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Girardis M, David S, Ferrer R, Helms J, Juffermans NP, Martin-Loeches I, Povoa P, Russell L, Shankar-Hari M, Iba T, Coloretti I, Parchim N, Nielsen ND. Understanding, assessing and treating immune, endothelial and haemostasis dysfunctions in bacterial sepsis. Intensive Care Med 2024; 50:1580-1592. [PMID: 39222142 DOI: 10.1007/s00134-024-07586-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 07/31/2024] [Indexed: 09/04/2024]
Abstract
The interplay between the immune system, coagulation, and endothelium is critical in regulating the host response to infection. However, in sepsis and other critical illnesses, a dysregulated immune response can lead to excessive alterations in these mechanisms, resulting in coagulopathy, endothelial dysfunction, and multi-organ dysfunction. This review aims to provide a comprehensive analysis of the pathophysiological mechanisms that govern the complex interplay between immune dysfunction, endothelial dysfunction, and coagulation in sepsis. It emphasises clinical significance, evaluation methods, and potential therapeutic interventions. Understanding these mechanisms is essential for developing effective treatments that can modulate the immune response, mitigate thrombosis, restore endothelial function, and ultimately improve patient survival.
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Affiliation(s)
- Massimo Girardis
- Anaesthesiology and Intensive Care Department, University Hospital of Modena, University of Modena, Reggio Emilia, Italy.
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Ricard Ferrer
- Intensive Care Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Julie Helms
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Service de Médecine Intensive-Réanimation, Nouvel Hôpital Civil, Strasbourg, France
| | - Nicole P Juffermans
- Department of Intensive Care and Translational Laboratory of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James' Hospital, Dublin, D08 NHY1, Ireland
- Hospital Clinic, Universitat de Barcelona, IDIBAPS, CIBERES, 08180, Barcelona, Spain
| | - Pedro Povoa
- NOVA Medical School, NOVA University of Lisbon, Lisbon, Portugal
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
- Department of Intensive Care, Hospital de São Francisco Xavier, CHLO, Lisbon, Portugal
| | - Lene Russell
- Copenhagen University Hospital Gentofte, Hellerup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Manu Shankar-Hari
- Institute for Regeneration and Repair, The University of Edinburgh, Edinburgh, UK
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Toshiaki Iba
- Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Irene Coloretti
- Anaesthesiology and Intensive Care Department, University Hospital of Modena, University of Modena, Reggio Emilia, Italy
| | - Nicholas Parchim
- Division of Pulmonary, Critical Care and Sleep Medicine & Section of Transfusion Medicine and Therapeutic Pathology, University of New Mexico School of Medicine, New Mexico, Mexico
| | - Nathan D Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine & Section of Transfusion Medicine and Therapeutic Pathology, University of New Mexico School of Medicine, New Mexico, Mexico
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Li Y, Zhang L, Wang Y, Gao M, Zhang C, Zhang Y, Zhang D. Development and Validation of a Nomogram for Predicting Sepsis-Induced Coagulopathy in Septic Patients: Mixed Retrospective and Prospective Cohort Study. Thromb Haemost 2024. [PMID: 38959956 DOI: 10.1055/a-2359-2563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
BACKGROUND Sepsis-induced coagulopathy (SIC) is a common cause of poor prognosis in critically ill patients in the intensive care unit (ICU). However, currently there are no tools specifically designed for predicting the occurrence of SIC in septic patients earlier. This study aimed to develop a predictive nomogram incorporating clinical markers and scoring systems to individually predict the probability of SIC in septic patients. METHODS Patients consecutively recruited in the stage between January 2022 and April 2023 constituted the development cohort for retrospective analysis to internally test the nomogram, and patients in the stage between May 2023 to November 2023 constituted the validation cohort for prospective analysis to externally validate the nomogram. Univariate logistic regression analysis of the development cohort was performed firstly, and then multivariate logistic regression analysis was performed using backward stepwise method to determine the best-fitting model and obtain the nomogram from it. The nomogram was validated in an independent external validation cohort, involving discrimination and calibration. A decision curve analysis was also performed to evaluate the net benefit of the insertion decision with this nomogram. RESULTS A total of 548 and 245 patients, 55.1 and 49.4% with SIC occurrence, were included in the development and validation cohorts, respectively. Predictors contained in the prediction nomogram included shock, platelets, and international normalized ratio (INR). Patients with shock (odds ratio [OR]: 4.499; 95% confidence interval [CI]: 2.730-7.414; p < 0.001), higher INR (OR: 349.384; 95% CI: 62.337-1958.221; p < 0.001), and lower platelet (OR: 0.985; 95% CI: 0.982-0.988; p < 0.001) had higher probabilities of SIC. The development model showed good discrimination, with an area under the receiver operating characteristic curve (AUROC) of 0.879 (95% CI: 0.850-0.908) and good calibration. Application of the nomogram in the validation cohort also gave good discrimination with an AUROC of 0.872 (95% CI: 0.826-0.917) and good calibration. The decision curve analysis of the nomogram provided better net benefit than the alternate options (intervention or no intervention). CONCLUSION By incorporating shock, platelets, and INR in the model, this useful nomogram could be accessibly utilized to predict SIC occurrence in septic patients. However, external validation is still required for further generalizability improvement of this nomogram.
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Affiliation(s)
- Yuting Li
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Liying Zhang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Youquan Wang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Meng Gao
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Chaoyang Zhang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yuhan Zhang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Dong Zhang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, Jilin, China
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Eralp Inan O, Kocaturk M, Cansev M, Ozarda Y, Yilmaz Z, Ulus IH. Thromboelastographic evaluation of the effectiveness of choline or CDP-choline treatment on endotoxin-induced hemostatic alterations in dogs. Res Vet Sci 2024; 171:105205. [PMID: 38479101 DOI: 10.1016/j.rvsc.2024.105205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 02/05/2024] [Accepted: 02/28/2024] [Indexed: 04/17/2024]
Abstract
Sepsis/endotoxemia associates with coagulation abnormalities. We showed previously that exogenous choline treatment reversed the changes in platelet count and function as well as prevented disseminated intravascular coagulation (DIC) in endotoxemic dogs. The aim of this follow-up study was to evaluate the effect of treatment with choline or cytidine-5'-diphosphocholine (CDP-choline), a choline donor, on endotoxin-induced hemostatic alterations using thromboelastography (TEG). Dogs were randomized to six groups and received intravenously (iv) saline, choline (20 mg/kg) or CDP-choline (70 mg/kg) in the control groups, whereas endotoxin (0.1 mg/kg, iv) was used alone or in combination with choline or CDP-choline at the same doses in the treatment groups. TEG variables including R- and K-time (clot formation), maximum amplitude (MA) and α-angle (clot stability), G value (clot elasticity), and EPL, A, and LY30 (fibrinolysis), as well as overall assessment of coagulation (coagulation index - CI), were measured before and at 0.5-48 h after the treatments. TEG parameters did not change significantly in the control groups, except for CI parameter after choline administration. Endotoxemia resulted in increased R-time and A value (P < 0.05), decreased K-time (P < 0.05), α-angle (P < 0.001) and CI values (P < 0.01) at different time points. Treatment with either choline or CDP-choline attenuated or prevented completely the alterations in TEG parameters in endotoxemic dogs with CDP-choline being more effective. These results confirm and extend the effectiveness of choline or CDP-choline in endotoxemia by further demonstrating their efficacy in attenuating or preventing the altered viscoelastic properties of blood clot measured by TEG.
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Affiliation(s)
- Oya Eralp Inan
- Department of Animal Science, Eskisehir Osmangazi University Faculty of Agriculture, Eskisehir, Turkey.
| | - Meric Kocaturk
- Department of Internal Medicine, Bursa Uludag University Faculty of Veterinary Medicine, Bursa, Turkey.
| | - Mehmet Cansev
- Department of Pharmacology, Bursa Uludag University Faculty of Medicine, Bursa, Turkey.
| | - Yesim Ozarda
- Department of Biochemistry, Yeditepe University Faculty of Medicine, Istanbul, Turkey.
| | - Zeki Yilmaz
- Department of Internal Medicine, Bursa Uludag University Faculty of Veterinary Medicine, Bursa, Turkey.
| | - Ismail Hakki Ulus
- Department of Pharmacology, Istanbul Okan University Faculty of Medicine, Istanbul, Turkey.
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4
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Scarlatescu E, Kim PY, Marchenko SP, Tomescu DR. Validation of the time to attain maximal clot amplitude after reaching maximal clot formation velocity parameter as a measure of fibrinolysis using rotational thromboelastometry and its application in the assessment of fibrinolytic resistance in septic patients: a prospective observational study: communication from the ISTH SSC Subcommittee on Fibrinolysis. J Thromb Haemost 2024; 22:1223-1235. [PMID: 38104723 DOI: 10.1016/j.jtha.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/12/2023] [Accepted: 12/04/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND In sepsis, fibrinolysis resistance correlates with worse outcomes. Practically, rotational thromboelastometry (ROTEM) is used to report residual clot amplitude relative to maximum amplitude at specified times after clot formation clot lysis indices (CLIs). However, healthy individuals can exhibit similar CLIs, thus making it challenging to solely diagnose the low fibrinolytic state. Furthermore, CLI does not include the kinetics of clot formation, which can affect overall fibrinolysis. Therefore, a more nuanced analysis, such as time to attain maximal clot amplitude after reaching maximal clot formation velocity (t-AUCi), is needed to better identify fibrinolysis resistance in sepsis. OBJECTIVES To evaluate the correlation between the degree of fibrinolytic activation and t-AUCi in healthy or septic individuals. METHODS Whole blood (n = 60) from septic or healthy donors was analyzed using tissue factor-activated (EXTEM) and nonactivated (NATEM) ROTEM assays. Lysis was initiated with tissue-type plasminogen activator, and CLI and t-AUCi were calculated. Standard coagulation tests and plasma fibrinolysis markers (D-dimer, plasmin-α2-antiplasmin complex, plasminogen activator inhibitor type 1, and plasminogen) were also measured. RESULTS t-AUCi values decreased with increasing fibrinolytic activity and correlated positively with CLI for different degrees of clot lysis both in EXTEM and NATEM. t-AUCi cutoff value of 1962.0 seconds in EXTEM predicted low fibrinolytic activity with 81.8% sensitivity and 83.7% specificity. In addition, t-AUCi is not influenced by clot retraction. CONCLUSION Whole-blood point-of-care ROTEM analyses with t-AUCi offers a more rapid and parametric evaluation of fibrinolytic potential compared with CLI, which can be used for a more rapid and accurate diagnosis of fibrinolysis resistance in sepsis.
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Affiliation(s)
- Ecaterina Scarlatescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Department of Anesthesia and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania.
| | - Paul Y Kim
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Sergey P Marchenko
- Department of Cardiac Surgery, Pavlov First St. Petersburg Medical University, St. Petersburg, Russian Federation
| | - Dana R Tomescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Department of Anesthesia and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania
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Williams B, Zou L, Pittet JF, Chao W. Sepsis-Induced Coagulopathy: A Comprehensive Narrative Review of Pathophysiology, Clinical Presentation, Diagnosis, and Management Strategies. Anesth Analg 2024; 138:696-711. [PMID: 38324297 PMCID: PMC10916756 DOI: 10.1213/ane.0000000000006888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 02/08/2024]
Abstract
Physiological hemostasis is a balance between pro- and anticoagulant pathways, and in sepsis, this equilibrium is disturbed, resulting in systemic thrombin generation, impaired anticoagulant activity, and suppression of fibrinolysis, a condition termed sepsis-induced coagulopathy (SIC). SIC is a common complication, being present in 24% of patients with sepsis and 66% of patients with septic shock, and is often associated with poor clinical outcomes and high mortality. 1 , 2 Recent preclinical and clinical studies have generated new insights into the molecular pathogenesis of SIC. In this article, we analyze the complex pathophysiology of SIC with a focus on the role of procoagulant innate immune signaling in hemostatic activation--tissue factor production, thrombin generation, endotheliopathy, and impaired antithrombotic functions. We also review clinical presentations of SIC, the diagnostic scoring system and laboratory tests, the current standard of care, and clinical trials evaluating the efficacies of anticoagulant therapies.
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Affiliation(s)
- Brittney Williams
- From the Division of Cardiothoracic Anesthesia, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
- Translational Research Program, Department of Anesthesiology & Center for Shock, Trauma and Anesthesiology Research (STAR), University of Maryland School of Medicine, Baltimore, Maryland
| | - Lin Zou
- Translational Research Program, Department of Anesthesiology & Center for Shock, Trauma and Anesthesiology Research (STAR), University of Maryland School of Medicine, Baltimore, Maryland
| | - Jean-Francois Pittet
- Division of Critical Care, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Wei Chao
- Translational Research Program, Department of Anesthesiology & Center for Shock, Trauma and Anesthesiology Research (STAR), University of Maryland School of Medicine, Baltimore, Maryland
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Kashima Y, Koami H, Sakamoto Y. The Relationship Between Acute-Phase Circuit Occlusion and Blood Calcium Concentration in an Ex Vivo Continuous Renal Replacement Therapy Model. Cureus 2024; 16:e59330. [PMID: 38817525 PMCID: PMC11139355 DOI: 10.7759/cureus.59330] [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] [Accepted: 04/29/2024] [Indexed: 06/01/2024] Open
Abstract
Background and objective Continuous renal replacement therapy (CRRT) is a blood purification therapy modality for the treatment of renal failure in critically ill hospitalized patients with multiorgan dysfunction, effectively preventing uremia and multiple organ failure while improving renal function. However, the perfusion of patient blood through extracorporeal circulation often results in unexpected early occlusion of the CRRT circuit or hemofilter, leading to frequent interruptions in CRRT and wastage of medical resources. Moreover, clinical research on such circuit occlusions is limited. In Japan, CRRT circuits require long-term perfusion, often lasting 24 hours or more, indicating the need for a model capable of inducing occlusion at any arbitrary time; this model can evaluate various aspects, including causes and underlying mechanisms, and contribute to the development of an occlusion prediction method. Hence, we hypothesized the need for a model for inducing occlusion at arbitrary time points. Consequently, we strove to develop an ex vivo circuit occlusion model involving the injection of calcium into circulating citrated animal blood to evaluate the relationship between the amount of calcium chloride injected, circuit occlusion time, and changes in circuit pressure over time. Methods We developed a circuit occlusion model using a commercially available CRRT circuit, polysulfone membrane hemofilter, heating extension tube, and thermostatic water bath, along with commercially available citrated bovine whole blood. The circuit was filled with blood over a 10-min duration using a roller pump and was occluded after a specific period by varying the flow rate of calcium injected into bovine whole blood. Additionally, continuous injection of 1 mEq/mL calcium chloride into the circuit was maintained while bovine whole blood circulated. Measurements were performed at each calcium injection flow rate (2, 3, and 4 mL/h), with each measurement performed five times. The group that did not receive calcium injection was used as the control (0 mL/h: Con), and the experiment was performed three times. Groups were defined as "0, 2, 3, and 4" for each calcium injection flow rate. The relationship among the amount of calcium chloride injected, circuit occlusion time, and changes in circuit pressure over time was evaluated. Furthermore, blood tests and blood viscoelastic tests were performed at arbitrary times. Results The circuit occlusion time varied with each calcium injection flow rate, and a significant difference was observed between each group (p<0.05). Circuit pressure gradually changed at four min before occlusion when calcium was injected at 2, 3, and 4 mL/h, with a more rapid change at one min before occlusion. We measured circuit pressure at four and one min before occlusion (-4 min, and -1 min, respectively), and at the time of circuit occlusion (0 min) in the Con and 4 mL/h groups. Significant differences were observed in AP between -4 min and 0 min and -1 min and 0 min at a calcium flow rate of 4 mL/h. Additionally, significant differences were seen in prefilter and return pressures between -4 min and 0 min, -4 min and -1 min, and -1 min and 0 min at a calcium flow rate of 4 mL/h (p<0.05). Conclusions Our proposed model accurately estimated the occlusion time based on changes in circuit pressure. This model can be used to create various experimental systems depending on the desired occlusion time.
