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Vandyck KB, Mazzeffi MA, Tanaka KA. Sepsis Management: Heeding the Sirens and Navigating Between Scylla and Charybdis. Anesth Analg 2024; 138:e44-e45. [PMID: 38771612 DOI: 10.1213/ane.0000000000006996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Affiliation(s)
- Kofi B Vandyck
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma,
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Virginia Health Sciences Center, Charlottesville, Virginia
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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2
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Yagi T, Fujita M, Harada K, Shin M, Esaki Y, Ayata R, Koga Y, Kaneda K, Tsuruta R. Time Course of Coagulopathy Evaluated with Rotational Thromboelastometry in Patients with Severe Coronavirus Disease 2019. Intern Med 2023; 62:717-722. [PMID: 36543214 PMCID: PMC10037019 DOI: 10.2169/internalmedicine.0993-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/13/2022] [Indexed: 12/24/2022] Open
Abstract
Objectives Coronavirus disease 2019 (COVID-19) reportedly causes thromboembolic complications due to coagulopathy with hypercoagulability and a hypofibrinolytic state. We evaluated the time-course of coagulopathy in patients with severe COVID-19 from admission to discharge from our intensive-care unit (ICU). Methods We conducted a retrospective study of adults with severe COVID-19 admitted to our ICU between January 20, 2021, and March 31, 2022. We obtained clinical information, laboratory data, and rotational thromboelastometry (ROTEM) parameters at admission and discharge. Results Fifteen patients were included. Fibrinogen and D-dimer values did not change significantly but were above the normal ranges at admission and discharge. Regarding ROTEM parameters, the maximum clot firmness in fibrinogen function (FIBTEM), a marker of hypercoagulability, did not change significantly but was above the normal range at admission and discharge [median (interquartile range), admission vs. discharge: 31 (25-34) mm vs. 31 (27-32) mm, p=0.589]. The maximum lysis at 60 minutes in the extrinsic coagulation pathway (EXTEM) and intrinsic coagulation pathway (INTEM), as markers of the fibrinolytic function, were both significantly lower at discharge than at admission [median (interquartile range), admission vs. discharge: EXTEM, 3 (2-4) vs. 1 (0-2), p=0.011; INTEM, 3 (1-6) vs. 1 (0-2), p=0.008]. Conclusion This study revealed a persistent hypercoagulable state at ICU discharge and a worse hypofibrinolytic state at discharge than at admission. These results may contribute to a better understanding of coagulopathies in the acute to subacute phases of severe COVID-19.
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Affiliation(s)
- Takeshi Yagi
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Motoki Fujita
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Kayoko Harada
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Masaru Shin
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Yusuke Esaki
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Ryo Ayata
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Yasutaka Koga
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Kotaro Kaneda
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Japan
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3
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Zając P, Kaziród-Wolski K, Oleś I, Sielski J, Siudak Z. Role of Fibrinolysis in the Management of Patients with COVID-19 and Thromboembolic Complications: A Review. J Cardiovasc Dev Dis 2022; 9:356. [PMID: 36286308 PMCID: PMC9604283 DOI: 10.3390/jcdd9100356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/12/2022] [Accepted: 10/14/2022] [Indexed: 11/16/2022] Open
Abstract
An impaired fibrinolytic process has been demonstrated in patients infected with SARS-CoV-2, including those in severe or critical condition. Disruption of fibrinolysis leads to fibrin deposition, which exacerbates inflammation and fibrosis and damages the pulmonary surfactant. Numerous authors point out the different course of coagulopathy in patients with COVID-19. It is reported that they may have a state of secondary hyperfibrinolysis, which may explain, at least in part, the increased incidence of venous thromboembolism, even among those patients already receiving appropriate anticoagulant treatment. This raises the question of whether current guidelines for the prevention and treatment of embolic-thrombotic complications, among patients with severe COVID-19, are sufficient. Some studies show evidence of clinical improvement in patients who have received fibrinolytic therapy, beyond the current indications for its implementation. However, when considering the inclusion of systemic fibrinolytic therapy, the benefits of such treatment should always be weighed over the risk of adverse effects. Thromboelastography and rotational thromboelastometry can be helpful in making such decisions. The purpose of this study was to review the current knowledge regarding fibrinolysis and its role in the treatment of patients with severe COVID-19, including those with thromboembolic complications.
