, but this was withdrawn in the latest version due to the lack of evidence. In contrast, recent international guidance released from the International Society on Thrombosis and Haemostasis has introduced the potential efficacy of other agents. In sepsis-related DIC, the basis for anticoagulant therapy comes from the mounting evidence for the anti-inflammatory effects which these agents possess and can prove beneficial in septic situations. Several studies have clearly shown the important cross-talk between coagulation and inflammation in patients with sepsis. More recently, neutrophil extracellular traps and damage-associated molecular patterns (DAMPs), especially histones, have been demonstrated to play a crucial role in the coagulopathy of sepsis. Once again, the natural anticoagulants have an important function in neutralizing the effects of DAMPs and histones. In this review, in addition to examining the important role of anticoagulants in the septic milieu, the clinical studies examining antithrombin, recombinant thrombomodulin and plasma-derived activated protein C are detailed. However, large-scale randomized controlled trials are yet to be performed, with important consideration of the timing, dosage and duration of treatment.

A randomized, controlled, multicenter trial of the effects of antithrombin on disseminated intravascular coagulation in patients with sepsis

INTRODUCTION

To test the hypothesis that the administration of antithrombin concentrate improves disseminated intravascular coagulation (DIC), resulting in recovery from DIC and better outcomes in patients with sepsis, we conducted a prospective, randomized controlled multicenter trial at 13 critical care centers in tertiary care hospitals.

METHODS

We enrolled 60 DIC patients with sepsis and antithrombin levels of 50 to 80% in this study. The participating patients were randomly assigned to an antithrombin arm receiving antithrombin at a dose of 30 IU/kg per day for three days or a control arm treated with no intervention. The primary efficacy end point was recovery from DIC on day 3. The analysis was conducted with an intention-to-treat approach. DIC was diagnosed according to the Japanese Association for Acute Medicine (JAAM) scoring system. The systemic inflammatory response syndrome (SIRS) score, platelet count and global markers of coagulation and fibrinolysis were measured on day 0 and day 3.

RESULTS

Antithrombin treatment resulted in significantly decreased DIC scores and better recovery rates from DIC compared with those observed in the control group on day 3. The incidence of minor bleeding complications did not increase, and no major bleeding related to antithrombin treatment was observed. The platelet count significantly increased; however, antithrombin did not influence the sequential organ failure assessment (SOFA) score or markers of coagulation and fibrinolysis on day 3.

CONCLUSIONS

Moderate doses of antithrombin improve DIC scores, thereby increasing the recovery rate from DIC without any risk of bleeding in DIC patients with sepsis.

TRIAL REGISTRATION

UMIN Clinical Trials Registry (UMIN-CTR) UMIN000000882.

Thrombomodulin is a Strong Predictor of Multiorgan Dysfunction Syndrome in Patients With Sepsis

BACKGROUND

Biomarkers of endothelial dysfunction are not recommended for routine laboratory investigation of the outcome prognosis and prediction of the course of sepsis.

METHODS

A total of 60 patients who fulfilled the criteria for diagnosis of sepsis were included in our study. Development of multiorgan dysfunction syndrome (MODS) in the first 48 hours was assessed. Differences between groups of patients with sepsis were assessed by Mann-Whitney U test and by Kruskal-Wallis test. Logistic regression analysis was performed to test the joint effect of different predictors.

RESULTS

Level of thrombomodulin was significantly higher in group of patients with MODS than without MODS (P = .015). Levels of antithrombin (P = .026) and protein C (P = .035) were significantly lower in patients with MODS. Level of thrombomodulin was the strongest predictor in MODS development in first 48 hours (P = .028).

CONCLUSION

The level of thrombomodulin not only was able to distinguish the severity of sepsis but also was a significant predictor of MODS development.

Studies on therapeutic effects and pathological features of an antithrombin preparation in septic disseminated intravascular coagulation patients

PURPOSE

Few reports have been made on the therapeutic effects as well as pathological features of an antithrombin preparation in patients diagnosed with septic disseminated intravascular coagulation (DIC) by the diagnostic criteria for acute DIC.

MATERIALS AND METHODS

A total of 88 sepsis patients who had received inpatient hospital care during the period from January 2000 through December 2008 were divided into two groups, an antithrombin group and a non-antithrombin group, to study the outcomes. Furthermore, the relationship between sepsis-related factors and DIC in 44 patients was studied.

RESULTS

The antithrombin group contained 34 patients, and the non-antithrombin group contained 54 patients. The outcomes were significantly better in the antithrombin group. The levels of protein C were low in DIC patients.