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Affiliation(s)
- Yu Kashima
- Medical Engineering, Junshin Gakuen University, Fukuoka, JPN
- Department of Emergency and Critical Care Medicine, Saga University, Saga, JPN
| | - Hiroyuki Koami
- Department of Emergency and Critical Care Medicine, Saga University, Saga, JPN
| | - Yuichiro Sakamoto
- Department of Emergency and Critical Care Medicine, Saga University, Saga, JPN
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Crochemore T, Scarlatescu E, Görlinger K, Rocha MDP, Carlos de Campos Guerra J, Campêlo DHC, de Aranda VF, Ricardi L, Gomes GS, Moura RAD, Assir FF, de Sá GRR, Lance MD, Hamerschlak N. Fibrinogen contribution to clot strength in patients with sepsis and hematologic malignancies and thrombocytopenia-a prospective, single-center, analytical, cross-sectional study. Res Pract Thromb Haemost 2024; 8:102362. [PMID: 38666064 PMCID: PMC11043640 DOI: 10.1016/j.rpth.2024.102362] [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: 02/05/2024] [Accepted: 02/21/2024] [Indexed: 04/28/2024] Open
Abstract
Background Patients with hematological malignancies (HM) frequently present thrombocytopenia and higher risk of bleeding. Although transfusion is associated with higher risk of adverse events and poor outcomes, prophylactic transfusion of platelets is a common practice to prevent hemorrhagic complications. Thromboelastometry has been considered a better predictor for bleeding than isolated platelet counts in different settings. In early stages of sepsis, hypercoagulability may occur due to higher fibrinogen levels. Objectives To evaluate the behavior of coagulation in patients with HM who develop sepsis and to verify whether a higher concentration of fibrinogen is associated with a proportional increase in maximum clot firmness (MCF) even in the presence of severe thrombocytopenia. Methods We performed a unicentric analytical cross-sectional study with 60 adult patients with HM and severe thrombocytopenia, of whom 30 had sepsis (sepsis group) and 30 had no infections (control group). Coagulation conventional tests and specific coagulation tests, including thromboelastometry, were performed. The main outcome evaluated was MCF. Results Higher levels of fibrinogen and MCF were found in sepsis group. Both fibrinogen and platelets contributed to MCF. The relative contribution of fibrin was significantly higher (60.5 ± 12.8% vs 43.6 ± 9.7%; P < .001) and that of platelets was significantly lower (39.5 ± 12.8% vs 56.4 ± 9.7%; P < .001) in the sepsis group compared with the control group. Conclusion Patients with sepsis and HM presented higher concentrations of fibrinogen than uninfected patients, resulting in greater MCF amplitudes even in the presence of thrombocytopenia.
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Affiliation(s)
- Tomaz Crochemore
- Intensive Care Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Intensive Care Department, Hospital Moriah, São Paulo, Brazil
- Medical Department, Werfen Latam, São Paulo, Brazil
| | - Ecaterina Scarlatescu
- Intensive Care Department, Bucharest and Fundeni Clinical Institute, University of Medicine and Pharmacy “Carol Davila,” Bucharest, Romania
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Essen, Germany
- Medical Department, TEM Innovations/Werfen PBM, Munich, Germany
| | | | - João Carlos de Campos Guerra
- Laboratory Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Departament of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | - Lucélia Ricardi
- Laboratory Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | | | - Marcus D. Lance
- Department of Anesthesiology, Aga Khan University, Nairobi, Kenya
| | - Nelson Hamerschlak
- Departament of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Unar A, Bertolino L, Patauner F, Gallo R, Durante-Mangoni E. Decoding Sepsis-Induced Disseminated Intravascular Coagulation: A Comprehensive Review of Existing and Emerging Therapies. J Clin Med 2023; 12:6128. [PMID: 37834771 PMCID: PMC10573475 DOI: 10.3390/jcm12196128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/09/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
Disseminated intravascular coagulation (DIC) is a recurrent complication of sepsis. Since DIC not only promotes organ dysfunction but also represents a strong prognostic factor, it is important to diagnose DIC as early as possible. When coagulation is activated, fibrinolysis is inhibited, blood thinners are consumed, and a condition is created that promotes blood clotting, making it more difficult for the body to remove fibrin or prevent it from being deposited in the blood vessels. This leads to microvascular thrombosis, which plays a role in organ dysfunction. Despite efforts to understand the underlying mechanisms of sepsis-induced DIC, healthcare providers worldwide still face challenges in effectively treating this condition. In this review, we provide an in-depth analysis of the available strategies for sepsis-induced DIC, considering their effectiveness, limitations, and potential for future advances. Corticosteroids (CS), recombinant thrombomodulin (rTM), vitamin C, fibrinolytic therapy, and platelet transfusion are among the treatments discussed in the review. In addition, we are specifically addressing immunomodulatory therapy (IMT) by investigating treatments such as granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF), interferon gamma (IFN-γ), and mesenchymal stem cell therapy (MSC). Finally, we also examined how these therapies might affect COVID-19 cases, which often present with sepsis-induced DIC. The review suggests that targeted experiments with randomization are needed to verify the effectiveness of these treatments and to discover novel approaches to treat sepsis-induced DIC. By increasing our knowledge of sepsis-induced DIC, we can develop targeted treatments that have the potential to save lives and improve outcomes.
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Affiliation(s)
- Ahsanullah Unar
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
| | - Lorenzo Bertolino
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
| | - Fabian Patauner
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
| | - Raffaella Gallo
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
| | - Emanuele Durante-Mangoni
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’, 80138 Naples, Italy; (A.U.); (L.B.); (F.P.); (R.G.)
- Unit of Infectious and Transplant Medicine, AORN Ospedali dei Colli-Monaldi Hospital, 80131 Naples, Italy
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9
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Samavedam S. Sepsis Induced Coagulopathy: Bringing Science to the Bedside. Indian J Crit Care Med 2023; 27:611-612. [PMID: 37719344 PMCID: PMC10504649 DOI: 10.5005/jp-journals-10071-24537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
How to cite this article: Samavedam S, Sepsis Induced Coagulopathy: Bringing Science to the Bedside. Indian J Crit Care Med 2023;27(9): 611-612.
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Affiliation(s)
- Srinivas Samavedam
- Department of Critical Care, Ramdevrao Hospital, Hyderabad, Telangana, India
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10
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Mohapatra P, Kumar A, Singh RK, Gupta R, Hussain M, Singh S, Kumar P. The Effect of Sepsis and Septic Shock on the Viscoelastic Properties of Clot Quality and Mass Using Thromboelastometry: A Prospective Observational Study. Indian J Crit Care Med 2023; 27:625-634. [PMID: 37719352 PMCID: PMC10504658 DOI: 10.5005/jp-journals-10071-24539] [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: 03/13/2023] [Accepted: 08/12/2023] [Indexed: 09/19/2023] Open
Abstract
Background Sepsis is associated with wide variable coagulation abnormalities. Thromboelastography (TEG) effectively measures the viscoelastic properties of the clots. This study aims to illustrate the viscoelastic properties of clot quality and mass in sepsis and septic shock patients using TEG, as an effective tool over standard coagulation tests. Materials and methods A single-center, prospective observational study was conducted. 50 patients each meeting the criteria for sepsis and septic shock, and a healthy group of 30 patients was included in the study. Blood samples were obtained and analyzed for standard coagulation tests, platelet count, fibrinogen, and TEG study. Results A total of 130 patients were included. Septic shock patients had a higher sequential (sepsis-related) organ failure score. Prothrombin time (PT) and activated partial thromboplastin time (aPTT) were increased significantly as compared to the sepsis and control groups. TEG markers such as alpha angle, and maximum amplitude (MA) were significantly prolonged while reaction time (R time), was significantly shortened in the sepsis group as compared to the healthy group, suggestive of a hypercoagulable state in sepsis patients. While in septic shock patients, MA and Lysis Index 30 (LY 30) were significantly prolonged and, R time was significantly shortened compared to all other groups. Even though LY30 in sepsis patients was found to be within the normal range (p < 0.001), 18% of patients had prolonged LY30 indicating a hypercoagulable state with impaired fibrinolysis. Conclusion Thromboelastography, as a point-of-care test combined with conventional coagulation tests can provide additional, clinically relevant information on coagulopathy, and outcome, and thus help guide treatment modality in sepsis and septic shock-induced coagulopathy. How to cite this article Mohapatra P, Kumar A, Singh RK, Gupta R, Hussain M, Singh S, et al. The Effect of Sepsis and Septic Shock on the Viscoelastic Properties of Clot Quality and Mass Using Thromboelastometry: A Prospective Observational Study. Indian J Crit Care Med 2023;27(9):625-634.
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Affiliation(s)
- Priyanka Mohapatra
- Department of Anesthesiology & Critical Care Medicine, Indira Gandhi Institute of Medical Science, Patna, Bihar, India
| | - Arvind Kumar
- Department of Anesthesiology & Critical Care Medicine, Indira Gandhi Institute of Medical Science, Patna, Bihar, India
| | - Rakesh Kumar Singh
- Department of Anesthesiology & Critical Care Medicine, Indira Gandhi Institute of Medical Science, Patna, Bihar, India
| | - Ruchi Gupta
- Department of Critical Care, Holy Family Hospital, New Delhi, India
| | - Mumtaz Hussain
- Department of Anesthesiology & Critical Care Medicine, Indira Gandhi Institute of Medical Science, Patna, Bihar, India
| | - Swati Singh
- Department of Anesthesiology & Critical Care Medicine, Indira Gandhi Institute of Medical Science, Patna, Bihar, India
| | - Pankaj Kumar
- Department of Anesthesiology & Critical Care Medicine, Indira Gandhi Institute of Medical Science, Patna, Bihar, India
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Tjerkstra MA, Wolfs AE, Verbaan D, Vandertop WP, Horn J, Müller MCA, Juffermans NP. A Systematic Review of Viscoelastic Testing in Patients with Subarachnoid Hemorrhage. World Neurosurg 2023; 175:102-112.e5. [PMID: 37004882 DOI: 10.1016/j.wneu.2023.03.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/26/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVE Bleeding and thromboembolic complications frequently occur after subarachnoid hemorrhage (SAH) and substantially contribute to poor outcome. Viscoelastic testing could be used for detection of coagulopathies after SAH. This review summarizes literature on the usefulness of viscoelastic testing to detect coagulopathy in patients with SAH and explores whether viscoelastic parameters are associated with SAH-related complications and clinical outcome. METHODS PubMed, Embase, and Google Scholar were systematically searched on August 18, 2022. Two authors independently selected studies that reported viscoelastic testing in patients with SAH and assessed the quality of studies using the Newcastle-Ottawa Scale or a previously reported framework for quality assessment. Data were meta-analyzed if methodologically possible. RESULTS The search yielded 19 studies (1160 patients with SAH). Pooling of data including all relevant studies was not possible for any of the outcome measurements because of methodological differences. Thirteen of 19 studies evaluated the association of coagulation profiles and SAH, of which 11 studies showed a hypercoagulable profile. Rebleeding was associated with platelet dysfunction, deep venous thrombosis was associated with faster clot initiation, and both delayed cerebral ischemia and poor outcome were associated with increased clot strength. CONCLUSIONS This explorative review shows that patients with SAH frequently have a hypercoagulable profile. Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) parameters are associated with rebleeding, delayed cerebral ischemia, deep venous thrombosis, and poor clinical outcome after SAH; however, more research on the subject is needed. Future studies should focus on determining the optimal time frame and cutoff values for TEG or ROTEM to predict these complications.