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Affiliation(s)
- Patrycja Zając
- The Reumatology Department, Province Hospital in Konskie, Poland ul. Gimnazjalna 41B, 26-200 Końskie, Poland
| | - Karol Kaziród-Wolski
- Collegium Medicum, Jan Kochanowski University in Kielce, al. IX Wieków Kielc 19A, 25-369 Kielce, Poland
| | - Izabela Oleś
- Collegium Medicum, Jan Kochanowski University in Kielce, al. IX Wieków Kielc 19A, 25-369 Kielce, Poland
| | - Janusz Sielski
- Collegium Medicum, Jan Kochanowski University in Kielce, al. IX Wieków Kielc 19A, 25-369 Kielce, Poland
| | - Zbigniew Siudak
- Collegium Medicum, Jan Kochanowski University in Kielce, al. IX Wieków Kielc 19A, 25-369 Kielce, Poland
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4
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Bunch CM, Moore EE, Moore HB, Neal MD, Thomas AV, Zackariya N, Zhao J, Zackariya S, Brenner TJ, Berquist M, Buckner H, Wiarda G, Fulkerson D, Huff W, Kwaan HC, Lankowicz G, Laubscher GJ, Lourens PJ, Pretorius E, Kotze MJ, Moolla MS, Sithole S, Maponga TG, Kell DB, Fox MD, Gillespie L, Khan RZ, Mamczak CN, March R, Macias R, Bull BS, Walsh MM. Immuno-Thrombotic Complications of COVID-19: Implications for Timing of Surgery and Anticoagulation. Front Surg 2022; 9:889999. [PMID: 35599794 PMCID: PMC9119324 DOI: 10.3389/fsurg.2022.889999] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/05/2022] [Indexed: 12/12/2022] Open
Abstract
Early in the coronavirus disease 2019 (COVID-19) pandemic, global governing bodies prioritized transmissibility-based precautions and hospital capacity as the foundation for delay of elective procedures. As elective surgical volumes increased, convalescent COVID-19 patients faced increased postoperative morbidity and mortality and clinicians had limited evidence for stratifying individual risk in this population. Clear evidence now demonstrates that those recovering from COVID-19 have increased postoperative morbidity and mortality. These data-in conjunction with the recent American Society of Anesthesiologists guidelines-offer the evidence necessary to expand the early pandemic guidelines and guide the surgeon's preoperative risk assessment. Here, we argue elective surgeries should still be delayed on a personalized basis to maximize postoperative outcomes. We outline a framework for stratifying the individual COVID-19 patient's fitness for surgery based on the symptoms and severity of acute or convalescent COVID-19 illness, coagulopathy assessment, and acuity of the surgical procedure. Although the most common manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is COVID-19 pneumonitis, every system in the body is potentially afflicted by an endotheliitis. This endothelial derangement most often manifests as a hypercoagulable state on admission with associated occult and symptomatic venous and arterial thromboembolisms. The delicate balance between hyper and hypocoagulable states is defined by the local immune-thrombotic crosstalk that results commonly in a hemostatic derangement known as fibrinolytic shutdown. In tandem, the hemostatic derangements that occur during acute COVID-19 infection affect not only the timing of surgical procedures, but also the incidence of postoperative hemostatic complications related to COVID-19-associated coagulopathy (CAC). Traditional methods of thromboprophylaxis and treatment of thromboses after surgery require a tailored approach guided by an understanding of the pathophysiologic underpinnings of the COVID-19 patient. Likewise, a prolonged period of risk for developing hemostatic complications following hospitalization due to COVID-19 has resulted in guidelines from differing societies that recommend varying periods of delay following SARS-CoV-2 infection. In conclusion, we propose the perioperative, personalized assessment of COVID-19 patients' CAC using viscoelastic hemostatic assays and fluorescent microclot analysis.
