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Matsuoka T, Fujishima S, Sasaki J, Gando S, Saitoh D, Kushimoto S, Ogura H, Abe T, Shiraishi A, Mayumi T, Kotani J, Takeyama N, Tsuruta R, Takuma K, Yamashita N, Shiraishi SI, Ikeda H, Shiino Y, Tarui T, Nakada TA, Hifumi T, Otomo Y, Okamoto K, Sakamoto Y, Hagiwara A, Masuno T, Ueyama M, Fujimi S, Yamakawa K, Umemura Y. COAGULOPATHY PARAMETERS PREDICTIVE OF OUTCOMES IN SEPSIS-INDUCED ACUTE RESPIRATORY DISTRESS SYNDROME: A SUBANALYSIS OF THE TWO PROSPECTIVE MULTICENTER COHORT STUDIES. Shock 2024; 61:89-96. [PMID: 38010069 DOI: 10.1097/shk.0000000000002269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
ABSTRACT Background: Although coagulopathy is often observed in acute respiratory distress syndrome (ARDS), its clinical impact remains poorly understood. Objectives: This study aimed to clarify the coagulopathy parameters that are clinically applicable for prognostication and to determine anticoagulant indications in sepsis-induced ARDS. Method: This study enrolled patients with sepsis-derived ARDS from two nationwide multicenter, prospective observational studies. We explored coagulopathy parameters that could predict outcomes in the Focused Outcome Research on Emergency Care for Acute Respiratory Distress Syndrome, Sepsis, and Trauma (FORECAST) cohort, and the defined coagulopathy criteria were validated in the Sepsis Prognostication in Intensive Care Unit and Emergency Room-Intensive Care Unit (SPICE-ICU) cohort. The correlation between anticoagulant use and outcomes was also evaluated. Results: A total of 181 patients with sepsis-derived ARDS in the FORECAST study and 61 patients in the SPICE-ICU study were included. In a preliminary study, we found the set of prothrombin time-international normalized ratio ≥1.4 and platelet count ≤12 × 10 4 /μL, and thrombocytopenia and elongated prothrombin time (TEP) coagulopathy as the best coagulopathy parameters and used it for further analysis; the odds ratio (OR) of TEP coagulopathy for in-hospital mortality adjusted for confounding was 3.84 (95% confidence interval [CI], 1.66-8.87; P = 0.005). In the validation cohort, the adjusted OR for in-hospital mortality was 32.99 (95% CI, 2.60-418.72; P = 0.002). Although patients without TEP coagulopathy showed significant improvements in oxygenation over the first 4 days, patients with TEP coagulopathy showed no significant improvement (ΔPaO 2 /FiO 2 ratio, 24 ± 20 vs. 90 ± 9; P = 0.026). Furthermore, anticoagulant use was significantly correlated with mortality and oxygenation recovery in patients with TEP coagulopathy but not in patients without TEP coagulopathy. Conclusion: Thrombocytopenia and elongated prothrombin time coagulopathy is closely associated with better outcomes and responses to anticoagulant therapy in sepsis-induced ARDS, and our coagulopathy criteria may be clinically useful.