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Affiliation(s)
- Maud A Tjerkstra
- Amsterdam UMC, University of Amsterdam, Department of Neurosurgery, Amsterdam Neuroscience, Amsterdam, the Netherlands.
| | - Anne E Wolfs
- Amsterdam UMC, University of Amsterdam, Department of Neurosurgery, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Dagmar Verbaan
- Amsterdam UMC, University of Amsterdam, Department of Neurosurgery, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - W Peter Vandertop
- Amsterdam UMC, University of Amsterdam, Department of Neurosurgery, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Janneke Horn
- Amsterdam UMC, University of Amsterdam, Department of Intensive Care, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Marcella C A Müller
- Amsterdam UMC, University of Amsterdam, Department of Intensive Care, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Nicole P Juffermans
- Amsterdam UMC, University of Amsterdam, Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam Neuroscience, Amsterdam, the Netherlands; Department of Intensive Care, OLVG Hospital, Amsterdam, the Netherlands
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12
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Bui-Thi HD, Le Minh K. Coagulation profiles in patients with sepsis/septic shock identify mixed hypo-hypercoagulation patterns based on rotational thromboelastometry: A prospective observational study. Thromb Res 2023; 227:51-59. [PMID: 37235948 DOI: 10.1016/j.thromres.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/21/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023]
Abstract
INTRODUCTION Sepsis-induced hemostatic disturbances are common and are associated with poor outcomes. Additionally, conventional coagulation tests (CCTs) overdiagnose hypocoagulation and cannot detect hypercoagulation and hyperfibrinolysis. The aim of this study was to describe the coagulation profiles of patients with sepsis/septic shock using rotational thromboelastometry (ROTEM) and to compare coagulation states between sepsis and septic shock groups and between surviving and non-surviving groups. MATERIALS AND METHODS This prospective, observational, single-center study was conducted in the intensive care unit (ICU) of the University Medical Center Ho Chi Minh City, from 6/2020-12/2021. Patients aged ≥18 years with sepsis or septic shock according to the Sepsis-3 criteria were included. ROTEM and CCTs were concurrently performed within the first 24 h of ICU admission. RESULTS In total, 161 patients were enrolled. Based on ROTEM, 72.7 % of patients with sepsis/septic shock had coagulation disorders, including 25.5 % hypercoagulation, 54.7 % hypocoagulation, 13.6 % mixed hypo-hypercoagulation patterns, and 18.6 % hyperfibrinolysis. A common mixed disorder subtype was characterized by prolonged initial clotting time (CT) with subsequently increased clot firmness. Fibrinogen levels and maximum clot formation (MCF)-fibtem were strongly correlated (rho = 0.73, p < 0.05). Hypocoagulation was observed more in the septic shock group than in the sepsis group. Compared to survivors, non-survivors had more prolonged CT-extem. CONCLUSIONS ROTEM could identify hypocoagulability, hypercoagulability, mixed hypo-hypercoagulability patterns, and hyperfibrinolysis in patients with sepsis/septic shock. Elevated MCF-fibtem and elevated fibrinogen levels were notably common and strongly correlated. The septic shock group had more hypocoagulation than the sepsis group. Lastly, non-survivors had more prolonged CT-extem than survivors.
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Affiliation(s)
- Hanh-Duyen Bui-Thi
- Department of Intensive Care, University Medical Center Ho Chi Minh City, The University of Medicine and Pharmacy at Ho Chi Minh City, 215 Hong Bang Street, Ward 11, District 5, Ho Chi Minh City, Viet Nam.
| | - Khoi Le Minh
- Department of Science and Training, University Medical Center Ho Chi Minh City, The University of Medicine and Pharmacy at Ho Chi Minh City, Viet Nam.
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13
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Itenov TS, Kromann ME, Ostrowski SR, Bestle MH, Mohr T, Gyldensted L, Lindhardt A, Thormar K, Sessler DI, Juffermans NP, Lundgren JD, Jensen JU. Mild induced hypothermia and coagulation and platelet function in patients with septic shock: Secondary outcome of a randomized trial. Acta Anaesthesiol Scand 2023. [PMID: 37129236 DOI: 10.1111/aas.14254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 05/03/2023]
Abstract
Coagulation abnormalities and microthrombi contribute to septic shock, but the impact of body temperature regulation on coagulation in patients with sepsis is unknown. We tested the hypothesis that mild induced hypothermia reduces coagulation and platelet aggregation in patients with septic shock. Secondary analysis of randomized controlled trial. Adult patients with septic shock who required mechanical ventilation from eight intensive care units in Denmark were randomly assigned to mild induced hypothermia for 24 h or routine thermal management. Viscoelastography and platelet aggregation were assessed at trial inclusion, after 12 h of thermal management, and 24 h after inclusion. A total of 326 patients were randomized to mild induced hypothermia (n = 163) or routine thermal management (n = 163). Mild induced hypothermia slightly prolonged activated partial thromboplastin time and thrombus initiation time (R time 8.0 min [interquartile range, IQR 6.6-11.1] vs. 7.2 min [IQR 5.8-9.2]; p = .004) and marginally inhibited thrombus propagation (angle 68° [IQR 59-73] vs. 71° [IQR 63-75]; p = .014). The effect was also present after 24 h. Clot strength remained unaffected (MA 71 mm [IQR 66-76] with mild induced hypothermia vs. 72 mm (65-77) with routine thermal management, p = .9). The proportion of patients with hyperfibrinolysis was not affected (0.7% vs. 3.3%; p = .19), but the proportion of patients with no fibrinolysis was high in the mild hypothermia group (8.8% vs. 40.4%; p < .001). The mild induced hypothermia group had lower platelet aggregation: ASPI 85U (IQR 50-113) versus 109U (IQR 74-148, p < .001), ADP 61U (IQR 40-83) versus 79 U (IQR 54-101, p < .001), TRAP 108 (IQR 83-154) versus 119 (IQR 94-146, p = .042) and COL 50U (IQR 34-66) versus 67U (IQR 46-92, p < .001). In patients with septic shock, mild induced hypothermia slightly impaired clot initiation, but did not change clot strength. Platelet aggregation was slightly impaired. The effect of mild induced hypothermia on viscoelastography and platelet aggregation was however not in a range that would have clinical implications. We did observe a substantial reduction in fibrinolysis.
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Affiliation(s)
- Theis S Itenov
- CHIP/PERSIMUNE, Department of infectious diseases, Rigshospitalet, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Anesthesiology, Copenhagen University Hospital - Bispebjerg, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health sciences, University of Copenhagen, Copenhagen, Denmark
| | - Maria E Kromann
- CHIP/PERSIMUNE, Department of infectious diseases, Rigshospitalet, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Sisse R Ostrowski
- Department of Clinical Medicine, Faculty of Health sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Immunology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten H Bestle
- Department of Clinical Medicine, Faculty of Health sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital - North Zealand, Copenhagen, Denmark
| | - Thomas Mohr
- Department of Anesthesiology, Copenhagen University Hospital - Herlev-Gentofte, Copenhagen, Denmark
| | - Louise Gyldensted
- Department of Anesthesiology, Copenhagen University Hospital - Herlev-Gentofte, Copenhagen, Denmark
| | - Anne Lindhardt
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital - North Zealand, Copenhagen, Denmark
| | - Katrin Thormar
- Department of Anesthesiology, Copenhagen University Hospital - Bispebjerg, Copenhagen, Denmark
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nicole P Juffermans
- Department of Intensive Care, OLVG Hospital, Amsterdam, the Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jens D Lundgren
- CHIP/PERSIMUNE, Department of infectious diseases, Rigshospitalet, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens-Ulrik Jensen
- CHIP/PERSIMUNE, Department of infectious diseases, Rigshospitalet, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health sciences, University of Copenhagen, Copenhagen, Denmark
- Respiratory Section, Department of Internal Medicine, Copenhagen University Hospital - Gentofte, Copenhagen, Denmark
- Outcomes Research Consortium, Cleveland, Ohio, USA
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14
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Zhu C, Hou Z, Zhu R, Zhou B, Sun Y, Li Z, Li X, Ding R, Luan Z, Liang Y, Wang L, Ma X. Comparisons of coagulation characteristics between elderly and non-elderly patients with sepsis: A prospective study. Surgery 2023; 173:1303-1310. [PMID: 36774318 DOI: 10.1016/j.surg.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 12/11/2022] [Accepted: 01/06/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND A blunt host defense response in older patients may contribute to different coagulation responses during sepsis. We aimed to investigate the differences in coagulation parameters between elderly and non-elderly patients with sepsis. METHODS Adult patients diagnosed with sepsis within 24 hours after admission to the intensive care unit between September 2018 and December 2020 were prospectively enrolled. Patients were categorized into the adult (18-64 years) and elderly (age ≥65 years) groups. Conventional coagulation parameters and inflammatory markers were measured on intensive care unit admission and on Days 3 and 7. Thromboelastography was performed on intensive care unit admission. The differences in the coagulation parameters between the 2 groups were evaluated. The adult and elderly patients were matched to adjust for baseline characteristics. Correlations between inflammatory markers and coagulation-related parameters were also analyzed. RESULTS Of the 567 patients, 303 (53.4%) were elderly. Compared with adult patients, elderly patients had lower prothrombin time elevation, lower fibrinogen, D-dimer, and fibrin/Fib degradation product levels, and lower proportion of disseminated intravascular coagulation on intensive care unit admission; and, they had lower dynamic platelet, lower fibrinogen, and D-dimer levels during the first week in the intensive care unit. Thromboelastography parameters were generally within the normal range, although elderly patients had lower R and K values and a higher alpha angle. Comparisons of coagulation parameters between the 2 groups revealed similar results in the matched cohort. The inflammatory markers correlated with prothrombin time, activated partial thromboplastin time, and antithrombin III. CONCLUSION Elderly patients had milder coagulation activation, accompanied by a decreased inflammatory response during sepsis, compared to non-elderly patients.
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Affiliation(s)
- Chengrui Zhu
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Zhenzhen Hou
- Department of Surgical Intensive Care Unit, Beijing Chaoyang Hospital Affiliated to Capital Medical University, China
| | - Ran Zhu
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Baosen Zhou
- Department of Clinical Epidemiology, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yini Sun
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Zhiliang Li
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Xu Li
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Renyu Ding
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Zhenggang Luan
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yingjian Liang
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Liang Wang
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Xiaochun Ma
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China.
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15
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Zhao XS, Meng ZL, Zhang T, Yang HN, Zhang JC, Fang W, Wang CT, Chen M. Combining Serum Procalcitonin Level, Thromboelastography, and Platelet Count to Predict Short-term Development of Septic Shock in Intensive Care Unit. Curr Med Sci 2023; 43:86-92. [PMID: 36752938 DOI: 10.1007/s11596-022-2689-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 10/09/2022] [Indexed: 02/09/2023]
Abstract
OBJECTIVE Despite the recent advances in diagnosis and treatment, sepsis continues to lead to high morbidity and mortality. Early diagnosis and prompt treatment are essential to save lives. However, most biomarkers can only help to diagnose sepsis, but cannot predict the development of septic shock in high-risk patients. The present study determined whether the combined measurement of procalcitonin (PCT), thromboelastography (TEG) and platelet (PLT) count can predict the development of septic shock. METHODS A retrospective study was conducted on 175 septic patients who were admitted to the intensive care unit between January 2017 and February 2021. These patients were divided into two groups: 73 patients who developed septic shock were assigned to the septic shock group, while the remaining 102 patients were assigned to the sepsis group. Then, the demographic, clinical and laboratory data were recorded, and the predictive values of PCT, TEG and PLT count for the development of septic shock were analyzed. RESULTS Compared to the sepsis group, the septic shock group had statistically lower PLT count and TEG measurements in the R value, K value, α angle, maximum amplitude, and coagulation index, but had longer prothrombin time (DT), longer activated partial thromboplastin time (APTT), and higher PCT levels. Furthermore, the Sequential Organ Failure Assessment (SOFA) score was higher in the septic shock group. The multivariate logistic regression analysis revealed that PCT, TEG and PLT count were associated with the development of septic shock. The area under the curve analysis revealed that the combined measurement of PCT, TEG and PLT count can be used to predict the development of septic shock with higher accuracy, when compared to individual measurements. CONCLUSION The combined measurement of PCT, TEG and PLT count is a novel approach to predict the development of septic shock in high-risk patients.
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Affiliation(s)
- Xue-Song Zhao
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China
- Department of Critical Care Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, China
- The First Affiliated Hospital of Shandong First Medical University (Shandong Provincial Qianfoshan Hospital), Jinan, 250021, China
| | - Zhao-Li Meng
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China
- Department of Critical Care Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, China
| | - Tuo Zhang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China
- Department of Critical Care Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, China
| | - Hong-Na Yang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China
- Department of Critical Care Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, China
| | - Ji-Cheng Zhang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China
- Department of Critical Care Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, China
| | - Wei Fang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China
- Department of Critical Care Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, China
| | - Chun-Ting Wang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China.
- Department of Critical Care Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, China.
| | - Man Chen
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China.
- Department of Critical Care Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, China.
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Sepsis-Induced Coagulopathy: An Update on Pathophysiology, Biomarkers, and Current Guidelines. Life (Basel) 2023; 13:life13020350. [PMID: 36836706 PMCID: PMC9961497 DOI: 10.3390/life13020350] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/16/2023] [Accepted: 01/20/2023] [Indexed: 02/03/2023] Open
Abstract
Significant cross talk occurs between inflammation and coagulation. Thus, coagulopathy is common in sepsis, potentially aggravating the prognosis. Initially, septic patients tend to exhibit a prothrombotic state through extrinsic pathway activation, cytokine-induced coagulation amplification, anticoagulant pathways suppression, and fibrinolysis impairment. In late sepsis stages, with the establishment of disseminated intravascular coagulation (DIC), hypocoagulability ensues. Traditional laboratory findings of sepsis, including thrombocytopenia, increased prothrombin time (PT) and fibrin degradation products (FDPs), and decreased fibrinogen, only present late in the course of sepsis. A recently introduced definition of sepsis-induced coagulopathy (SIC) aims to identify patients at an earlier stage when changes to coagulation status are still reversible. Nonconventional assays, such as the measurement of anticoagulant proteins and nuclear material levels, and viscoelastic studies, have shown promising sensitivity and specificity in detecting patients at risk for DIC, allowing for timely therapeutic interventions. This review outlines current insights into the pathophysiological mechanisms and diagnostic options of SIC.
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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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Coagulation Disorders in Sepsis and COVID-19-Two Sides of the Same Coin? A Review of Inflammation-Coagulation Crosstalk in Bacterial Sepsis and COVID-19. J Clin Med 2023; 12:jcm12020601. [PMID: 36675530 PMCID: PMC9866352 DOI: 10.3390/jcm12020601] [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: 11/22/2022] [Revised: 12/27/2022] [Accepted: 01/10/2023] [Indexed: 01/15/2023] Open
Abstract
Sepsis is a major cause of morbidity and mortality worldwide. Sepsis-associated coagulation disorders are involved in the pathogenesis of multiorgan failure and lead to a subsequently worsening prognosis. Alongside the global impact of the COVID-19 pandemic, a great number of research papers have focused on SARS-CoV-2 pathogenesis and treatment. Significant progress has been made in this regard and coagulation disturbances were once again found to underlie some of the most serious adverse outcomes of SARS-CoV-2 infection, such as acute lung injury and multiorgan dysfunction. In the attempt of untangling the mechanisms behind COVID-19-associated coagulopathy (CAC), a series of similarities with sepsis-induced coagulopathy (SIC) became apparent. Whether they are, in fact, the same disease has not been established yet. The clinical picture of CAC shows the unique feature of an initial phase of intravascular coagulation confined to the respiratory system. Only later on, patients can develop a clinically significant form of systemic coagulopathy, possibly with a consumptive pattern, but, unlike SIC, it is not a key feature. Deepening our understanding of CAC pathogenesis has to remain a major goal for the research community, in order to design and validate accurate definitions and classification criteria.