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Affiliation(s)
- Connor M. Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Ernest E. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO, United States
| | - Hunter B. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO, United States
| | - Matthew D. Neal
- Pittsburgh Trauma Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Anthony V. Thomas
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN, United States
| | - Nuha Zackariya
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN, United States
| | - Jonathan Zhao
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Sufyan Zackariya
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Toby J. Brenner
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Margaret Berquist
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Hallie Buckner
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Grant Wiarda
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Daniel Fulkerson
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN, United States
- Department of Neurosurgery, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Wei Huff
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN, United States
- Department of Neurosurgery, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Hau C. Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Genevieve Lankowicz
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | | | | | - Etheresia Pretorius
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Maritha J. Kotze
- Division of Chemical Pathology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Muhammad S. Moolla
- Division of General Medicine, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Sithembiso Sithole
- Division of General Medicine, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Tongai G. Maponga
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Douglas B. Kell
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
- The Novo Nordisk Foundation Centre for Biosustainability, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Mark D. Fox
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN, United States
| | - Laura Gillespie
- Department of Quality Assurance and Performance Improvement, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Rashid Z. Khan
- Department of Hematology, Michiana Hematology Oncology, Mishawaka, IN, United States
| | - Christiaan N. Mamczak
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN, United States
- Department of Orthopaedic Trauma, Memorial Hospital South Bend, South Bend, IN, United States
| | - Robert March
- Department of Cardiothoracic Surgery, St. Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Rachel Macias
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN, United States
- Department of Plastic and Reconstructive Surgery, St. Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Brian S. Bull
- Department of Pathology and Human Anatomy, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Mark M. Walsh
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN, United States
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
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5
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Heubner L, Mirus M, Vicent O, Güldner A, Tiebel O, Beyer-Westendorf J, Fries D, Spieth PM. Point of care coagulation management in anesthesiology and critical care. Minerva Anestesiol 2022; 88:615-628. [PMID: 35416466 DOI: 10.23736/s0375-9393.22.16380-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Point of care (POC) devices are increasingly used in the ICU and in anesthesia. Besides POC-devices for blood gas analysis, several devices are available for coagulation measurements. Although basic principles for thromboelastographic measurements are not novel, some promising developments were made during the last decade improving both user-friendliness and measurement reliability. For instance, POC measurements of activated clotting time (ACT) for heparin monitoring is still regarded as standard-of-care in cardiac interventions and surgery. In the field of anesthesia and intensive care medicine, POC-devices for thromboelastographic and platelet aggregation measurements are widely used. Their impact in case of bleeding and patient blood management for cardiothoracic and trauma surgery is well known. Moreover, there are promising concepts for anticoagulation monitoring including new oral anticoagulant drugs. Coagulation POC-devices may also identify patients at specific risk for thromboembolic events quickly. On the other hand, benefits of POC-devices need to be balanced against limitations, which include technical restrictions and operator related errors, mainly affecting reproducibility and interpretation of results. Therefore, it is recommendable to consider results of POC-coagulation testing in comparison to standard laboratory tests (SLT). Nevertheless, in urgent or emergency situations POC results enable fast decision making to optimize patient care.
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Affiliation(s)
- Lars Heubner
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany. -
| | - Martin Mirus
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Oliver Vicent
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Andreas Güldner
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Oliver Tiebel
- Institute of Clinical Chemistry, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Division of Hematology and Hemostasis, Department of Medicine I, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Dietmar Fries
- Department for General and Surgical Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Peter M Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
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6
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Viscoelastic Hemostatic Assays: A Primer on Legacy and New Generation Devices. J Clin Med 2022; 11:jcm11030860. [PMID: 35160311 PMCID: PMC8836477 DOI: 10.3390/jcm11030860] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 02/06/2023] Open
Abstract
Viscoelastic hemostatic assay (VHAs) are whole blood point-of-care tests that have become an essential method for assaying hemostatic competence in liver transplantation, cardiac surgery, and most recently, trauma surgery involving hemorrhagic shock. It has taken more than three-quarters of a century of research and clinical application for this technology to become mainstream in these three clinical areas. Within the last decade, the cup and pin legacy devices, such as thromboelastography (TEG® 5000) and rotational thromboelastometry (ROTEM® delta), have been supplanted not only by cartridge systems (TEG® 6S and ROTEM® sigma), but also by more portable point-of-care bedside testing iterations of these legacy devices (e.g., Sonoclot®, Quantra®, and ClotPro®). Here, the legacy and new generation VHAs are compared on the basis of their unique hemostatic parameters that define contributions of coagulation factors, fibrinogen/fibrin, platelets, and clot lysis as related to the lifespan of a clot. In conclusion, we offer a brief discussion on the meteoric adoption of VHAs across the medical and surgical specialties to address COVID-19-associated coagulopathy.