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Affiliation(s)
- Tadashi Matsuoka
- Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Seitaro Fujishima
- Center for Preventive Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Junchi Sasaki
- Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, Tokyo, Japan
| | | | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan
| | | | | | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Kiyotsugu Takuma
- Emergency and Critical Care Center, Kawasaki Municipal Hospital, Japan
| | - Norio Yamashita
- Department of Emergency and Critical Care Medicine, School of Medicine, Kurume University, Japan
| | | | - Hiroto Ikeda
- Department of Emergency Medicine, Trauma and Resuscitation Center, Teikyo University School of Medicine
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Japan
| | - Takehiko Tarui
- Department of Emergency Medical Care, Kyorin University Faculty Health Sciences, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine Chiba University Graduate School of Medicine, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan
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Frank CS, Larsen JB. Prognostic Impact of the International Society on Thrombosis and Hemostasis Disseminated Intravascular Coagulation Score in Sepsis: A Systematic Review. Semin Thromb Hemost 2023. [PMID: 36731487 DOI: 10.1055/s-0043-1761216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The International Society on Thrombosis and Haemostasis (ISTH) diagnostic criteria for disseminated intravascular coagulation (DIC) are widely used for DIC diagnosis. However, the prognostic value of the score may vary between different patient populations and settings. This systematic review investigated the association between the ISTH DIC score and mortality in sepsis patients. A literature search was conducted in PubMed and Embase. Inclusion criteria were studies including adult and pediatric patients hospitalized with sepsis, using any sepsis definition, and investigating the association between mortality and the ISTH DIC score. The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. In total, 42 studies were included. A positive association between the ISTH DIC score and mortality was consistently reported, with odds ratios of death in DIC versus non-DIC patients ranging from 1.125 (95% confidence interval [CI]: 0.838-1.511) to 21.008 (95% CI: 1.408-313.405) in adults and from 1.378 (95% CI: 1.004-1.893) to 2.99 (95% CI: 0.54-16.6) in pediatric populations. However, the DIC score only had a low-moderate positive predictive value for mortality, as area under receiver-operator characteristics ranged from 0.602 (95% CI: 0.575-0.630) to 0.815 (95% CI: 0.676-0.954) in adults. Of note, only few studies adjusted for potential confounders such as age, gender, and comorbidity. The ISTH DIC score is consistently associated with sepsis-related mortality but is not a strong positive predictor for mortality. Nevertheless, the score may still have a prognostic value and its use in sepsis is encouraged.
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Affiliation(s)
- Christian Sandberg Frank
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Julie Brogaard Larsen
- 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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Management Strategies in Septic Coagulopathy: A Review of the Current Literature. Healthcare (Basel) 2023; 11:healthcare11020227. [PMID: 36673595 PMCID: PMC9858837 DOI: 10.3390/healthcare11020227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/14/2023] Open
Abstract
One of the 'organs' that can be affected by sepsis is the coagulation system. Coagulopathy in sepsis may take the form of sepsis-induced coagulopathy (SIC) or sepsis-associated disseminated intravascular coagulation (DIC). It is important to identify SIC early, as at this stage of coagulopathy anticoagulants may be of the greatest benefit. The most recent diagnostic scoring systems for septic coagulopathy come from the International Society on Thrombosis and Hemostasis and the Japanese Association for Acute Medicine. Recommendations regarding the management of septic coagulopathy differ between organizations. Moreover, septic coagulopathy is an area of intense research in recent years. Therefore we searched three databases to review the most recent management strategies in septic coagulopathy. The mainstream management strategies in septic coagulopathy include the causal treatment of sepsis, unfractionated heparin, low-molecular-weight heparin, antithrombin, and recombinant human thrombomodulin. The last two have been associated with the highest survival benefit. Nevertheless, the indiscriminate use of these anticoagulants should be avoided due to the lack of mortality benefit and increased risk of bleeding. The early diagnosis of SIC and monitoring of coagulation status during sepsis is crucial for the timely management and selection of the most suitable treatment at a time. New directions in septic coagulopathy include new diagnostic biomarkers, dynamic diagnostic models, genetic markers for SIC management, and new therapeutic agents. These new research avenues may potentially result in timelier SIC diagnosis and improved management of all stages of septic coagulopathy by making it more effective, safe, and personalized.
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Giustozzi M, Ehrlinder H, Bongiovanni D, Borovac JA, Guerreiro RA, Gąsecka A, Papakonstantinou PE, Parker WAE. Coagulopathy and sepsis: Pathophysiology, clinical manifestations and treatment. Blood Rev 2021; 50:100864. [PMID: 34217531 DOI: 10.1016/j.blre.2021.100864] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/31/2021] [Accepted: 06/22/2021] [Indexed: 12/13/2022]
Abstract
Sepsis is a complex syndrome with a high incidence, increasing by 8.7% annually over the last 20 years. Coagulopathy is a leading factor associated with mortality in patients with sepsis and range from slight thrombocytopenia to fatal disorders, such as disseminated intravascular coagulation (DIC). Platelet reactivity increases during sepsis but prospective trials of antiplatelet therapy during sepsis have been disappointing. Thrombocytopenia is a known predictor of worse prognosis during sepsis. The mechanisms underlying thrombocytopenia in sepsis have yet to be fully understood but likely involves decreased platelet production, platelet sequestration and increased consumption. DIC is an acquired thrombohemorrhagic syndrome, resulting in intravascular fibrin formation, microangiopathic thrombosis, and subsequent depletion of coagulation factors and platelets. DIC can be resolved with treatment of the underlying disorder, which is considered the cornerstone in the management of this syndrome. This review presents the current knowledge on the pathophysiology, diagnosis, and treatment of sepsis-associated coagulopathies.