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Carsetti A, Vitali E, Pesaresi L, Antolini R, Casarotta E, Damiani E, Adrario E, Donati A. Anesthetic management of patients with sepsis/septic shock. Front Med (Lausanne) 2023; 10:1150124. [PMID: 37035341 PMCID: PMC10076637 DOI: 10.3389/fmed.2023.1150124] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/28/2023] [Indexed: 04/11/2023] Open
Abstract
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, while septic shock is a subset of sepsis with persistent hypotension requiring vasopressors to maintain a mean arterial pressure (MAP) of ≥65 mmHg and having a serum lactate level of >2 mmol/L, despite adequate volume resuscitation. Sepsis and septic shock are medical emergencies and time-dependent diseases with a high mortality rate for which early identification, early antibiotic therapy, and early source control are paramount for patient outcomes. The patient may require surgical intervention or an invasive procedure aiming to control the source of infection, and the anesthesiologist has a pivotal role in all phases of patient management. During the preoperative assessment, patients should be aware of all possible organ dysfunctions, and the severity of the disease combined with the patient's physiological reserve should be carefully assessed. All possible efforts should be made to optimize conditions before surgery, especially from a hemodynamic point of view. Anesthetic agents may worsen the hemodynamics of shock patients, and the anesthesiologist must know the properties of each anesthetic agent. All possible efforts should be made to maintain organ perfusion supporting hemodynamics with fluids, vasoactive agents, and inotropes if required.
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Affiliation(s)
- Andrea Carsetti
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
- *Correspondence: Andrea Carsetti
| | - Eva Vitali
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Lucia Pesaresi
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Riccardo Antolini
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Erika Casarotta
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Elisa Damiani
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Erica Adrario
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Abele Donati
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
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Bunch CM, Chang E, Moore EE, Moore HB, Kwaan HC, Miller JB, Al-Fadhl MD, Thomas AV, Zackariya N, Patel SS, Zackariya S, Haidar S, Patel B, McCurdy MT, Thomas SG, Zimmer D, Fulkerson D, Kim PY, Walsh MR, Hake D, Kedar A, Aboukhaled M, Walsh MM. SHock-INduced Endotheliopathy (SHINE): A mechanistic justification for viscoelastography-guided resuscitation of traumatic and non-traumatic shock. Front Physiol 2023; 14:1094845. [PMID: 36923287 PMCID: PMC10009294 DOI: 10.3389/fphys.2023.1094845] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/07/2023] [Indexed: 03/03/2023] Open
Abstract
Irrespective of the reason for hypoperfusion, hypocoagulable and/or hyperfibrinolytic hemostatic aberrancies afflict up to one-quarter of critically ill patients in shock. Intensivists and traumatologists have embraced the concept of SHock-INduced Endotheliopathy (SHINE) as a foundational derangement in progressive shock wherein sympatho-adrenal activation may cause systemic endothelial injury. The pro-thrombotic endothelium lends to micro-thrombosis, enacting a cycle of worsening perfusion and increasing catecholamines, endothelial injury, de-endothelialization, and multiple organ failure. The hypocoagulable/hyperfibrinolytic hemostatic phenotype is thought to be driven by endothelial release of anti-thrombogenic mediators to the bloodstream and perivascular sympathetic nerve release of tissue plasminogen activator directly into the microvasculature. In the shock state, this hemostatic phenotype may be a counterbalancing, yet maladaptive, attempt to restore blood flow against a systemically pro-thrombotic endothelium and increased blood viscosity. We therefore review endothelial physiology with emphasis on glycocalyx function, unique biomarkers, and coagulofibrinolytic mediators, setting the stage for understanding the pathophysiology and hemostatic phenotypes of SHINE in various etiologies of shock. We propose that the hyperfibrinolytic phenotype is exemplified in progressive shock whether related to trauma-induced coagulopathy, sepsis-induced coagulopathy, or post-cardiac arrest syndrome-associated coagulopathy. Regardless of the initial insult, SHINE appears to be a catecholamine-driven entity which early in the disease course may manifest as hyper- or hypocoagulopathic and hyper- or hypofibrinolytic hemostatic imbalance. Moreover, these hemostatic derangements may rapidly evolve along the thrombohemorrhagic spectrum depending on the etiology, timing, and methods of resuscitation. Given the intricate hemochemical makeup and changes during these shock states, macroscopic whole blood tests of coagulative kinetics and clot strength serve as clinically useful and simple means for hemostasis phenotyping. We suggest that viscoelastic hemostatic assays such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are currently the most applicable clinical tools for assaying global hemostatic function-including fibrinolysis-to enable dynamic resuscitation with blood products and hemostatic adjuncts for those patients with thrombotic and/or hemorrhagic complications in shock states.
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Affiliation(s)
- Connor M Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States.,Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Eric Chang
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Ernest E Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, United States
| | - Hunter B Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, United States.,Department of Transplant Surgery, Denver Health and University of Colorado Health Sciences Center, Denver, CO, United States
| | - Hau C Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States.,Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Mahmoud D Al-Fadhl
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Anthony V Thomas
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Nuha Zackariya
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Shivani S Patel
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Sufyan Zackariya
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Saadeddine Haidar
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Bhavesh Patel
- Division of Critical Care, Department of Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Scott G Thomas
- Department of Trauma Surgery, Memorial Leighton Trauma Center, South Bend, IN, United States
| | - Donald Zimmer
- Department of Trauma Surgery, Memorial Leighton Trauma Center, South Bend, IN, United States
| | - Daniel Fulkerson
- Department of Trauma Surgery, Memorial Leighton Trauma Center, South Bend, IN, United States
| | - Paul Y Kim
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | | | - Daniel Hake
- Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Archana Kedar
- Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Michael Aboukhaled
- Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Mark M Walsh
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States.,Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
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21
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Shinada K, Koami H, Matsuoka A, Sakamoto Y. Prediction of return of spontaneous circulation in out-of-hospital cardiac arrest with non-shockable initial rhythm using point-of-care testing: a retrospective observational study. World J Emerg Med 2023; 14:89-95. [PMID: 36911060 PMCID: PMC9999141 DOI: 10.5847/wjem.j.1920-8642.2023.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 11/10/2022] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) is a public health concern, and many studies have been conducted on return of spontaneous circulation (ROSC) and its prognostic factors. Rotational thromboelastometry (ROTEM®), a point-of-care testing (POCT) method, has been useful for predicting ROSC in patients with OHCA, but very few studies have focused on patients with non-shockable rhythm. We examined whether the parameters of POCT could predict ROSC in patients with OHCA and accompanying non-shockable rhythm. METHODS This is a single-center, retrospective observational study. Complete blood count, blood gas, and ROTEM POCT measurements were used. This study included patients with non-traumatic OHCA aged 18 years or older who were transported to the emergency department and evaluated using POCT between January 2013 and December 2021. The patients were divided into the ROSC and non-ROSC groups. Prehospital information and POCT parameters were compared using receiver operating characteristic (ROC) curve analysis, and further logistic regression analysis was performed. RESULTS Sixty-seven and 135 patients were in the ROSC and non-ROSC groups, respectively. The ROC curves showed a high area under the curve (AUC) for K+ of 0.77 (95% confidence interval [CI]: 0.71-0.83) and EXTEM amplitude 5 min after clotting time (A5) of 0.70 (95%CI: 0.62-0.77). The odds ratios for ROSC were as follows: female sex 3.67 (95%CI: 1.67-8.04); K+ 0.64 (95%CI: 0.48-0.84); and EXTEM A5 1.03 (95%CI: 1.01-1.06). CONCLUSION In OHCA patients with non-shockable rhythm, K+ level and the ROTEM parameter EXTEM A5 may be useful in predicting ROSC.
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Affiliation(s)
- Kota Shinada
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, Saga City, Saga Prefecture 849-8501, Japan
| | - Hiroyuki Koami
- Division of Translational Research in Intensive Care Medicine, Faculty of Medicine, Saga University, Saga City, Saga Prefecture 849-8501, Japan
| | - Ayaka Matsuoka
- Division of Translational Research in Intensive Care Medicine, Faculty of Medicine, Saga University, Saga City, Saga Prefecture 849-8501, Japan
| | - Yuichiro Sakamoto
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, Saga City, Saga Prefecture 849-8501, Japan
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22
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Breel JS, Wensing AGCL, Eberl S, Preckel B, Schober P, Müller MCA, Klautz RJM, Hollmann MW, Hermanns H. Patients with infective endocarditis undergoing cardiac surgery have distinct ROTEM profiles and more bleeding complications compared to patients without infective endocarditis. PLoS One 2023; 18:e0284329. [PMID: 37053130 PMCID: PMC10101476 DOI: 10.1371/journal.pone.0284329] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/28/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND The coagulation system is crucial in the pathogenesis of infective endocarditis and undergoes significant changes during course of the disease. However, little is known about the implications of those changes in the perioperative period. Aim of the present study was to delineate the specific coagulation patterns and their clinical consequence in patients undergoing cardiac surgery due to infective endocarditis. METHODS In this single-centre, exploratory, prospective observational study, we investigated the incidence and degree of coagulopathy in patients with (n = 31) and without infective endocarditis (n = 39) undergoing cardiac valve surgery. The primary outcome was the differences between these two groups in rotational thromboelastometry (ROTEM) results before, during and after surgery. The secondary outcomes were the differences between the groups in heparin sensitivity, bleeding complications, and transfusion requirements. RESULTS Most ROTEM parameters in EXTEM, INTEM and FIBTEM assays were significantly altered in patients with infective endocarditis. Clotting time in the EXTEM assay was significantly prolonged in the endocarditis group at all time-points, while all clot firmness parameters (A5, A10 and MCF) were significantly increased. The heparin sensitivity index was significantly lower in the endocarditis group (median index 0.99 vs 1.17s. IU-1.kg-1, p = .008), indicating increased heparin resistance. Patients with infective endocarditis had more bleeding complications as assessed by the universal definition of perioperative bleeding score (OR 3.0, p = .018), and more patients with endocarditis underwent early re-exploration (p = .018). CONCLUSIONS The findings of this exploratory investigation show significantly altered coagulation profiles in patients with infective endocarditis, with concomitant hyper- and hypocoagulability. Furthermore, the incidence of bleeding complications and transfusion requirements were increased in patients with endocarditis. These results show the potential of ROTEM to detect coagulation abnormalities in patients with infective endocarditis. Existing point-of-care coagulation testing guided algorithms for optimizing perioperative coagulation management possibly need to be adjusted for these high-risk patients undergoing cardiac surgery.
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Affiliation(s)
- Jennifer S Breel
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Agnes G C L Wensing
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Susanne Eberl
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Benedikt Preckel
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Patrick Schober
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Marcella C A Müller
- Department of Intensive Care, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Robert J M Klautz
- Department of Cardiac Surgery, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Henning Hermanns
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
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23
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Matsuoka A, Koami H, Shinada K, Sakamoto Y. Investigation of differences in coagulation characteristics between hospitalized patients with SARS-CoV-2 Alpha, Delta, and Omicron variant infection using rotational thromboelastometry (ROTEM): A single-center, retrospective, observational study. J Clin Lab Anal 2022; 36:e24796. [PMID: 36441617 PMCID: PMC9756981 DOI: 10.1002/jcla.24796] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 11/12/2022] [Accepted: 11/19/2022] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND The severe acute respiratory syndrome coronavirus 2 Omicron variant has a low rate of serious illness, is highly contagious, and has spread rapidly since January 2022. The number of severe cases and deaths remains problematic. Here, we aimed to elucidate the coagulation pathology of Omicron-infected patients using rotational thromboelastometry. METHODS Patients with coronavirus disease 2019, hospitalized and treated from January 2021 to April 2022, were included. The Alpha-Delta and Omicron groups were defined during admission. Blood tests, clinical course, and rotational thromboelastometry measurements were compared using a propensity score-matched cohort. RESULTS Both groups had 21 patients each. Lactate dehydrogenase (Alpha-Delta group [interquartile range] vs. Omicron group [interquartile range]; 449 [368-518] U/L vs. 241 [196-398] U/L, p = 0.01) and ferritin (1428 [1145-3061] ng/dl vs. 481 [188-881] ng/dl, p = 0.0002) levels were significantly lower in the Omicron group. In rotational thromboelastometry, the thrombus hardness indexes FIBTEM A5 (29 [23-34] mm vs. 23 [18-28] mm, p = 0.034) and maximum clot firmness (34 [27-40] mm vs. 26 [21-33] mm, p = 0.021) were significantly lower in the Omicron group, whereas the fibrinolysis index FIBTEM LI60 (98 [92-100] % vs. 100 [100-100] %, p = 0.0082) was higher. CONCLUSION Severe coagulation abnormalities may be less likely in Omicron-infected patients than in those infected with the previous Alpha and Delta variants.
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Affiliation(s)
- Ayaka Matsuoka
- Department of Emergency and Critical Care Medicine Faculty of MedicineSaga UniversitySaga CityJapan
| | - Hiroyuki Koami
- Department of Emergency and Critical Care Medicine Faculty of MedicineSaga UniversitySaga CityJapan
| | - Kota Shinada
- Department of Emergency and Critical Care Medicine Faculty of MedicineSaga UniversitySaga CityJapan
| | - Yuichiro Sakamoto
- Department of Emergency and Critical Care Medicine Faculty of MedicineSaga UniversitySaga CityJapan
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24
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Abstract
Platelet transfusions are commonly administered for the prevention or treatment of bleeding in patients with acquired thrombocytopenia across a range of clinical contexts. Recent data, including randomized trials, have highlighted uncertainties in the risk-benefit balance of this therapy, which is the subject of this review. Hemovigilance systems report that platelets are the most frequently implicated component in transfusion reactions. There is considerable variation in platelet count increment after platelet transfusion, and limited evidence of efficacy for clinical outcomes, including prevention of bleeding. Bleeding events commonly occur despite the different policies for platelet transfusion prophylaxis. The underlying mechanisms of harm reported in randomized trials may be related to the role of platelets beyond hemostasis, including mediating inflammation. Research supports the implementation of a restrictive platelet transfusion policy. Research is needed to better understand the impact of platelet donation characteristics on outcomes, and to determine the optimal thresholds for platelet transfusion before invasive procedures or major surgery (eg, laparotomy). Platelet transfusion policies should move toward a risk-adapted approach that does not focus solely on platelet count.