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7
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Fibrinolysis Shutdown in Severe COVID-19: Highly Prevalent but not Independently Predictive of Thrombosis or Poorer Outcomes. J Am Coll Surg 2022; 234:97-98. [PMID: 35213468 DOI: 10.1097/xcs.0000000000000007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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8
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Lorini FL, Di Matteo M, Gritti P, Grazioli L, Benigni A, Zacchetti L, Bianchi I, Fabretti F, Longhi L. Coagulopathy and COVID-19. Eur Heart J Suppl 2021; 23:E95-E98. [PMID: 34650364 PMCID: PMC8503535 DOI: 10.1093/eurheartj/suab100] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
SARS-CoV-2 infection is associated with frequent thrombotic events, at the micro and macro-vascular level, due to the perpetuation of a state of hypercoagulability. The so-called ‘COVID-19 associated coagulopathy’ (CAC) represents a key aspect in the genesis of organ damage from SARS-CoV-2. The main coagulative alterations described in the literature are represented by high levels of D-dimer and fibrinogen. Although CAC has some common features with disseminated intravascular coagulation and sepsis-induced coagulopathy, there are important differences between these clinical pictures and the phenotype of CAC is unique. The pathogenesis of CAC is complex and is affected by the strong interconnection between the inflammatory system and coagulation, in the phenomenon of immunothrombosis and thrombo-inflammation. Several mechanisms come into play, such as inflammatory cytokines, neutrophils, the complement system as well as an alteration of the fibrinolytic system. Finally, an altered platelet function and especially endothelial dysfunction also play a central role in the pathophysiology of CAC. Heparin has several potential effects in CAC, in fact in addition to the anticoagulant effect, it could have a direct antiviral effect and anti-inflammatory properties. The high incidence of thrombo-embolic phenomena despite the use of antithrombotic prophylaxis have led some experts to recommend the use of anticoagulant doses of heparin, but at present the optimal anticoagulant regimen remains to be determined.
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Affiliation(s)
- Ferdinando Luca Lorini
- Dipartimento di Anestesia e Terapia Intensiva, Ospedale Papa Giovanni XXIII, Bergamo, Italia
| | - Maria Di Matteo
- Dipartimento di Anestesia e Terapia Intensiva, Ospedale Papa Giovanni XXIII, Bergamo, Italia
| | - Paolo Gritti
- Dipartimento di Anestesia e Terapia Intensiva, Ospedale Papa Giovanni XXIII, Bergamo, Italia
| | - Lorenzo Grazioli
- Dipartimento di Anestesia e Terapia Intensiva, Ospedale Papa Giovanni XXIII, Bergamo, Italia
| | - Alberto Benigni
- Dipartimento di Anestesia e Terapia Intensiva, Ospedale Papa Giovanni XXIII, Bergamo, Italia
| | - Lucia Zacchetti
- Dipartimento di Anestesia e Terapia Intensiva, Ospedale Papa Giovanni XXIII, Bergamo, Italia
| | - Isabella Bianchi
- Dipartimento di Anestesia e Terapia Intensiva, Ospedale Papa Giovanni XXIII, Bergamo, Italia
| | - Fabrizio Fabretti
- Dipartimento di Anestesia e Terapia Intensiva, Ospedale Papa Giovanni XXIII, Bergamo, Italia
| | - Luca Longhi
- Dipartimento di Anestesia e Terapia Intensiva, Ospedale Papa Giovanni XXIII, Bergamo, Italia
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9
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Kanji R, Kubica J, Navarese EP, Gorog DA. Endogenous fibrinolysis-Relevance to clinical thrombosis risk assessment. Eur J Clin Invest 2021; 51:e13471. [PMID: 33296082 DOI: 10.1111/eci.13471] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/05/2020] [Accepted: 12/06/2020] [Indexed: 12/11/2022]
Abstract
