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Levi M, Vincent JL, Tanaka K, Radford AH, Kayanoki T, Fineberg DA, Hoppensteadt D, Fareed J. Effect of a Recombinant Human Soluble Thrombomodulin on Baseline Coagulation Biomarker Levels and Mortality Outcome in Patients With Sepsis-Associated Coagulopathy. Crit Care Med 2020; 48:1140-1147. [PMID: 32697484 PMCID: PMC7365672 DOI: 10.1097/ccm.0000000000004426] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To assess the effects of recombinant human soluble thrombomodulin treatment on 28-day all-cause mortality in subgroups categorized by baseline coagulation biomarker levels (prothrombin fragment 1.2, thrombin-antithrombin complex, D-dimer) in patients with sepsis-associated coagulopathy in the Sepsis Coagulopathy Asahi Recombinant LE Thrombomodulin trial (SCARLET) (NCT01598831). DESIGN Post hoc, subgroup analysis of a randomized, double-blind, placebo-controlled, multinational, multicenter phase 3 study. SETTING ICUs at 159 sites in 26 countries. PATIENTS Eight-hundred adults with sepsis-associated coagulopathy defined as international normalized ratio greater than 1.40 and platelet count between 30 × 10/L and 150 × 10/L or greater than 30% decrease within 24 hours with concomitant cardiovascular and/or respiratory failure. INTERVENTIONS Patients randomized and treated with recombinant human soluble thrombomodulin (0.06 mg/kg/d; n = 395) or equivalent placebo (n = 405) for 6 days. MEASUREMENTS AND MAIN RESULTS Recombinant human soluble thrombomodulin did not significantly reduce 28-day all-cause mortality in the Sepsis Coagulopathy Asahi Recombinant LE Thrombomodulin trial: absolute risk reduction was 2.55% (p = 0.32) in patients with sepsis-associated coagulopathy. In this post hoc analysis, mortality steadily increased with increasing baseline prothrombin fragment 1.2 and thrombin-antithrombin complex levels in the placebo group; for those values exceeding the upper limit of normal, the mortality increases in the recombinant human soluble thrombomodulin group were lower or negligible with increasing baseline prothrombin fragment 1.2 and thrombin-antithrombin complex. Consequently, absolute risk reductions were greater in subgroups with higher baseline prothrombin fragment 1.2 or thrombin-antithrombin complex. Absolute risk reductions were also greater in subgroups with baseline coagulation biomarker levels at or above median of the entire study population, ranging from 4.2% (95% CI, -5.0% to 13.4%) to 5.5% (95% CI, -4.0% to 14.9%). CONCLUSIONS Compared with patients receiving placebo, patients treated with recombinant human soluble thrombomodulin having higher baseline thrombin generation biomarker levels had lower mortality. Further research regarding the predictive role of coagulation biomarkers for recombinant human soluble thrombomodulin treatment response in sepsis-associated coagulopathy is warranted to evaluate clinical relevance.
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Affiliation(s)
- Marcel Levi
- Department of Medicine and Cardiometabolic Programme - NIHR UCLH/UCL BRC, University College London Hospitals NHS Trust, London, United Kingdom
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Iba T, Levy JH, Raj A, Warkentin TE. Advance in the Management of Sepsis-Induced Coagulopathy and Disseminated Intravascular Coagulation. J Clin Med 2019; 8:E728. [PMID: 31121897 PMCID: PMC6572234 DOI: 10.3390/jcm8050728] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 05/17/2019] [Accepted: 05/20/2019] [Indexed: 12/18/2022] Open
Abstract
Coagulopathy commonly occurs in sepsis as a critical host response to infection that can progress to disseminated intravascular coagulation (DIC) with an increased mortality. Recent studies have further defined factors responsible for the thromboinflammatory response and intravascular thrombosis, including neutrophil extracellular traps, extracellular vesicles, damage-associated molecular patterns, and endothelial glycocalyx shedding. Diagnosing DIC facilitates sepsis management, and is associated with improved outcomes. Although the International Society on Thrombosis and Haemostasis (ISTH) has proposed criteria for diagnosing overt DIC, these criteria are not suitable for early detection. Accordingly, the ISTH DIC Scientific Standardization Committee has proposed a new category termed "sepsis-induced coagulopathy (SIC)" to facilitate earlier diagnosis of DIC and potentially more rapid interventions in these critically ill patients. Therapy of SIC includes both treatment of the underlying infection and correcting the coagulopathy, with most therapeutic approaches focusing on anticoagulant therapy. Recently, a phase III trial of recombinant thrombomodulin was performed in coagulopathic patients. Although the 28-day mortality was improved by 2.6% (absolute difference), it did not reach statistical significance. However, in patients who met entry criteria for SIC at baseline, the mortality difference was approximately 5% without increased risk of bleeding. In this review, we discuss current advances in managing SIC and DIC.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo 113-8421, Japan.
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC 27705, USA.
| | - Aditya Raj
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo 113-8421, Japan.
- Imperial College London, South Kensington, London SW7 2AZ, UK.
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, and Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON L8S4L8, Canada.