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25
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Bunch CM, Berquist M, Ansari A, McCoy ML, Langford JH, Brenner TJ, Aboukhaled M, Thomas SJ, Peck E, Patel S, Cancel E, Al-Fadhl MD, Zackariya N, Thomas AV, Aversa JG, Greene RB, Seder CW, Speybroeck J, Miller JB, Kwaan HC, Walsh MM. The Choice between Plasma-Based Common Coagulation Tests and Cell-Based Viscoelastic Tests in Monitoring Hemostatic Competence: Not an either-or Proposition. Semin Thromb Hemost 2022; 48:769-784. [PMID: 36174601 DOI: 10.1055/s-0042-1756302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
There has been a significant interest in the last decade in the use of viscoelastic tests (VETs) to determine the hemostatic competence of bleeding patients. Previously, common coagulation tests (CCTs) such as the prothrombin time (PT) and partial thromboplastin time (PTT) were used to assist in the guidance of blood component and hemostatic adjunctive therapy for these patients. However, the experience of decades of VET use in liver failure with transplantation, cardiac surgery, and trauma has now spread to obstetrical hemorrhage and congenital and acquired coagulopathies. Since CCTs measure only 5 to 10% of the lifespan of a clot, these assays have been found to be of limited use for acute surgical and medical conditions, whereby rapid results are required. However, there are medical indications for the PT/PTT that cannot be supplanted by VETs. Therefore, the choice of whether to use a CCT or a VET to guide blood component therapy or hemostatic adjunctive therapy may often require consideration of both methodologies. In this review, we provide examples of the relative indications for CCTs and VETs in monitoring hemostatic competence of bleeding patients.
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Affiliation(s)
- Connor M Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Margaret Berquist
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Aida Ansari
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Max L McCoy
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Jack H Langford
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Toby J Brenner
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Michael Aboukhaled
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Samuel J Thomas
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Ethan Peck
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Shivani Patel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Emily Cancel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Mahmoud D Al-Fadhl
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Nuha Zackariya
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Anthony V Thomas
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - John G Aversa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ryan B Greene
- Department of Interventional Radiology, St. Joseph Regional Medical Center, Mishawaka, Indiana
| | - Christopher W Seder
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jacob Speybroeck
- Department of Orthopedic Surgery, Case Western Medical Center, Cleveland, Ohio
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Hau C Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark M Walsh
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana.,Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
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26
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INTERCEPT Pathogen Reduction in Platelet Concentrates, in Contrast to Gamma Irradiation, Induces the Formation of trans-Arachidonic Acids and Affects Eicosanoid Release during Storage. Biomolecules 2022; 12:biom12091258. [PMID: 36139096 PMCID: PMC9496540 DOI: 10.3390/biom12091258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/01/2022] [Accepted: 09/05/2022] [Indexed: 11/24/2022] Open
Abstract
Pathogen inactivation techniques for blood products have been implemented to optimize clinically safe blood components supply. The INTERCEPT system uses amotosalen together with ultraviolet light wavelength A (UVA) irradiation. Irradiation-induced inactivation of nucleic acids may actually be accompanied by modifications of chemically reactive polyunsaturated fatty acids known to be important mediators of platelet functions. Thus, here, we investigated eicosanoids and the related fatty acids released upon treatment and during storage of platelet concentrates for 7 days, complemented by the analysis of functional and metabolic consequences of these treatments. Metabolic and functional issues like glucose consumption, lactate formation, platelet aggregation, and clot firmness hardly differed between the two treatment groups. In contrast to gamma irradiation, here, we demonstrated that INTERCEPT treatment immediately caused new formation of trans-arachidonic acid isoforms, while 11-hydroxyeicosatetraenoic acid (11-HETE) and 15-HETE were increased and two hydroperoxyoctadecadienoic acid (HpODE) isoforms decreased. During further storage, these alterations remained stable, while the release of 12-lipoxygenase (12-LOX) products such as 12-HETE and 12-hydroxyeicosapentaenoic acid (12-HEPE) was further attenuated. In vitro synthesis of trans-arachidonic acid isoforms suggested that thiol radicals formed by UVA treatment may be responsible for the INTERCEPT-specific effects observed in platelet concentrates. It is reasonable to assume that UVA-induced molecules may have specific biological effects which need to be further investigated.
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27
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Galli E, Maggio E, Pomero F. Venous Thromboembolism in Sepsis: From Bench to Bedside. Biomedicines 2022; 10:biomedicines10071651. [PMID: 35884956 PMCID: PMC9313423 DOI: 10.3390/biomedicines10071651] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/04/2022] [Accepted: 07/04/2022] [Indexed: 12/22/2022] Open
Abstract
Septic patients were commonly affected by coagulation disorders; thus, they are at high risk of thrombotic complications. In the last decades, novel knowledge has emerged about the interconnected and reciprocal influence of immune and coagulation systems. This phenomenon is called immunothrombosis, and it indicates an effective response whereby immune cells and the coagulation cascade cooperate to limit pathogen invasion and endothelial damage. When this network becomes dysregulated due to a systemic inflammatory activation, as occurs during sepsis, it can result in pathological thrombosis. Endothelium, platelets and neutrophils are the main characters involved in this process, together with the TF and coagulation cascade, playing a critical role in both the host defense and in thrombogenesis. A deeper understanding of this relationship may allow us to answer the growing need for clinical instruments to establish the thrombotic risk and treatments that consider more the connection between coagulation and inflammation. Heparin remains the principal therapeutical response to this phenomenon, although not sufficiently effective. To date, no other significant alternatives have been found yet. In this review, we discuss the role of sepsis-related inflammation in the development and resolution of venous thromboembolism and its clinical implications, from bench to bedside.
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Affiliation(s)
- Eleonora Galli
- Internal Medicine Residency Program, University of Turin, 10100 Turin, TO, Italy;
- Department of Internal Medicine, M. and P. Ferrero Hospital, 12060 Verduno, CN, Italy;
| | - Elena Maggio
- Department of Internal Medicine, M. and P. Ferrero Hospital, 12060 Verduno, CN, Italy;
| | - Fulvio Pomero
- Department of Internal Medicine, M. and P. Ferrero Hospital, 12060 Verduno, CN, Italy;
- Correspondence: ; Tel.: +39-01721408100
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28
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Tsantes AG, Konstantinidi A, Parastatidou S, Ioakeimidis G, Tsante KA, Mantzios PG, Kriebardis AG, Gialeraki A, Houhoula D, Iacovidou N, Piovani D, Bonovas S, Tsantes AE, Sokou R. Assessment of agreement between EXTEM and NATEM thromboelastometry measurement assays in critically ill neonates. Eur J Haematol 2022; 109:327-335. [PMID: 35690886 DOI: 10.1111/ejh.13812] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/06/2022] [Accepted: 06/08/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To investigate the agreement between the EXTEM and NATEM measurements. METHODS In this retrospective observational study, EXTEM and NATEM analyses were performed on blood samples from 162 ill neonates, providing 324 paired measurements. The agreement between EXTEM and NATEM measurements was evaluated by the nonparametric spearman's rank correlation to assess the correlation between the paired measurements, by the Bland-Altman analysis for the graphical presentation of the agreement, and by the Deming regression model to assess the significance of the agreement. The agreement between the two methods for the detection of bleeding events was determined by kappa statistic. RESULTS Strong correlations were found between EXTEM and NATEM measurements for A10, MCF. The Bland-Altman plots showed good agreement for A10, MCF, LI60, and alpha angle parameters, while CT showed a nearly linear slope indicating that bias increased with the mean. The highest agreement for bleeding events was found for the A10 parameter (κ = 0.70, p < .001), while the lowest for the CT parameter (κ = 0.36, p = .94). CONCLUSIONS NATEM parameters that reflect clot firmness and fibrinolytic activity are strongly correlated with the corresponding EXTEM measurements with a good agreement between them, indicating that these two methods could be used interchangeably.
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Affiliation(s)
- Andreas G Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Stavroula Parastatidou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece
| | - Georgios Ioakeimidis
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece
| | - Konstantina A Tsante
- Laboratory of Reliability and Quality Control in Laboratory Hematology, Department of Biomedical Science, School of Health and Caring Science, University of West Attica, Athens, Greece
| | - Petros G Mantzios
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasios G Kriebardis
- Laboratory of Reliability and Quality Control in Laboratory Hematology, Department of Biomedical Science, School of Health and Caring Science, University of West Attica, Athens, Greece
| | - Argyri Gialeraki
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitra Houhoula
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Nicoletta Iacovidou
- Neonatal Department, National and Kapodistrian University of Athens, Aretaieio Hospital, Athens, Greece
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IRCCS Humanitas Research Hospital, Milan, Italy
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IRCCS Humanitas Research Hospital, Milan, Italy
| | - Argirios E Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Rozeta Sokou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece
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29
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Matsuoka A, Koami H, Shinada K, Sasaki A, Yamazaki H, Mori K, Nakayama K, Asahi M, Yoshitake K, Narumi S, Koba M, Kawaguchi A, Sakamoto Y. Investigation of predictors of bleeding complications in COVID-19 using rotational thromboelastometry (ROTEM Ⓡ): A retrospective study. Health Sci Rep 2022; 5:e655. [PMID: 35620542 PMCID: PMC9125870 DOI: 10.1002/hsr2.655] [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: 03/11/2022] [Revised: 04/18/2022] [Accepted: 05/06/2022] [Indexed: 01/08/2023] Open
Abstract
Background Hemorrhagic complications in patients with coronavirus 19 disease (COVID-19) are infrequent but associated with a prognosis. This study aimed to elucidate the risk factors for bleeding complications in patients with COVID-19 using rotational thromboelastometry (ROTEM) parameters and blood tests performed at admission. Methods In total, 31 patients with severe COVID-19 treated intensively at Saga University Hospital were included in this study. Patients were divided into two groups according to the presence or absence of hemorrhagic complications. Results from the blood tests performed at admission and during hospitalization, and ROTEM values acquired upon admission, were compared between the two groups. Results There were significant differences in ROTEM values upon admission between the bleeding and non-bleeding groups. Receiver operating curve analysis showed that the area under the curve for prothrombin time international normalized ratio (PT-INR) and extrinsically-activated test with tissue factor (EXTEM) amplitude at 10 min (A10) were 0.82 (0.52-0.92) and 0.81 (0.58-0.93), respectively. Logistic regression analysis with PT-INR and EXTEM A10 as factors calculated an odds ratio of 1.94 (1.04-3.62) and EXTEM A10 0.86 (0.71-1.05) for bleeding complications occurrence. Conclusion ROTEM may be a sensitive predictor for bleeding complications in patients with COVID-19.
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Affiliation(s)
- Ayaka Matsuoka
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Hiroyuki Koami
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Kota Shinada
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Akira Sasaki
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Hirotaka Yamazaki
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Kosuke Mori
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Kento Nakayama
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Miho Asahi
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Kunimasa Yoshitake
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Shogo Narumi
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Mayuko Koba
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Atsushi Kawaguchi
- Education and Research Center for Community Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
| | - Yuichiro Sakamoto
- Department of Emergency and Critical Care Medicine, Faculty of MedicineSaga UniversitySaga CitySagaJapan
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Pavoni V, Gianesello L, Conti D, Ballo P, Dattolo P, Prisco D, Görlinger K. "In Less than No Time": Feasibility of Rotational Thromboelastometry to Detect Anticoagulant Drugs Activity and to Guide Reversal Therapy. J Clin Med 2022; 11:1407. [PMID: 35268498 PMCID: PMC8911211 DOI: 10.3390/jcm11051407] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/23/2022] [Accepted: 03/03/2022] [Indexed: 02/04/2023] Open
Abstract
Anticoagulant drugs (i.e., unfractionated heparin, low-molecular-weight heparins, vitamin K antagonists, and direct oral anticoagulants) are widely employed in preventing and treating venous thromboembolism (VTE), in preventing arterial thromboembolism in nonvalvular atrial fibrillation (NVAF), and in treating acute coronary diseases early. In certain situations, such as bleeding, urgent invasive procedures, and surgical settings, the evaluation of anticoagulant levels and the monitoring of reversal therapy appear essential. Standard coagulation tests (i.e., activated partial thromboplastin time (aPTT) and prothrombin time (PT)) can be normal, and the turnaround time can be long. While the role of viscoelastic hemostatic assays (VHAs), such as rotational thromboelastometry (ROTEM), has successfully increased over the years in the management of bleeding and thrombotic complications, its usefulness in detecting anticoagulants and their reversal still appears unclear.
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Affiliation(s)
- Vittorio Pavoni
- Anesthesia and Intensive Care Unit, Emergency Department and Critical Care Area, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy; (V.P.); (D.C.)
| | - Lara Gianesello
- Department of Anesthesia and Intensive Care, Orthopedic Anesthesia, University-Hospital Careggi, 50134 Florence, Italy
| | - Duccio Conti
- Anesthesia and Intensive Care Unit, Emergency Department and Critical Care Area, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy; (V.P.); (D.C.)
| | - Piercarlo Ballo
- Cardiology Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy;
| | - Pietro Dattolo
- Nephrology Unit Florence 1, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy;
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy;
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany;
- Medical Department, Tem Innovations, 81829 Munich, Germany
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Pavoni V, Gianesello L, Pazzi M, Dattolo P, Prisco D. Questions about COVID-19 associated coagulopathy: possible answers from the viscoelastic tests. J Clin Monit Comput 2022; 36:55-69. [PMID: 34264472 PMCID: PMC8280589 DOI: 10.1007/s10877-021-00744-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/09/2021] [Indexed: 12/30/2022]
Abstract
Abnormal coagulation parameters are often observed in patients with coronavirus disease 2019 (COVID-19) and the severity of derangement has been associated with a poor prognosis. The COVID-19 associated coagulopathy (CAC) displays unique features that include a high risk of developing thromboembolic complications. Viscoelastic tests (VETs), such as thromboelastometry (ROTEM), thromboelastography (TEG) and Quantra Hemostasis Analyzer (Quantra), provide "dynamic" data on clot formation and dissolution; they are used in different critical care settings, both in hemorrhagic and in thrombotic conditions. In patients with severe COVID-19 infection VETs can supply to clinicians more information about the CAC, identifying the presence of hypercoagulable and hypofibrinolysis states. In the last year, many studies have proposed to explain the underlying characteristics of CAC; however, there remain many unanswered questions. We tried to address some of the important queries about CAC through VETs analysis.