The development of an obstructive luminal thrombus is pathological and considered a failure of endogenous fibrinolysis. The consequences may be fatal, or result in lasting downstream organ damage. Therefore, assessment of endogenous fibrinolytic status in an individual may identify those at risk of occlusive thrombus formation and provide prognostic information. Arterial thrombi are more platelet rich and more resistant to fibrinolysis than venous thrombi. Several recent studies using global tests of fibrinolysis in patients with acute coronary syndromes (ACS) have shown that despite dual antiplatelet therapy, patients with impaired fibrinolytic status have an increased risk of adverse cardiovascular events, compared with those with effective fibrinolytic function. Such data add significantly to the predictive value of established cardiovascular risk factors and conventional biomarkers. Most data reported have been obtained with the Global Thrombosis Test and the turbidimetric plasma clot lysis assay. A few small studies in patients with ischaemic stroke suggest a similar predictive role of fibrinolytic status assessment in these patients. Studies reporting an association between impaired fibrinolysis and future venous thrombotic events are limited, and in the form of case-control studies. Viscoelastic assays may have a role in the prediction of venous thromboembolic risk. Assays of fibrinolytic function should be used to obtain a more accurate risk of future thrombotic events, particularly in the setting of ACS. The availability of point-of-care tests helps facilitate this and should encourage future studies to assess personalised antithrombotic treatment combinations to optimise fibrinolytic status and reduce thrombosis risk.
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Affiliation(s)
- Rahim Kanji
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.,Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Eliano P Navarese
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.,Faculty of Medicine, University of Alberta, Edmonton, Canada
| | - Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.,Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, UK.,School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Stevenage, UK
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10
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Coopersmith CM, Antonelli M, Bauer SR, Deutschman CS, Evans LE, Ferrer R, Hellman J, Jog S, Kesecioglu J, Kissoon N, Martin-Loeches I, Nunnally ME, Prescott HC, Rhodes A, Talmor D, Tissieres P, De Backer D. The Surviving Sepsis Campaign: Research Priorities for Coronavirus Disease 2019 in Critical Illness. Crit Care Med 2021; 49:598-622. [PMID: 33591008 DOI: 10.1097/ccm.0000000000004895] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To identify research priorities in the management, pathophysiology, and host response of coronavirus disease 2019 in critically ill patients. DESIGN The Surviving Sepsis Research Committee, a multiprofessional group of 17 international experts representing the European Society of Intensive Care Medicine and Society of Critical Care Medicine, was virtually convened during the coronavirus disease 2019 pandemic. The committee iteratively developed the recommendations and subsequent document. METHODS Each committee member submitted a list of what they believed were the most important priorities for coronavirus disease 2019 research. The entire committee voted on 58 submitted questions to determine top priorities for coronavirus disease 2019 research. RESULTS The Surviving Sepsis Research Committee provides 13 priorities for coronavirus disease 2019. Of these, the top six priorities were identified and include the following questions: 1) Should the approach to ventilator management differ from the standard approach in patients with acute hypoxic respiratory failure?, 2) Can the host response be modulated for therapeutic benefit?, 3) What specific cells are directly targeted by severe acute respiratory syndrome coronavirus 2, and how do these cells respond?, 4) Can early data be used to predict outcomes of coronavirus disease 2019 and, by extension, to guide therapies?, 5) What is the role of prone positioning and noninvasive ventilation in nonventilated patients with coronavirus disease?, and 6) Which interventions are best to use for viral load modulation and when should they be given? CONCLUSIONS Although knowledge of both biology and treatment has increased exponentially in the first year of the coronavirus disease 2019 pandemic, significant knowledge gaps remain. The research priorities identified represent a roadmap for investigation in coronavirus disease 2019.