CONCLUSION

Our results suggest that early administration of antithrombin might improve outcomes of septic DIC patients in the diagnostic criteria for Japanese Association for Acute Medicine acute DIC.

Severe sepsis, coagulation, and fibrinolysis: dead end or one way?

It was suggested more than 30 yrs ago that inhibition of the clotting cascade by natural anticoagulants could decrease the high mortality observed in patients suffering from severe sepsis and septic shock. Unfortunately, this therapeutic "paradigm" has led to a dead end, illustrated by the failure of all randomized trials and the recent withdrawal of recombinant activated protein C. Should we now definitely give up trying to treat septic coagulation disturbances or is there any therapeutic alternative?

The coagulopathy in sepsis: significance and implications for treatment

Sepsis related coagulopathy ranges from mild laboratory alterations up to severe disseminated intravascular coagulation (DIC). There is evidence that DIC is involved in the pathogenesis of microvascular dysfunction contributing to organ failure. Additionally, the systemic activation of coagulation, by consuming platelets and coagulation factors, may cause bleeding. Thrombin generation via the tissue factor/factor VIIa route, contemporary depression of antithrombin and protein C anticoagulant systems, as well as impaired fibrin degradation, due to high circulating levels of PAI-1, contribute to enhanced intravascular fibrin deposition. This deranged coagulopathy is an independent predictor of clinical outcome in patients with severe sepsis. Innovative supportive strategies aiming at the inhibition of coagulation activation should comprise inhibition of tissue factor-mediated activation or restoration of physiological anticoagulant pathways, as the administration of recombinant human activated protein C or concentrate. In spite of some promising initial studies, additional trials are needed to define their clinical effectiveness in adults and children with severe sepsis.

Blood coagulation disorders in septic patients

Host defense and blood coagulation are tightly connected and interacting systems, necessary for the integrity of an organism. Complex mechanisms regulate the intensity of a host response to invading pathogens or other potentially dangerous situations. Under regular conditions, this response is limited in time and located to the site of injury. Sometimes, however, systemic host response is overwhelming and disproportional and causes damage, not cure. Dependent on the genetical predisposition of the host, its current immunocompetence, or the type of injury, the reaction leads to the clinical picture of the different degrees of sepsis. Septic organ dysfunction is caused by intravascular fibrin deposition as a result of coagulation activation, anticoagulant breakdown, and shut down of fibrinolysis. This article describes the major pathophysiologic reactions in these situations and presents www.SepDIC.eu, an online tool on sepsis and associated coagulopathy.

Thrombocytopenia and thrombosis in disseminated intravascular coagulation (DIC)

Disseminated intravascular coagulation (DIC) is the physiologic result of pathologic overstimulation of the coagulation system. Despite multiple triggers, a myriad of laboratory abnormalities, and a clinical presentation ranging from gross hemostatic failure to life-threatening thrombosis, or even both simultaneously, a simplified clinical approach augmented by a few readily available tests allows prompt identification of the process and elucidation of treatment opportunities. Platelet counts in DIC may be low, especially in acute sepsis-associated DIC, yet increased in malignancy-associated chronic DIC. Thrombotic risk is not a function of the platelet count, and thrombocytopenia does not protect the patient from thrombosis. The stratification of both thrombotic risk and hemorrhagic risk will be addressed.

Effects of antithrombin III in patients with disseminated intravascular coagulation diagnosed by newly developed diagnostic criteria for critical illness

A study was conducted to test the hypotheses that antithrombin III (antithrombin) improves disseminated intravascular coagulation (DIC) when applied to DIC patients diagnosed by sensitive criteria and that the administration of high-dose antithrombin is a beneficial treatment for DIC. Twenty-three DIC patients diagnosed based on the Japanese Association for Acute Medicine (JAAM) DIC diagnostic criteria were treated with either high-dose (60 IU/kg/day) or low-dose (30 IU/kg/day) antithrombin concentrates for 3 days. The clinical conditions that cause DIC were restricted to systemic inflammatory response syndrome (SIRS) and sepsis. Data of antithrombin activity, platelet counts, coagulation and fibrinolytic markers, and DIC scores before antithrombin administration (day 0), on days 1 to 3, and on day 7 were retrospectively collected from computer-based records. Patients who met the JAAM DIC criteria were administered either high-dose (12 patients) or low-dose (11 patients) antithrombin. The patients' backgrounds and antithrombin activity (high dose, 51.5 +/- 14.5%; low dose, 62.6 +/- 19.3%; P = .153) on day 0 were identical in the 2 groups. The JAAM DIC score and prothrombin time ratio on day 7 significantly improved when compared with those on day 0. However, mortality at 28 days as well as interaction within the antithrombin doses administered showed no difference. There were also no differences in the time course of the platelet counts, coagulation and fibrinolytic markers, and DIC scores in the 2 groups. The authors conclude that the effects of antithrombin on prognosis and coagulation and fibrinolytic parameters are independent of the doses administered in patients with SIRS/sepsis-associated DIC.