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Affiliation(s)
- Vittorio Pavoni
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Lara Gianesello
- Department of Anesthesia and Intensive Care, Orthopedic Anesthesia, University-Hospital Careggi, Largo Palagi, 1, 50139, Florence, Italy.
| | - Maddalena Pazzi
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Pietro Dattolo
- Nephrology Unit Florence 1, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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32
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Darbandi AD, Saadat GH, Butler BA, Bokhari F. Clinical Outcomes and Surgical Complications Among Patients with Bleeding Disorders After Acute Hip Fracture Surgery. J Orthop Trauma 2022; 36:104-110. [PMID: 35061653 DOI: 10.1097/bot.0000000000002212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare short-term (≤30 days) outcomes of hip fracture between patients with and without bleeding disorders. DESIGN Retrospective database review. SETTING The study setting included hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS Patients with acute hip fractures were identified from the National Surgical Quality Improvement Program database between 2016 and 2019. INTERVENTION Open reduction internal fixation or hemiarthroplasty. MAIN OUTCOME MEASUREMENTS Mortality, readmission, reoperation, length of stay, and complication were main outcome measurements. RESULTS There were 63,718 patients undergoing hip surgery, and 16.0% had a bleeding disorder. After adjusting for confounders, multivariable regression models showed that cases with bleeding disorders were associated with higher rates of transfusion [odds ratio (OR) 1.404; confidence interval (CI), 1.335-1.479], myocardial infarction (OR 1.367; CI, 1.190-1.572), pneumonia (OR 1.193; CI, 1.078-1.321), renal failure (OR 1.843; CI, 1.363-2.491), surgical site infections (OR 1.429; CI, 1.185-1.175), sepsis (OR 1.25; CI, 1.034-1.511), and readmission (OR 1.314; CI, 1.224-1.408). However, bleeding disorders were not associated with mortality (OR 0.947; CI, 0.866-1.036) or reoperation (OR 1.061; CI, 0.925-1.220). CONCLUSIONS Hip fracture surgery in patients with bleeding disorders is not associated with higher risks of short-term mortality or reoperation. However, special consideration should be taken when calculating preoperative risks of complications among bleeding disorder patients. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Ghulam H Saadat
- Department of Trauma and Burns, John H Stroger Hospital of Cook County, Chicago, IL; and
| | - Bennet A Butler
- Department of Orthopedic Surgery, Northwestern Memorial Hospital, Chicago, IL
| | - Faran Bokhari
- Department of Trauma and Burns, John H Stroger Hospital of Cook County, Chicago, IL; and
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Yang F, Peng C, Peng L, Wang J, Li Y, Li W. A Machine Learning Approach for the Prediction of Traumatic Brain Injury Induced Coagulopathy. Front Med (Lausanne) 2021; 8:792689. [PMID: 34957161 PMCID: PMC8703138 DOI: 10.3389/fmed.2021.792689] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/08/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Traumatic brain injury-induced coagulopathy (TBI-IC), is a disease with poor prognosis and increased mortality rate. Objectives: Our study aimed to identify predictors as well as develop machine learning (ML) models to predict the risk of coagulopathy in this population. Methods: ML models were developed and validated based on two public databases named Medical Information Mart for Intensive Care (MIMIC)-IV and the eICU Collaborative Research Database (eICU-CRD). Candidate predictors, including demographics, family history, comorbidities, vital signs, laboratory findings, injury type, therapy strategy and scoring system were included. Models were compared on area under the curve (AUC), accuracy, sensitivity, specificity, positive and negative predictive values, and decision curve analysis (DCA) curve. Results: Of 999 patients in MIMIC-IV included in the final cohort, a total of 493 (49.35%) patients developed coagulopathy following TBI. Recursive feature elimination (RFE) selected 15 variables, including international normalized ratio (INR), prothrombin time (PT), sepsis related organ failure assessment (SOFA), activated partial thromboplastin time (APTT), platelet (PLT), hematocrit (HCT), red blood cell (RBC), hemoglobin (HGB), blood urea nitrogen (BUN), red blood cell volume distribution width (RDW), creatinine (CRE), congestive heart failure, myocardial infarction, sodium, and blood transfusion. The external validation in eICU-CRD demonstrated that adapting boosting (Ada) model had the highest AUC of 0.924 (95% CI: 0.902–0.943). Furthermore, in the DCA curve, the Ada model and the extreme Gradient Boosting (XGB) model had relatively higher net benefits (ie, the correct classification of coagulopathy considering a trade-off between false- negatives and false-positives)—over other models across a range of threshold probability values. Conclusions: The ML models, as indicated by our study, can be used to predict the incidence of TBI-IC in the intensive care unit (ICU).
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Affiliation(s)
- Fan Yang
- Department of Plastic Surgery and Burns, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Chi Peng
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Liwei Peng
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Jian Wang
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Yuejun Li
- Department of Plastic Surgery and Burns, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Weixin Li
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
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Hulshof AM, Olie RH, Vries MJA, Verhezen PWM, van der Meijden PEJ, ten Cate H, Henskens YMC. Rotational Thromboelastometry in High-Risk Patients on Dual Antithrombotic Therapy After Percutaneous Coronary Intervention. Front Cardiovasc Med 2021; 8:788137. [PMID: 35004899 PMCID: PMC8727359 DOI: 10.3389/fcvm.2021.788137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/06/2021] [Indexed: 11/23/2022] Open
Abstract
Aims: Patients using antithrombotic drugs after percutaneous coronary intervention (PCI) are at risk for bleeding and recurrent ischemia. We aimed to explore routine and tissue plasminogen activated (tPA) ROTEM results in a post-PCI population on dual antithrombotic treatment. Methods and Results: In this prospective cohort, 440 patients treated with double antithrombotic therapy after recent PCI and with ≥3 risk factors for either ischemic or bleeding complications were included and compared with a control group (n = 95) consisting of perioperative patients not using antithrombotic medication. Laboratory assessment, including (tPA) ROTEM, was performed one month post-PCI and bleeding/ischemic complications were collected over a five-month follow-up. Patients were stratified by antithrombotic regimen consisting of a P2Y12 inhibitor with either aspirin (dual antiplatelet therapy; DAPT, n = 323), a vitamin K antagonist (VKA, n = 69) or a direct oral anticoagulant (DOAC, n = 48). All post-PCI patients had elevated ROTEM clot stiffness values, but only the DAPT group additionally presented with a decreased fibrinolytic potential as measured with tPA ROTEM. Patients receiving anticoagulants had prolonged clotting times (CT) when compared to the control and DAPT group; EXTEM and FIBTEM CT could best discriminate between patients (not) using anticoagulants (AUC > 0.97). Furthermore, EXTEM CT was significantly prolonged in DAPT patients with bleeding complications during follow-up (68 [62–70] vs. 62 [57–68], p = 0.030). Conclusion: ROTEM CT has high potential for identifying anticoagulants and tPA ROTEM could detect a diminished fibrinolytic potential in patients using DAPT. Furthermore, the ability of EXTEM CT to identify patients at risk for bleeding may be promising and warrants further research.
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Affiliation(s)
- Anne-Marije Hulshof
- Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- *Correspondence: Anne-Marije Hulshof
| | - Renske H. Olie
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Department of Internal Medicine, Maastricht University, Maastricht, Netherlands
- Thrombosis Expert Centre Maastricht, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Minka J. A. Vries
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Paul W. M. Verhezen
- Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Paola E. J. van der Meijden
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Hugo ten Cate
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Department of Internal Medicine, Maastricht University, Maastricht, Netherlands
- Thrombosis Expert Centre Maastricht, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Yvonne M. C. Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, Netherlands
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
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A pilot study evaluating the Calibrated Automated Thrombogram assay and application of plasma-thromboelastography for detection of hemostatic aberrations in horses with gastrointestinal disease. BMC Vet Res 2021; 17:346. [PMID: 34749707 PMCID: PMC8573990 DOI: 10.1186/s12917-021-03058-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 10/19/2021] [Indexed: 01/15/2023] Open
Abstract
Background Critically ill horses, such as horses with gastrointestinal (GI) disease, often suffer from hemostatic aberrations. Global hemostatic tests examining the initiation of coagulation, clot strength and fibrinolysis, such as the Calibrated Automated Thrombogram (CAT) and plasma-thromboelastography (TEG) have not been evaluated in horses. This study aimed to evaluate CAT and apply plasma-TEG in horses. Test performance of CAT was evaluated on equine platelet poor plasma with intra- and inter-assay variability (CV) and a heparin dilution curve. To examine clinical performance of both tests, group comparisons were assessed comparing healthy horses, horses with mild and severe GI disease with both CAT and plasma-TEG. Results For CAT, intra- and inter-assay CVs were established for lag-time (1.7, 4.7%), endogenous thrombin potential (1.6, 4.6%), peak (2.6, 3.9%) and time to peak (ttPeak) (1.9, 3.4%). Increasing heparin concentrations led to the expected decrease in thrombin generation. In the group comparison analysis, CAT showed significant higher peak (p = 0.04) and ttPeak (p = 0.008) in the severe GI disease group compared to horses with mild GI disease and healthy horses, respectively. Plasma-TEG showed an increased angle (p = 0.032), maximum amplitude (p = 0.017) and shear elastic force (G) (p = 0.017) in the severe GI disease group compared to healthy horses. Conclusions CAT performed well in horses. Both CAT and plasma-TEG identified hemostatic aberrations in horses with severe GI disease compared to healthy horses. Further studies including more horses, are needed to fully appreciate the use of CAT and plasma-TEG in this species. Supplementary Information The online version contains supplementary material available at 10.1186/s12917-021-03058-7.
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Fibrinolytic Impairment and Mortality in Pediatric Septic Shock: A Single-Center Prospective Observational Study. Pediatr Crit Care Med 2021; 22:969-977. [PMID: 33965991 DOI: 10.1097/pcc.0000000000002759] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Fibrinolytic shutdown is associated with poor prognosis in adult sepsis, but data in the pediatric population are sparse. This study aimed to identify the association between impaired fibrinolysis and mortality in pediatric septic shock. DESIGN A prospective, observational study conducted between August 2019 and August 2020. SETTING PICU at a pediatric tertiary hospital in Hanoi, Vietnam. PATIENTS Fifty-six pediatric patients who met septic shock criteria were enrolled. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Conventional coagulation tests and rotational thromboelastometry were performed at diagnosis. The fibrinolytic activity on extrinsic pathway thromboelastometry was negatively correlated with the Vasoactive-Inotropic Score at 24 hours post-PICU admission, peak lactate level during the first 24 hours, Pediatric Logistic Organ Dysfunction-2 score, and Pediatric Risk of Mortality-III score (all p < 0.05). Compared with patients with nonovert disseminated intravascular coagulation, dysfunction of less than two organs, and who survived, patients with overt disseminated intravascular coagulation, dysfunction of greater than two organs, and who died showed significantly lower fibrinolytic activity, represented by significantly higher lysis indexes (%) and lower maximum lysis (%) (all p < 0.05). The threshold values for prediction of mortality were lysis index 60 minutes greater than 97.5 (area under the curve = 0.86; sensitivity = 73%; specificity = 90%), maximum lysis less than 6.5 (area under the curve = 0.83; sensitivity = 73%; specificity = 87%), and lysis index 45 minutes greater than 99.5 (area under the curve = 0.83; sensitivity = 73%; specificity = 85%). Hypofibrinolysis was associated with prolonged PICU length of stay in survivors and with early mortality in nonsurvivors. CONCLUSIONS Fibrinolytic shutdown in pediatric septic shock is associated with an increase in disease severity and mortality. This highlights the need for further investigations regarding whether fibrinolytic therapy improved the outcome of pediatric septic shock.
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COVID-19 and Peripheral Artery Thrombosis: A Mini Review. Curr Probl Cardiol 2021; 47:100992. [PMID: 34571103 PMCID: PMC8462005 DOI: 10.1016/j.cpcardiol.2021.100992] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 09/14/2021] [Indexed: 12/12/2022]
Abstract
For more than 2 years, health care systems have been floundering in a massive crisis of coronavirus disease 2019 (COVID-19) pandemic. While acute respiratory distress syndrome is the main complication in patients with COVID-19, as the pandemic continues, more data about the nonrespiratory effects of the coronavirus is obtained, including developing Coagulopathy-related manifestations, in the form of venous and arterial thromboembolism. Although arterial thrombosis a rare complication of this disease, it proves to be an effective factor in the mortality and morbidity of COVID-19 patients. The pathophysiology of thrombosis reveals a complex relation between hemostasis and immune system that can be disrupted by COVID-19. Thrombectomy, anticoagulant therapy, and thrombolysis are the main treatments in these patients. In addition, appropriate thromboprophylaxis treatment should be considered in COVID-19 patients. In this article, we have successfully reviewed the arterial thrombotic events in patients reported around the world, including the diagnostic and management method of choice.
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Cannata G, Mariotti Zani E, Argentiero A, Caminiti C, Perrone S, Esposito S. TEG ® and ROTEM ® Traces: Clinical Applications of Viscoelastic Coagulation Monitoring in Neonatal Intensive Care Unit. Diagnostics (Basel) 2021; 11:1642. [PMID: 34573982 PMCID: PMC8465234 DOI: 10.3390/diagnostics11091642] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/28/2021] [Accepted: 09/04/2021] [Indexed: 12/14/2022] Open
Abstract
The concentration of the majority of hemostatic proteins differs considerably in early life, especially in neonates compared to adulthood. Knowledge of the concept of developmental hemostasis is an essential prerequisite for the proper interpretation of conventional coagulation tests (CCT) and is critical to ensure the optimal diagnosis and treatment of hemorrhagic and thrombotic diseases in neonatal age. Viscoelastic tests (VETs) provide a point-of-care, real-time, global, and dynamic assessment of the mechanical properties of the coagulation system with the examination of both cellular and plasma protein contributions to the initiation, formation, and lysis of clots. In this work, we provide a narrative review of the basic principles of VETs and summarize current evidence regarding the two most studied point-of-care VETs, thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®), in the field of neonatal care. A literature analysis shows that viscoelastic hemostatic monitoring appears to be a useful additive technique to CCT, allowing targeted therapy to be delivered quickly. These tools may allow researchers to determine the neonatal coagulation profile and detect neonatal patients at risk for postoperative bleeding, coagulation abnormalities in neonatal sepsis, and other bleeding events in a timely manner, guiding transfusion therapies using the goal-oriented transfusion algorithm. However, diagnosis and treatment algorithms incorporating VETs for neonatal patients in a variety of clinical situations should be developed and applied to improve clinical outcomes. Further studies should be performed to make routinary diagnostic and therapeutic application possible for the neonatal population.