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Affiliation(s)
- Michela Giustozzi
- Internal Vascular and Emergency Medicine and Stroke Unit, University of Perugia, Perugia, Italy.
| | - Hanne Ehrlinder
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Dario Bongiovanni
- Technical University of Munich, School of Medicine, University hospital rechts der Isar, Department of Internal Medicine I, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany; Department of Cardiovascular Medicine, Humanitas Clinical and Research Center IRCCS and Humanitas University, Rozzano, Milan, Italy
| | - Josip A Borovac
- Department of Pathophysiology, University of Split School of Medicine, Split, Croatia; Clinic for Cardiovascular Diseases, University Hospital of Split (KBC Split), Split, Croatia
| | | | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Panteleimon E Papakonstantinou
- Second Cardiology Department, Evangelismos Hospital, Athens, Greece; Hypertension Unit "ESH Excellence Centre", First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - William A E Parker
- Cardiovascular Research Unit, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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5
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Iba T, Warkentin TE, Connors JM, Levy JH. Therapeutic strategies in patients with coagulopathy and disseminated intravascular coagulation: awareness of the phase-dependent characteristics. Minerva Med 2021; 112:701-712. [PMID: 33709675 DOI: 10.23736/s0026-4806.21.07469-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Disseminated intravascular coagulation (DIC) has long been understood as a condition where both thrombotic and hemostatic abnormalities coexist. DIC is a difficult complication for clinicians to manage as it is due to multiple underlying complications of pathophysiologic abnormalities in diverse disease states. Ongoing research continues to define the meaning of DIC, evaluate therapeutic options, and how it presents with the complex paradigm of systemic activation of coagulation. In this review we introduce the current topis regarding this tough situation. EVIDENCE ACQUISITION Online search of published medical literature through MEDLINE and Web of Sience using the term "disseminated intravascular coagulation", "coagulopathy", "coagulation disorder", "hemostasis", "fibrinolysis", "thrombus" and "anticoagulants". EVIDENCE SYNTHESIS Articles were chosen for inclusion based on their relevance to disseminated intravascular coagulation, coagulopathy, hemostasis and thrombosis in sepsis, COVID-19, trauma, and obstetrics. Reference lists were reviewed to identify additional relevant articles. CONCLUSIONS DIC is recognized as a pathologically triggered and dysregulated systemic activation of coagulation in response to various noxious stimuli. DIC's phenotype and clinical manifestations can vary from prothrombotic to hemorrhagic, depending on the underlying diseases. However, the fundamental mechanisms of systemic and vascular endothelial dysfunction can be explained as different phases of the acute response, with an initial prothrombotic phase that can commonly change to hemostatic insufficiency. Thrombin is the key initiator of the pathophysiologic process along with endothelial injury and initially fibrinolysis activation followed by fibrinolysis suppression. There is no established approach for managing DIC beyond initially treating the underlying disease and replacement therapy for the management of coagulopathy. Targeting anticoagulation therapy with antithrombin concentrates and recombinant thrombomodulin for the prevention of microthrombus formation, and antifibrinolytic therapy using tranexamic acid for the coagulopathy after massive bleeding, continue to be studied as therapeutic options.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan -
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, and Department of Medicine, McMaster University, Hamilton, Canada
| | - Jean Marie Connors
- Hematology Division Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
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6
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Adelborg K, Larsen JB, Hvas AM. Disseminated intravascular coagulation: epidemiology, biomarkers, and management. Br J Haematol 2021; 192:803-818. [PMID: 33555051 DOI: 10.1111/bjh.17172] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Disseminated intravascular coagulation (DIC) is a systemic activation of the coagulation system, which results in microvascular thrombosis and, simultaneously, potentially life-threatening haemorrhage attributed to consumption of platelets and coagulation factors. Underlying conditions, e.g. infection, cancer, or obstetrical complications are responsible for the initiation and propagation of the DIC process. This review provides insights into the epidemiology of DIC and the current understanding of its pathophysiology. It details the use of diagnostic biomarkers, current diagnostic recommendations from international medical societies, and it provides an overview of emerging diagnostic and prognostic biomarkers. Last, it provides guidance on management. It is concluded that timely and accurate diagnosis of DIC and its underlying condition is essential for the prognosis. Treatment should primarily focus on the underlying cause of DIC and supportive treatment should be individualised according to the underlying aetiology, patient's symptoms and laboratory records.