Effects of anticoagulant strategies on activation of inflammation and coagulation

Acute inflammatory events, such as those that occur in sepsis, lead to dysregulation of the coagulation cascade. The hemostatic imbalance in sepsis, characterized by the excessive activation of procoagulant pathways and the impairment of anticoagulant activity, leads to disseminated intravascular coagulation and results in microvascular thrombosis, tissue hypoperfusion and, ultimately, multiple organ failure and death. Furthermore, natural anti-inflammatory mechanisms of the endogenous anticoagulants are diminished by the impaired coagulation. Supportive strategies aiming at inhibiting activation of coagulation and inflammation by treatment with exogenous anticoagulants have been found to be beneficial in experimental and initial clinical studies. This review summarizes the available experimental and clinical data regarding the interaction between coagulation and inflammation, focusing on the two anticoagulants which are in clinical use, antithrombin and activated protein C. Identification of the different biological mechanisms of the two endogenous anticoagulants might help to determine target patient populations as well as to develop new anticoagulant analogs that differ in there respective effects in coagulation and inflammation.

Analysis of hemostasis alterations in sepsis

This laboratory study tested new methods to analyze hemostasis alterations in septic patients. Samples of ethylenediamine tetraacetic acid (EDTA) plasma and citrated plasma were collected from 62 patients with clinical diagnosis of sepsis. Additionally, a subset of EDTA-plasma samples from each patient was stabilized 1 + 1 with 2.5 mol/l arginine, pH 8.6, to conserve the real hemostasis activation state. EDTA-arginine plasma, EDTA plasma and citrated plasma samples were tested in duplicate. The patients at admission to the intensive care unit had 36 +/- 26 (normal, 0.8 +/- 0.2) ng/ml global endotoxin reactivity, 188 +/- 66% (normal, 100 +/- 20%) fibrinogen function, 179 +/- 66% (normal, 100 +/- 20%) fibrinogen antigen, 4.0 +/- 3.6 (normal, 0.049 +/- 0.025) microg/ml D-dimer, 313 +/- 307% (normal, 100 +/- 30%) plasmin-antiplasmin complex, 8.7 +/- 11.4 (normal, 1.1 +/- 0.7) U/ml plasminogen activator inhibitor-1, 12.1 +/- 10.5 (normal, 1.3 +/- 0.4) ng/ml thrombin-antithrombin III complex, 173 +/- 62% (normal, 100 +/- 20%) thrombin, 568 +/- 225 (normal, 140 +/- 42) pg/ml tissue factor, and 2.56 +/- 2.48 (normal, 0.19 +/- 0.04) microg/ml soluble intercellular adhesion molecule-1. Endotoxin (lipopolysaccharide and/or beta-glucan) reactivity (EDTA plasma), fibrinogen function + antigen + ratio and plasminogen activator inhibitor-1 (citrated plasma), and D-dimer, soluble intercellular adhesion molecule-1, thrombin activity (EDTA-arginine-stabilized plasma) presented large aberrations in septic patients when compared with normal values and may therefore be particularly interesting as markers of hemostasis alteration. Whether the observed alterations are of clinical significance has to be determined in well defined patient groups.

Gerinnungsaktive Substanzen als Sepsistherapeutika

Whereas antithrombin and tifacogin failed to improve clinical outcome in cases of severe sepsis, drotrecogin alfa (activated) increased the chances of survival of patients with this condition. Concerns about efficacy and safety of drotrecogin alfa have been raised because of internal and external validity and internal consistency problems found in the PROWESS study, and because of the drug's single positive pivotal phase III documentation that led to restricted marketing authorisations for only a subgroup of studied patients whose randomisation had not been stratified. Concerns intensified with data from ADDRESS, the PROWESS follow-up, and paediatric studies. It is difficult to make rational and safe recommendations for drotrecogin alfa use on the available evidence. Further trials have been suggested. The relevant bodies should review product approval in light of their own guidelines for marketing authorisations on the basis of single pivotal trials and request the further study required to prevent the possibility of patients receiving a non-efficacious and potentially lethal drug.