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Affiliation(s)
- Giulia Cannata
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
| | - Elena Mariotti Zani
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
| | - Alberto Argentiero
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
| | - Caterina Caminiti
- Research and Innovation Unit, University Hospital of Parma, via Gramsci 14, 43126 Parma, Italy;
| | - Serafina Perrone
- Neonatology Unit, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy;
| | - Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
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Ninan K F, Iyadurai R, Varghese JK, Geevar T, Nair SC, Yadav B, Carey RAB, Sadiq J M, Koshy M, Ralph R, Peter JV. Thromboelastograph:A prognostic marker in sepsis with organ dysfunction without overt bleeding. J Crit Care 2021; 65:177-183. [PMID: 34171693 DOI: 10.1016/j.jcrc.2021.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 06/08/2021] [Accepted: 06/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Coagulation abnormalities are not infrequent in sepsis. It is unclear if abnormalities in thromboelastogram (TEG) are associated with mortality in patients with severe sepsis without overt bleeding. MATERIALS AND METHODS In this prospective study, patients were categorised as those with normal coagulation, hypercoagulable or hypercoagulable state based on admission TEG parameters (R time, K time, Maximum amplitude (MA), α angle). Their association with mortality was explored using Fisher's exact and Mann-Whitney U test as appropriate. RESULTS The study cohort (n = 87; 49 male) with median (IQR) age 51 (42-60) years and admission SOFA score 8 (6-11) included scrub typhus (24.1%), pneumonia (22.6%) and urosepsis (10.3%). Non-invasive and invasive ventilation and vasopressors were required in 28.1%, 68.9% and 74%, respectively. Mortality was 24.1%. Based on R time, K time and α angle, 3.5% to 9.3% had a hypercoagulable state and 26.7 to 29.9% were hypocoagulable. Prolonged R time (p = 0.04) and reduced alpha angle (p = 0.01) in patients with hypocoagulable state was associated with mortality. K time, α angle and MA were significantly different in patients requiring transfusion (p < 0.001). CONCLUSION A subset of patients with severe sepsis without overt bleeding are hypocoagulable. Hypocoagulability is associated with mortality and need for transfusion.
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Affiliation(s)
- Fibi Ninan K
- Department of Medicine, Christian Medical College (CMC), Vellore, India.
| | - Ramya Iyadurai
- Department of Medicine, Christian Medical College (CMC), Vellore, India
| | | | - Tulasi Geevar
- Department of Transfusion Medicine and Immunohematology, CMC, Vellore, India
| | - Sukesh C Nair
- Department of Transfusion Medicine and Immunohematology, CMC, Vellore, India
| | - Bijesh Yadav
- Department of Biostatistics, CMC, Vellore, India
| | | | - Mohammad Sadiq J
- Department of Medicine, Christian Medical College (CMC), Vellore, India
| | - Maria Koshy
- Department of Medicine, Christian Medical College (CMC), Vellore, India
| | - Ravikar Ralph
- Department of Medicine, Christian Medical College (CMC), Vellore, India
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40
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Luo C, Hu H, Gong J, Zhou Y, Chen Z, Cai S. The Value of Thromboelastography in the Diagnosis of Sepsis-Induced Coagulopathy. Clin Appl Thromb Hemost 2021; 26:1076029620951847. [PMID: 32870718 PMCID: PMC7469719 DOI: 10.1177/1076029620951847] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Thromboelastography (TEG) is regularly used for monitoring abnormalities of the coagulation system in patients with sepsis. However, it is unclear whether TEG parameters are associated with sepsis-induced coagulopathy (SIC). Thus, we aimed to assess the diagnostic value of TEG for SIC. The medical records of patients who underwent TEG from January 2016 to December 2016 were analyzed retrospectively. The patients were divided into sepsis group and non-sepsis group. Baseline patient characteristics and coagulation function indexes were compared. Receiver–operating characteristic curve analysis was used to determine predictors of SIC. A total of 167 patients were included, of whom 84 had sepsis. The clot formation speed (K) was significantly higher(P < 0.001), and the maximum amplitude (MA) and angle were significantly lower (both P < 0.001) in the sepsis group than that in non-sepsis group. Patients with SIC had higher Sepsis-related Organ Failure Assessment scores than those patients without SIC (P < 0.001). The area under the curve of K for diagnosing SIC was 0.910. The area under the curve of angle and MA for excluding SIC was 0.895 and 0.882, respectively. Thus, TEG parameters have good diagnostic value for SIC.
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Affiliation(s)
- Cuizhu Luo
- Department of Critical Care Medicine, 198153Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China.,Department of Critical Care Medicine, Jiang Xi Ping Xiang People's Hospital, Pingxiang Economic and Technological Development District, Ping Xiang, Jiang Xi, China
| | - Hongbin Hu
- Department of Critical Care Medicine, 198153Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Jian Gong
- Department of Critical Care Medicine, The Third People' Hospital of Long Gang Distric, Shenzhen, China
| | - Yun Zhou
- Department of Critical Care Medicine, Jiang Xi Ping Xiang People's Hospital, Pingxiang Economic and Technological Development District, Ping Xiang, Jiang Xi, China
| | - Zhongqing Chen
- Department of Critical Care Medicine, 198153Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Shumin Cai
- Department of Critical Care Medicine, 198153Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
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Sokou R, Tsantes AG, Konstantinidi A, Ioakeimidis G, Lampridou M, Parastatidou S, Theodoraki M, Piovani D, Iliodromiti Z, Boutsikou T, Iacovidou N, Douramani P, Poulis A, Kokoris S, Kriebardis AG, Bonovas S, Tsantes AE. Rotational Thromboelastometry in Neonates Admitted to a Neonatal Intensive Care Unit: A Large Cross-sectional Study. Semin Thromb Hemost 2021; 47:875-884. [PMID: 34130345 DOI: 10.1055/s-0041-1729964] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The aim of the present study was to assess the coagulation profile in neonatal critical illness using rotational thromboelastometry (ROTEM), and to investigate its association with disease severity and its potential prognostic role in this clinical setting. Over a period of 67 months (July 2014-February 2020) 423 critically ill neonates with confirmed or suspected sepsis, perinatal hypoxia, or respiratory distress syndrome, hospitalized in our neonatal intensive care unit were included in the study. Demographic, clinical, and laboratory data were recorded on admission day and arterial blood was analyzed on ROTEM analyzer using the standard extrinsically activated rotational thromboelastometry assay (EXTEM). Neonatal illness severity scores (Modified NEOMOD [Neonatal Multiple Organ Dysfunction] and SNAPPE [Score for Neonatal Acute Physiology with Perinatal Extension]) were calculated at the same time as ROTEM analysis. Mortality during in-hospital stay was the main outcome measure. Multivariable analyses showed that a 10 mm decrease in EXTEM clot amplitude recorded at 10 minutes (A10) is significantly associated with a higher mortality (odds ratio [OR] = 1.69, 95% confidence interval [CI]: 1.33-2.08). Higher modified NEOMOD (OR = 1.36, 95% CI: 1.26-1.47) and higher SNAPPE scores (OR = 1.06, 95% CI: 1.04-1.08) were also associated with increased mortality. The CT and A10 variables demonstrated the best prognostic performance among the EXTEM parameters for mortality (area under the curve [AUC] = 0.78; 95% CI: 0.69-0.86 and AUC = 0.76; 95% CI: 0.66-0.85, respectively), showing an optimal cut-off CT ≥63 seconds and A10 ≤37 mm. Using optimal cut-off values of the EXTEM parameters for prediction of mortality, neonates with CT ≥63 seconds were 7.4 times more likely to die (OR = 7.40, 95% CI: 3.50-15.65), while neonates with A10 ≤37 mm were 5.8 times more likely to die (OR = 5.88, 95% CI: 2.94-12.50). An EXTEM hypocoagulable profile on disease onset was shown to be an independent risk factor for in-hospital mortality in neonatal critical illness.
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Affiliation(s)
- Rozeta Sokou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikaia, Piraeus, Greece
| | - Andreas G Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Georgios Ioakeimidis
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikaia, Piraeus, Greece
| | - Maria Lampridou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikaia, Piraeus, Greece
| | - Stavroula Parastatidou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikaia, Piraeus, Greece
| | - Martha Theodoraki
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikaia, Piraeus, Greece
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Zoe Iliodromiti
- Neonatal Department, National and Kapodistrian University of Athens, Aretaeio Hospital, Athens, Greece
| | - Theodora Boutsikou
- Neonatal Department, National and Kapodistrian University of Athens, Aretaeio Hospital, Athens, Greece
| | - Nicoletta Iacovidou
- Neonatal Department, National and Kapodistrian University of Athens, Aretaeio Hospital, Athens, Greece
| | - Panagiota Douramani
- Laboratory of Haematology and Blood Bank Unit, "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Aristarchos Poulis
- Laboratory of Haematology and Blood Bank Unit, "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Styliani Kokoris
- Laboratory of Haematology and Blood Bank Unit, "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasios G Kriebardis
- Laboratory of Hematology, Department of Biomedical Science, School of Health and Caring Science, University of West Attica, Egaleo, Greece
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Argirios E Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Kim SM, Kim SI, Yu G, Kim JS, Hong SI, Kim WY. Hypercoagulability in Septic Shock Patients With Thrombocytopenia. J Intensive Care Med 2021; 37:721-727. [PMID: 34105409 DOI: 10.1177/08850666211024188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite thrombocytopenia, patients with sepsis often experience hypercoagulability. However, limited information is available on the prevalence and effect of hypercoagulability in patients with sepsis-induced thrombocytopenia. Hence, we evaluated the prevalence of hypercoagulability and the association between hypercoagulability and clinical outcomes in septic shock patients with thrombocytopenia. METHODS Thromboelastography (TEG) was performed prospectively in 1294 patients with septic shock at the emergency department (ED) between January 2016 and December 2019. After excluding 405 patients who did not require resuscitation, refused enrollment, or developed septic shock after ED presentation, 889 patients were included. We defined thrombocytopenia as an admission platelet count lower than 150,000/µl according to SOFA score. We defined hypocoagulability and hypercoagulability as coagulation index (CI)< -3 and >3 on TEG, respectively. RESULTS Of the 889 septic shock patients (mean age 65.6 ± 12.7 years, 58.6% male), 473 (53.2%) had thrombocytopenia. Eighty-five (18.0%) patients showed hypercoagulable TEG and73 (15.4%) patients showed hypocoagulable TEG. The hypercoagulable TEG group had a significantly higher fibrinogen level and a lower 28-day mortality rate than the normal and hypocoagulable TEG groups (518 vs. 347 and 315 mg/dL; 7.1% vs. 21.1% and 36.8%, P < 0.01, respectively). In multivariate analysis, hypercoagulable TEG was associated with a decreased mortality rate (odds ratio: 0.395; 95% confidence interval, 0.162-0.965). CONCLUSIONS In septic shock patients with thrombocytopenia, hypercoagulability was not uncommon. TEG can quickly distinguish the hypercoagulability and hypocoagulability states and serve as a valuable tool for evaluating the degree and risk in septic shock patients with thrombocytopenia.
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Affiliation(s)
- Sang-Min Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Sang-Il Kim
- Department of Emergency Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Gina Yu
- Department of Emergency Medicine, University of Yonsei College of Medicine, Seoul, Republic of Korea
| | - June-Sung Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Seok In Hong
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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Herrmann J, Notz Q, Schlesinger T, Stumpner J, Kredel M, Sitter M, Schmid B, Kranke P, Schulze H, Meybohm P, Lotz C. Point of care diagnostic of hypercoagulability and platelet function in COVID-19 induced acute respiratory distress syndrome: a retrospective observational study. Thromb J 2021; 19:39. [PMID: 34078393 PMCID: PMC8170428 DOI: 10.1186/s12959-021-00293-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/17/2021] [Indexed: 12/20/2022] Open
Abstract
Background Coronavirus disease 2019 (COVID-19) associated coagulopathy (CAC) leads to thromboembolic events in a high number of critically ill COVID-19 patients. However, specific diagnostic or therapeutic algorithms for CAC have not been established. In the current study, we analyzed coagulation abnormalities with point-of-care testing (POCT) and their relation to hemostatic complications in patients suffering from COVID-19 induced Acute Respiratory Distress Syndrome (ARDS). Our hypothesis was that specific diagnostic patterns can be identified in patients with COVID-19 induced ARDS at risk of thromboembolic complications utilizing POCT. Methods This is a single-center, retrospective observational study. Longitudinal data from 247 rotational thromboelastometries (Rotem®) and 165 impedance aggregometries (Multiplate®) were analysed in 18 patients consecutively admitted to the ICU with a COVID-19 induced ARDS between March 12th to June 30th, 2020. Results Median age was 61 years (IQR: 51–69). Median PaO2/FiO2 on admission was 122 mmHg (IQR: 87–189), indicating moderate to severe ARDS. Any form of hemostatic complication occurred in 78 % of the patients with deep vein/arm thrombosis in 39 %, pulmonary embolism in 22 %, and major bleeding in 17 %. In Rotem® elevated A10 and maximum clot firmness (MCF) indicated higher clot strength. The delta between EXTEM A10 minus FIBTEM A10 (ΔA10) > 30 mm, depicting the sole platelet-part of clot firmness, was associated with a higher risk of thromboembolic events (OD: 3.7; 95 %CI 1.3–10.3; p = 0.02). Multiplate® aggregometry showed hypoactive platelet function. There was no correlation between single Rotem® and Multiplate® parameters at intensive care unit (ICU) admission and thromboembolic or bleeding complications. Conclusions Rotem® and Multiplate® results indicate hypercoagulability and hypoactive platelet dysfunction in COVID-19 induced ARDS but were all in all poorly related to hemostatic complications..