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Affiliation(s)
- Kasper Adelborg
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Denmark
| | - Julie B Larsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Denmark
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7
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Ehrhardt JD, Boneva D, McKenney M, Elkbuli A. Antithrombin Deficiency in Trauma and Surgical Critical Care. J Surg Res 2020; 256:536-542. [PMID: 32799002 DOI: 10.1016/j.jss.2020.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 07/01/2020] [Accepted: 07/08/2020] [Indexed: 02/08/2023]
Abstract
Antithrombin deficiency (ATD) was described in 1965 by Olav Egeberg as the first known inherited form of thrombophilia. Today, it is understood that ATDs can be congenital or acquired, leading to qualitative, quantitative, or mixed abnormalities in antithrombin (AT). All ATDs ultimately hinder AT's ability to serve as an endogenous anticoagulant and antiinflammatory agent. As a result, ATD patients possess higher risk for thromboembolism and can develop recurrent venous and arterial thromboses. Because heparin relies on AT to augment its physiologic function, patients with ATD often exhibit profound heparin resistance. Although rare as a genetic disorder, acquired forms of ATD are seen with surprising frequency in critically ill patients. This review discusses ATD in the context of surgical critical care with specific relevance to trauma, thermal burns, cardiothoracic surgery, and sepsis.
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Affiliation(s)
- John D Ehrhardt
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida
| | - Dessy Boneva
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida; Department of Surgery, University of South Florida, Tampa, Florida
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida; Department of Surgery, University of South Florida, Tampa, Florida
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida.
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8
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Wiedermann CJ. Anticoagulant therapy for septic coagulopathy and disseminated intravascular coagulation: where do KyberSept and SCARLET leave us? Acute Med Surg 2020; 7:e477. [PMID: 31988789 PMCID: PMC6971424 DOI: 10.1002/ams2.477] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 11/18/2019] [Indexed: 12/12/2022] Open
Abstract
The use of antithrombin and thrombomodulin to restore impaired anticoagulant pathways in septic coagulopathy has been shown to significantly increase the resolution rate of disseminated intravascular coagulation. In KyberSept and SCARLET, two large, international, randomized controlled trials in patients with sepsis, these anticoagulants have not shown significantly reduced mortality. The aim of this assessment was to compare the heterogeneity in responses to treatment in the two trials according to different patient phenotypes. Results of the KyberSept and SCARLET trials reported in original and post-hoc publications were analyzed and directly compared for treatment effects in various patient subgroups. In both KyberSept and SCARLET, the septic coagulopathy phenotype that benefited most from endogenous anticoagulant supplementation showed markers of excessive activation of coagulation. Interaction between concomitant thromboprophylactic heparin and the endogenous anticoagulants abrogated the efficacy of both antithrombin and thrombomodulin. In both trials, higher disease severity was associated with better treatment outcome. In conclusion, in two landmark studies of endogenous anticoagulants in patients with sepsis, similar findings of beneficial effects in the coagulopathy phenotype and interactions with heparin comedication and disease severity support the potential roles that thrombomodulin and antithrombin might play in treating septic coagulopathy and disseminated intravascular coagulation. Further prospective validation is warranted. Future trial designs to definitively establish the therapeutic relevance of antithrombin and thrombomodulin in septic coagulopathy should focus on involvement of patients characterized by coagulopathy and disease severity as well as interactions between endogenous anticoagulants and exogenous heparin.