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Affiliation(s)
- Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University, Atlanta, GA
| | - Massimo Antonelli
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Italy
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
| | - Clifford S Deutschman
- Department of Pediatrics, Cohen Children's Medical center, Northwell Health, New Hyde Park, NY
- Feinstein Institute for Medical Research/Elmezzi Graduate School of Molecular Medicine, Manhasset, NY
| | - Laura E Evans
- Department of Medicine, University of Washington, Seattle, WA
| | - Ricard Ferrer
- Department of Intensive Care, SODIR-VHIR Research Group, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Judith Hellman
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA
| | - Sameer Jog
- Department of Intensive Care Medicine, Deenanath Mangeshkar Hospital, Pune, India
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Niranjan Kissoon
- Department of Pediatrics and Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), Department of Intensive Care Medicine, St. James's University Hospital, Trinity Centre for Health Sciences, Dublin, Ireland
- Hospital Clinic, IDIBAPS, Universided de Barcelona, CIBERes, Barcelona, Spain
| | - Mark E Nunnally
- Departments of Anesthesiology, Perioperative Care and Pain Medicine, Neurology, Surgery and Medicine, New York University, New York, NY
| | - Hallie C Prescott
- Department of Medicine, University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI
| | - Andrew Rhodes
- St George's University Hospitals NHS Foundation Trust and St George's University of London, London, United Kingdom
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Pierre Tissieres
- Pediatric Intensive Care, AP-HP Paris Saclay University, Le Kremlin-Bicetre and Institute of Integrative Biology of the Cell, CNRS, CEA, Paris-Saclay University, Gif-sur-Yvette, France
| | - Daniel De Backer
- Chirec Hospitals, Université Libre de Bruxelles, Brussels, Belgium
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Pavoni V, Gianesello L, Pazzi M, Horton A, Suardi LR. Derangement of the coagulation process using subclinical markers and viscoelastic measurements in critically ill patients with coronavirus disease 2019 pneumonia and non-coronavirus disease 2019 pneumonia. Blood Coagul Fibrinolysis 2021; 32:80-86. [PMID: 33196505 DOI: 10.1097/mbc.0000000000000971] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Systemic coagulation abnormalities including clotting activation and inhibition of anticoagulant factors have been observed in patients with pneumonia. In severe coronavirus disease 2019 (COVID-19) the alteration of coagulation parameters was associated with poor prognosis. We evaluated the difference in coagulopathy between critically ill patients with COVID-19 pneumonia (COVID group) and non-COVID-19 pneumonia (non-COVID group), using traditional coagulation markers and rotational thromboelastometry (ROTEM). Standard laboratory and ROTEM parameters were evaluated in 45 patients (20 COVID group patients and 25 non-COVID group patients) at time of admission to the Intensive Care Unit (ICU) (T0) and at 5 (T5) and 10 days (T10) later. In all evaluations times, platelet count was found higher in COVID group rather than in non-COVID group. At T0, COVID group revealed a fibrinogen value greater than non-COVID group. d-Dimer values were high in both groups and they were not statistically different. At T0 COVID group showed a significant reduction of clot formation time in INTEM and in EXTEM and a significant increase of maximum clot firmness in INTEM, EXTEM and FIBTEM respect to non-COVID group. Moreover, COVID group demonstrated a coagulability state with ROTEM profiles higher than non-COVID group at T5 and T10. Coagulation profiles showed that critically ill patients with COVID-19 pneumonia are characterized by a higher coagulable state than others; this greater procoagulative state persists over time.
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Affiliation(s)
- Vittorio Pavoni
- Anesthesia and Intensive Care Unit, Emergency Department and Critical Care, Santa Maria Annunziata Hospital
| | - Lara Gianesello
- Department of Anesthesia and Intensive Care, University-Hospital Careggi, Florence, Italy
| | - Maddalena Pazzi
- Anesthesia and Intensive Care Unit, Emergency Department and Critical Care, Santa Maria Annunziata Hospital
| | - Andrew Horton
- School of Dentistry, University of Utah Health, Salt Lake City, Utah, USA
| | - Lorenzo R Suardi
- Infectious Diseases Department, Santa Maria Annunziata Hospital, Florence, Italy
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