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Affiliation(s)
- Johannes Herrmann
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Oberdürrbacherstr. 6, 97080, Wuerzburg, Germany.
| | - Quirin Notz
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Oberdürrbacherstr. 6, 97080, Wuerzburg, Germany
| | - Tobias Schlesinger
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Oberdürrbacherstr. 6, 97080, Wuerzburg, Germany
| | - Jan Stumpner
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Oberdürrbacherstr. 6, 97080, Wuerzburg, Germany
| | - Markus Kredel
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Oberdürrbacherstr. 6, 97080, Wuerzburg, Germany
| | - Magdalena Sitter
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Oberdürrbacherstr. 6, 97080, Wuerzburg, Germany
| | - Benedikt Schmid
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Oberdürrbacherstr. 6, 97080, Wuerzburg, Germany
| | - Peter Kranke
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Oberdürrbacherstr. 6, 97080, Wuerzburg, Germany
| | - Harald Schulze
- Institute of Experimental Biomedicine, Julius-Maximilians-University Wuerzburg, Wuerzburg, Germany
| | - Patrick Meybohm
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Oberdürrbacherstr. 6, 97080, Wuerzburg, Germany
| | - Christopher Lotz
- Department of Anesthesiology and Critical Care, University Hospital Wuerzburg, Oberdürrbacherstr. 6, 97080, Wuerzburg, Germany
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Harmon MBA, Heijnen NFL, de Bruin S, Sperna Weiland NH, Meijers JCM, de Boer AM, Schultz MJ, Horn J, Juffermans NP. Induced normothermia ameliorates the procoagulant host response in human endotoxaemia. Br J Anaesth 2021; 126:1111-1118. [PMID: 33896590 PMCID: PMC8258978 DOI: 10.1016/j.bja.2021.02.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/01/2021] [Accepted: 02/22/2021] [Indexed: 12/02/2022] Open
Abstract
Background Dysregulation of coagulation occurs commonly in sepsis, ranging from mild coagulopathy with decreased platelets to disseminated intravascular coagulation (DIC). We investigated the effect of induced normothermia on coagulation during lipopolysaccharide (LPS)-induced endotoxaemia in healthy volunteers. Methods Twelve volunteers received an infusion of bacterial lipopolysaccharide (Escherichia coli; 2 ng kg−1) and were assigned to either induced normothermia or control. Induced normothermia to maintain core temperature at 37°C consisted of external surface cooling, cold i.v. fluids, and medication to reduce shivering (buspirone, clonidine, and magnesium sulphate). The primary outcome was the DIC score (International Society on Thrombosis and Haemostasis guideline). Prothrombin time (PT), activated partial thromboplastin time (aPTT), D-dimer, plasma von Willebrand factor (vWf), and rotational thromboelastometry (ROTEM) were measured before and 1, 3, 6, and 8 h after LPS infusion. Differences between groups were tested with a mixed effects model. Results In control subjects, lipopolysaccharide caused a fever, transiently decreased platelet levels and lowered activated partial thromboplastin time, while prolonging prothrombin time and increasing D-Dimer and vWf levels. Normothermia prevented the DIC-score exceeding 4, which occurred in 50% of control subjects. Normothermia also reduced the fall in platelet count by 67x109 L−1([95%CI:27-107]; p=0.002), aPTT (mean difference:3s [95%CI:1-5]; p=0.005) and lowered vWf levels by 89% ([95%CI:6-172]; p=0.03), compared to the fever group. ROTEM measurements were unaffected by lipopolysaccharide. Conclusion In human endotoxaemia, induced normothermia decreases markers of endothelial activation and DIC. Maintaining normothermia may reduce coagulopathy in hyperinflammatory states.
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Affiliation(s)
- Matthew B A Harmon
- Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands; Department of Intensive Care Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
| | - Nanon F L Heijnen
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Sanne de Bruin
- Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands; Department of Intensive Care Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Niek H Sperna Weiland
- Department of Anaesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Joost C M Meijers
- Department of Experimental Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands; Department of Molecular and Cellular Haemostasis, Sanquin, Amsterdam, the Netherlands
| | - Anita M de Boer
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Marcus J Schultz
- Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands; Department of Intensive Care Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands; Mahidol Oxford Research Unit, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Janneke Horn
- Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands; Department of Intensive Care Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands; Department of Intensive Care Medicine, OLVG Hospital, Amsterdam, the Netherlands
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Ling P, Tang R, Wang H, Deng X, Chen J. miR-1184 regulates inflammatory responses and cell apoptosis by targeting TRADD in an LPS-induced cell model of sepsis. Exp Ther Med 2021; 21:630. [PMID: 33936286 PMCID: PMC8082660 DOI: 10.3892/etm.2021.10062] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/11/2020] [Indexed: 11/29/2022] Open
Abstract
MicroRNAs (miRs) have been reported to be potential clinical biomarkers for sepsis. miR-1184 is a multifunctional microRNA that exerts roles in the development of various diseases. However, the role of miR-1184 in children with sepsis remain unknown. In the present study, THP-1 cells were stimulated with 1 µg/ml lipopolysaccharide (LPS) for 24 h to establish an in vitro sepsis model. Reverse transcription-quantitative PCR was used to evaluate the expression of miR-1184 in clinical specimens, and of IL-6, TNF-α, IL-1β, miR-1184 and TNF receptor type 1-associated DEATH domain protein (TRADD) in cells with and without LPS treatment. Cell apoptosis was assessed using flow cytometry. Binding between miR-1184 and TRADD was predicted using bioinformatics software, and a luciferase reporter assay was performed to verify the interaction between miR-1184 and TRADD in LPS-induced THP-1 cells. In addition, western blot analysis was performed to detect TRADD and proteins associated with the NF-κB pathway. The results showed that miR-1184 was downregulated in the blood of children with sepsis and LPS-induced THP-1 cells. Overexpression of miR-1184 alleviated the LPS-induced production of inflammatory cytokines and cell apoptosis. Moreover, TRADD was verified to be a direct target of miR-1184. Upregulation of TRADD reversed the effects of miR-1184 on the LPS-induced inflammatory response and apoptosis of THP-1 cells. Furthermore, the NF-κB pathway was shown to be associated with the regulatory role of miR-1184 in sepsis. The present study provides evidence that miR-1184 exerts inhibitory effects on inflammatory responses and apoptosis in sepsis by targeting TRADD, which suggests that miR-1184 may be a novel potential target for the therapy of children with sepsis.
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Affiliation(s)
- Ping Ling
- Pediatric Intensive Care Unit, Guiyang Maternal and Child Health Care Hospital, Guiyang, Guizhou 550003, P.R. China
| | - Rong Tang
- Pediatric Intensive Care Unit, Guiyang Maternal and Child Health Care Hospital, Guiyang, Guizhou 550003, P.R. China
| | - Huazhu Wang
- Pediatric Intensive Care Unit, Guiyang Maternal and Child Health Care Hospital, Guiyang, Guizhou 550003, P.R. China
| | - Xiuqin Deng
- Pediatric Intensive Care Unit, Guiyang Maternal and Child Health Care Hospital, Guiyang, Guizhou 550003, P.R. China
| | - Jianli Chen
- Pediatric Intensive Care Unit, Guiyang Maternal and Child Health Care Hospital, Guiyang, Guizhou 550003, P.R. China
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Lu Z, Zhang J, Hong J, Wu J, Liu Y, Xiao W, Hua T, Yang M. Development of a Nomogram to Predict 28-Day Mortality of Patients With Sepsis-Induced Coagulopathy: An Analysis of the MIMIC-III Database. Front Med (Lausanne) 2021; 8:661710. [PMID: 33889591 PMCID: PMC8056034 DOI: 10.3389/fmed.2021.661710] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/04/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Sepsis-induced coagulopathy (SIC) is a common cause for inducing poor prognosis of critically ill patients in intensive care unit (ICU). However, currently there are no tools specifically designed for assessing short-term mortality in SIC patients. This study aimed to develop a practical nomogram to predict the risk of 28-day mortality in SIC patients. Methods: In this retrospective cohort study, we extracted patients from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Sepsis was defined based on Sepsis 3.0 criteria and SIC based on Toshiaki Iba's criteria. Kaplan–Meier curves were plotted to compare the short survival time between SIC and non-SIC patients. Afterward, only SIC cohort was randomly divided into training or validation set. We employed univariate logistic regression and stepwise multivariate analysis to select predictive features. The proposed nomogram was developed based on multivariate logistic regression model, and the discrimination and calibration were verified by internal validation. We then compared model discrimination with other traditional severity scores and machine learning models. Results: 9432 sepsis patients in MIMIC III were enrolled, in which 3280 (34.8%) patients were diagnosed as SIC during the first ICU admission. SIC was independently associated with the 7- and 28-day mortality of ICU patients. K–M curve indicated a significant difference in 7-day (Log-Rank: P < 0.001 and P = 0.017) and 28-day survival (Log-Rank: P < 0.001 and P < 0.001) between SIC and non-SIC groups whether the propensity score match (PSM) was balanced or not. For nomogram development, a total of thirteen variables of 3,280 SIC patients were enrolled. When predicted the risk of 28-day mortality, the nomogram performed a good discrimination in training and validation sets (AUROC: 0.78 and 0.81). The AUROC values were 0.80, 0.81, 0.71, 0.70, 0.74, and 0.60 for random forest, support vector machine, sequential organ failure assessment (SOFA) score, logistic organ dysfunction score (LODS), simplified acute physiology II score (SAPS II) and SIC score, respectively, in validation set. And the nomogram calibration slope was 0.91, the Brier value was 0.15. As presented by the decision curve analyses, the nomogram always obtained more net benefit when compared with other severity scores. Conclusions: SIC is independently related to the short-term mortality of ICU patients. The nomogram achieved an optimal prediction of 28-day mortality in SIC patient, which can lead to a better prognostics assessment. However, the discriminative ability of the nomogram requires validation in external cohorts to further improve generalizability.
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Affiliation(s)
- Zongqing Lu
- The 2nd Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China.,The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jin Zhang
- The 2nd Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China.,The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jianchao Hong
- The 2nd Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China.,The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jiatian Wu
- The 2nd Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China.,The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yu Liu
- Key Laboratory of Intelligent Computing & Signal Processing, Ministry of Education, Anhui University, Hefei, China
| | - Wenyan Xiao
- The 2nd Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China.,The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Tianfeng Hua
- The 2nd Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China.,The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Min Yang
- The 2nd Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China.,The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
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Gergi M, Goodwin A, Freeman K, Colovos C, Volod O. Viscoelastic hemostasis assays in septic, critically ill coronavirus disease 2019 patients: a practical guide for clinicians. Blood Coagul Fibrinolysis 2021; 32:225-228. [PMID: 33443923 PMCID: PMC8451615 DOI: 10.1097/mbc.0000000000000999] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Coronavirus disease 2019 (COVID-19)-associated coagulopathy is unusual, poorly defined and is linked with significant hypercoagulability and microthrombotic and macrothrombotic complications leading to worse outcomes and higher mortality. Conventional coagulation assays do not always actively reflect these derangements and might fail to detect this coagulopathy. Viscoelastic hemostatic assays (VHA) provide a possible tool that adds to conventional coagulation assays in identifying this hypercoagulable state. VHA has been mostly used in surgery and trauma but it's still not well defined in sepsis patients with lack of large randomized trials. Few studies described VHA findings in patients with COVID-19 showing significant hypercoagulability and fibrinolysis shutdown. Clinicians taking care of these patients might have little experience interpreting VHA results. By reviewing the available literature on the use of VHA in sepsis, and the current knowledge on COVID-19-associated coagulopathy we provide clinicians with a practical guide on VHA utilization in patients with COVID-19.
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Affiliation(s)
- Mansour Gergi
- Department of Medicine/Division of Hematology Oncology
| | | | | | | | - Oksana Volod
- Department of Pathology, University of Vermont Medical Center, Burlington, Vermont, USA
- Cedars-Sinai Medical Center-David Geffen School of Medicine at UCLA
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Hu YL, McRae HL, Refaai MA. Efficacy of viscoelastic hemostatic assay testing in patients with sepsis-induced disseminated intravascular coagulation. Eur J Haematol 2021; 106:873-875. [PMID: 33682140 DOI: 10.1111/ejh.13617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Yue Lin Hu
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, University of Rochester Medical Center, Rochester, NY, USA
| | - Hannah L McRae
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, University of Rochester Medical Center, Rochester, NY, USA
| | - Majed A Refaai
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, University of Rochester Medical Center, Rochester, NY, USA
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Abstract
Hemostatic derangement is a hallmark in severe COVID-19. Markedly elevation of D-dimer and fibrinogen degradation product levels were observed in patients with severe COVID-19 higher and 71.4% of nonsurvivors met the International Society of Thrombosis and Haemostasis criteria of disseminated intravascular coagulation (DIC). Although the clinical and epidemiological features of COVID-19 have been well-described, the underlying mechanism influencing disease severity remains to be elucidated. Herein, the aim of this review article is to evaluate hemostasis in the pathogenesis of COVID-19 and its role in the management of this unprecedented pandemic.
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Affiliation(s)
- Ka U Lio
- Medical student, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Parth Rali
- Division of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, Pennsylvania, USA
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50
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Creel-Bulos C, Auld SC, Caridi-Scheible M, Barker NA, Friend S, Gaddh M, Kempton CL, Maier CL, Nahab F, Sniecinski R. Fibrinolysis Shutdown and Thrombosis in a COVID-19 ICU. Shock 2021; 55:316-320. [PMID: 32769822 PMCID: PMC8858425 DOI: 10.1097/shk.0000000000001635] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
ABSTRACT The coronavirus disease (COVID-19) pandemic has threatened millions of lives worldwide with severe systemic inflammation, organ dysfunction, and thromboembolic disease. Within our institution, many critically ill COVID-19-positive patients suffered major thrombotic events, prompting our clinicians to evaluate hypercoagulability outside of traditional coagulation testing.We determined the prevalence of fibrinolysis shutdown via rotational thromboelastometry (ROTEM, Instrumentation Laboratories, Bedford, Mass) in patients admitted to the intensive care unit over a period of 3 weeks. In 25 patients who had a ROTEM test, we found that 11 (44%) met criteria for fibrinolysis shutdown. Eight of 9 (73%) of the VTE patients met criteria for fibrinolysis shutdown.Given the high rate of fibrinolysis shutdown in these patients, our data support using viscoelastic testing to evaluate for the presence of impaired fibrinolysis. This may help identify patient subsets who might benefit from the administration of fibrinolytics.
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Affiliation(s)
- Christina Creel-Bulos
- Emory Critical Care Center, Division of Critical Care Medicine, Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Sara C. Auld
- Emory Critical Care Center, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Mark Caridi-Scheible
- Emory Critical Care Center, Division of Critical Care Medicine, Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | | | - Sarah Friend
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Manila Gaddh
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Christine L. Kempton
- Hemophilia of Georgia Center for Bleeding and Clotting Disorders of Emory and Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Cheryl L. Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Fadi Nahab
- Division of Vascular Neurology, Department of Neurology and Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Roman Sniecinski
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
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