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Affiliation(s)
- Christian J Wiedermann
- Institute of Public Health Medical Decision Making and HTA Medical Informatics and Technology University of Health Sciences Hall Austria
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Suzuki J, Sasabuchi Y, Hatakeyama S, Matsui H, Sasahara T, Morisawa Y, Yamada T, Yasunaga H. The effect of antithrombin added to recombinant human-soluble thrombomodulin for severe community-acquired pneumonia-associated disseminated intravascular coagulation: a retrospective cohort study using a nationwide inpatient database. J Intensive Care 2020; 8:8. [PMID: 31956416 PMCID: PMC6958595 DOI: 10.1186/s40560-019-0419-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 12/09/2019] [Indexed: 12/22/2022] Open
Abstract
Background Studies showed potential benefits of recombinant human-soluble thrombomodulin (rhTM) and antithrombin for treating sepsis associated disseminated intravascular coagulation. However, benefits of their combination have been inconclusive. Methods Using a nationwide inpatient database in Japan, we performed propensity-score matched analyses to compare outcomes between rhTM combined with antithrombin and rhTM alone for severe community-acquired pneumonia associated disseminated intravascular coagulation from July 2010 to March 2015. The outcomes included in-hospital mortality and requirement of red cell transfusion. Results Propensity score matching created 189 pairs of patients who received rhTM combined with antithrombin or rhTM alone within 2 days of admission. There was no significant difference between the two groups for in-hospital mortality (40.2% vs. 45.5%). Patients treated with rhTM and antithrombin were more likely to require red cell transfusion than those treated with rhTM alone (37.0% vs. 25.9%). Conclusions Compared with rhTM alone, combination of rhTM with antithrombin for severe community-acquired pneumonia-associated disseminated intravascular coagulation may be ineffective for reducing mortality and may increase bleeding.
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Affiliation(s)
- Jun Suzuki
- 1Division of Infectious Diseases, Jichi Medical University Hospital, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498 Japan
| | - Yusuke Sasabuchi
- 2Data Science Center, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498 Japan
| | - Shuji Hatakeyama
- 1Division of Infectious Diseases, Jichi Medical University Hospital, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498 Japan.,3Division of General Medicine, Jichi Medical University Hospital, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498 Japan
| | - Hiroki Matsui
- 4Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033 Japan
| | - Teppei Sasahara
- 1Division of Infectious Diseases, Jichi Medical University Hospital, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498 Japan.,5Department of Infection and Immunity, School of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498 Japan
| | - Yuji Morisawa
- 1Division of Infectious Diseases, Jichi Medical University Hospital, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498 Japan
| | - Toshiyuki Yamada
- 6Department of Clinical Laboratory Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498 Japan
| | - Hideo Yasunaga
- 4Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033 Japan
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10
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What's New in Shock, June 2019? Shock 2019; 51:675-677. [PMID: 31090682 DOI: 10.1097/shk.0000000000001340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Matsumoto H, Takeba J, Umakoshi K, Nakabayashi Y, Moriyama N, Annen S, Ohshita M, Kikuchi S, Sato N, Aibiki M. Successful treatment for disseminated intravascular coagulation (DIC) corresponding to phenotype changes in a heat stroke patient. J Intensive Care 2019; 7:2. [PMID: 30675362 PMCID: PMC6332900 DOI: 10.1186/s40560-019-0359-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Heat stroke induces coagulofibrinolytic activation, which leads to life-threatening disseminated intravascular coagulation (DIC). However, treatment strategies for DIC in heat stroke have not yet been established, and also, the time course changes in coagulofibrinolytic markers have not been thoroughly evaluated. We report a severe heat stroke case with DIC who was eventually saved by anti-DIC treatments in accordance with changes in coagulofibrinolytic markers. CASE PRESENTATION A 45-year-old man was found unconscious outside, and his body temperature was elevated to 41.9 °C. For heat stroke, we performed an immediate tracheal intubation under the general anesthesia along with cooling by iced gastric lavage, cold fluid administration, and an intravascular cooling using Thermogard™. About 4 h after admission, his core temperature fell to 37 °C. We assessed coagulofibrinolytic biomarkers and treated in accordance with changes in these parameters. This case exhibited a biphasic change varying from an enhanced to a suppressed fibrinolytic type of DIC depending on the relative balance between fibrinolytic activation and the level of plasminogen activator inhibitor-1 (PAI-1). In the early phase with consumption coagulopathy and enhanced fibrinolysis, we transfused a large amount of fresh frozen plasma (FFP) and platelets with tranexamic acid, an antifibrinolytic agent, possibly providing relief for the bleeding tendency. Anticoagulant therapy using recombinant human thrombomodulin-α (rh-TM-α) and antithrombin III (ATIII) concentrate was especially effective for DIC with a suppressed fibrinolytic phenotype in the later phase, after which organ failure that included severe hepatic failure was remarkably improved. CONCLUSION The present case may indicate the clinical significance of monitoring coagulifibrinolytic changes and the potential benefits of anticoagulants for heat stroke-induced DIC.
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Affiliation(s)
- Hironori Matsumoto
- Graduate School of Medicine, Department of Emergency and Critical Care Medicine, Ehime University, Shitsukawa 454, Toon, Ehime 791-0295 Japan
| | - Jun Takeba
- Graduate School of Medicine, Department of Emergency and Critical Care Medicine, Ehime University, Shitsukawa 454, Toon, Ehime 791-0295 Japan
| | - Kensuke Umakoshi
- Graduate School of Medicine, Department of Emergency and Critical Care Medicine, Ehime University, Shitsukawa 454, Toon, Ehime 791-0295 Japan
| | - Yuki Nakabayashi
- Graduate School of Medicine, Department of Emergency and Critical Care Medicine, Ehime University, Shitsukawa 454, Toon, Ehime 791-0295 Japan
| | - Naoki Moriyama
- Graduate School of Medicine, Department of Emergency and Critical Care Medicine, Ehime University, Shitsukawa 454, Toon, Ehime 791-0295 Japan
| | - Suguru Annen
- Graduate School of Medicine, Department of Emergency and Critical Care Medicine, Ehime University, Shitsukawa 454, Toon, Ehime 791-0295 Japan
| | - Muneaki Ohshita
- Graduate School of Medicine, Department of Emergency and Critical Care Medicine, Ehime University, Shitsukawa 454, Toon, Ehime 791-0295 Japan
| | - Satoshi Kikuchi
- Graduate School of Medicine, Department of Emergency and Critical Care Medicine, Ehime University, Shitsukawa 454, Toon, Ehime 791-0295 Japan
| | - Norio Sato
- Graduate School of Medicine, Department of Emergency and Critical Care Medicine, Ehime University, Shitsukawa 454, Toon, Ehime 791-0295 Japan
| | - Mayuki Aibiki
- Graduate School of Medicine, Department of Emergency and Critical Care Medicine, Ehime University, Shitsukawa 454, Toon, Ehime 791-0295 Japan
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12
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Chahin AB, Opal JM, Opal SM. Whatever happened to the Shwartzman phenomenon? Innate Immun 2018; 24:466-479. [PMID: 30409091 PMCID: PMC6830869 DOI: 10.1177/1753425918808008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/12/2018] [Accepted: 09/27/2018] [Indexed: 12/21/2022] Open
Abstract
Ninety years ago, Gregory Shwartzman first reported an unusual discovery following the intradermal injection of sterile culture filtrates from principally Gram-negative strains from bacteria into normal rabbits. If this priming dose was followed in 24 h by a second intravenous challenge (the provocative dose) from same culture filtrate, dermal necrosis at the first injection site would regularly occur. This peculiar, but highly reproducible, event fascinated the microbiologists, hematologists, and immunologists of the time, who set out to determine the mechanisms that underlie the pathogenesis of this reaction. The speed of this reaction seemed to rule out an adaptive, humoral, immune response as its cause. Histopathologic material from within the necrotic center revealed fibrinoid, thrombo-hemorrhagic necrosis within small arterioles and capillaries in the micro-circulation. These pathologic features bore a striking resemblance to a more generalized coagulopathic phenomenon following two repeated endotoxin injections described 4 yr earlier by Sanarelli. This reaction came to be known as the generalized Shwartzman phenomenon, while the dermal reaction was named the localized or dermal Shwartzman reaction. A third category was later added, called the single organ or mono-visceral form of the Shwartzman phenomenon. The occasional occurrence of typical pathological features of the generalized Shwartzman reaction limited to a single organ is notable in many well-known clinical events (e.g., hyper-acute kidney transplant rejection, fulminant hepatic necrosis, or adrenal apoplexy in Waterhouse-Fredrickson syndrome). We will briefly review the history and the significant insights gained from understanding this phenomenon regarding the circuitry and control mechanisms responsible for disseminated intravascular coagulation, the vasculopathy and the immunopathy of sepsis.
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Affiliation(s)
- Abdullah B Chahin
- Infectious Disease Service and Critical Care Division, Memorial
Hospital of Rhode Island and the Alpert Medical School of Brown University,
Providence, USA
| | - Jason M Opal
- Department of History and Classical Studies, McGill University,
Montreal, Canada
| | - Steven M Opal
- The Infectious Disease Division, Rhode Island Hospital and the
Alpert Medical School of Brown University, Providence, USA
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