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Tanaka K, Tawara S, Tsuruta K, Hoppensteadt D, Fareed J. Pharmacological Differentiation of Thrombomodulin Alfa and Activated Protein C on Coagulation and Fibrinolysis In Vitro. Clin Appl Thromb Hemost 2018; 24:859-866. [PMID: 29683037 PMCID: PMC6714727 DOI: 10.1177/1076029618770274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Although thrombomodulin alfa (TM alfa), recombinant human soluble thrombomodulin, exerts antithrombogenic effects through activated protein C (APC), clinical trials suggested that TM alfa has a lower bleeding risk than does recombinant human APC. To address the mechanism explaining this difference, effects of TM alfa and APC on thrombogenic, coagulation, and fibrinolytic processes were compared in vitro. TM alfa and APC inhibited generation of thrombogenic markers, thrombin, and prothrombin fragment F1+2 and prolonged coagulation parameters, activated clotting time (ACT), and activated partial thromboplastin time (APTT). Concentrations of TM alfa effective for thrombin and F1+2 generation inhibition were comparable to those of APC. However, effects of TM alfa on ACT and APTT were clearly weaker than those of APC. TM alfa significantly prolonged clot lysis time (CLT) and decreased LY30, a parameter of degree of fibrinolysis in thromboelastography, whereas APC significantly shortened CLT and increased LY30. These results suggested that while the antithrombogenic effects of TM alfa were similar to those of APC, its anticoagulant effects were lower. In addition, effects of TM alfa were antifibrinolytic, while those of APC were profibrinolytic.
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Affiliation(s)
- Kosuke Tanaka
- 1 Scientific Affairs, Asahi Kasei Pharma America Corporation, Waltham, MA, USA
| | - Shunsuke Tawara
- 2 Laboratory for Pharmacology, Pharmaceuticals Research Center, Asahi Kasei Pharma Corporation, Shizuoka, Japan
| | - Kazuhisa Tsuruta
- 3 Project Management Department, Pharmaceutical Business Administration Division, Asahi Kasei Pharma Corporation, Tokyo, Japan
| | - Debra Hoppensteadt
- 4 Department of Pathology and Pharmacology, Loyola University Medical Center, Maywood, IL, USA
| | - Jawed Fareed
- 4 Department of Pathology and Pharmacology, Loyola University Medical Center, Maywood, IL, USA
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Anti-inflammatory mechanism of ulinastatin: Inhibiting the hyperpermeability of vascular endothelial cells induced by TNF-α via the RhoA/ROCK signal pathway. Int Immunopharmacol 2017; 46:220-227. [DOI: 10.1016/j.intimp.2017.03.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 03/06/2017] [Indexed: 12/11/2022]
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Affiliation(s)
- A.S. Bredan
- Department for Molecular Biomedical Research, VIB, Ghent, Belgium
| | - A. Cauwels
- Department of Molecular Biology, Ghent University, Ghent, Belgium
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Zhang Z. The efficacy of activated protein C for the treatment of sepsis: incorporating observational evidence with a Bayesian approach. BMJ Open 2015; 5:e006524. [PMID: 25596198 PMCID: PMC4298096 DOI: 10.1136/bmjopen-2014-006524] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE The present study aimed to combine observational evidence with randomised controlled trials (RCTs) by using the Bayesian approach. DATA SOURCES Electronic databases, including PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, EMBASE and EBSCO were searched from inception to January 2014. STUDY ELIGIBILITY RCTs and observational studies (OS) investigating the effectiveness of activated protein C (aPC) on mortality reduction were included for analysis. PARTICIPANTS Patients with sepsis. INTERVENTION aPC. SYNTHESIS METHODS Observational evidence was incorporated into the analysis by using power transformed priors in a Bayesian. Trial sequential analysis was performed to examine changes over time and whether further studies need to be conducted. MAIN RESULTS a total of 7 RCTs and 12 OS were included for the analysis. There was moderate heterogeneity among included RCTs (I(2)=48.6%, p=0.07). The pooled OR for mortality from RCTs was 1.00 (95% CI 0.84 to 1.19). In OS, there was potential publication bias as indicated by the funnel plot and the pooled OR for mortality with the use of aPC was 0.67 (95% CI 0.62 to 0.72). The pooled effect sizes of RCTs were changed by using different power transform priors derived from observational evidence. When observational evidence was used at its 'face value', the treatment effect of aPC was statistically significant in reducing mortality. CONCLUSIONS while RCT evidence showed no beneficial effect of aPC on sepsis, observational evidence showed a significant treatment effect of aPC. By using power transform priors in Bayesian model, we explicitly demonstrated how RCT evidence could be changed by observational evidence. TRIAL REGISTRATION NUMBER The protocol for the current study was registered in PROSPERO (registration number: CRD42014009562).
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Affiliation(s)
- Zhongheng Zhang
- Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Jinhua, Zhejiang, People's Republic of China
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Heldenberg E, Givon A, Simon D, Bass A, Almogy G, Peleg K. Terror attacks increase the risk of vascular injuries. Front Public Health 2014; 2:47. [PMID: 24910849 PMCID: PMC4039167 DOI: 10.3389/fpubh.2014.00047] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 05/03/2014] [Indexed: 11/25/2022] Open
Abstract
Objectives: Extensive literature exists about military trauma as opposed to the very limited literature regarding terror-related civilian trauma. However, terror-related vascular trauma (VT), as a unique type of injury, is yet to be addressed. Methods: A retrospective analysis of the Israeli National Trauma Registry was performed. All patients in the registry from 09/2000 to 12/2005 were included. The subgroup of patients with documented VT (N = 1,545) was analyzed and further subdivided into those suffering from terror-related vascular trauma (TVT) and non-terror-related vascular trauma (NTVT). Both groups were analyzed according to mechanism of trauma, type and severity of injury and treatment. Results: Out of 2,446 terror-related trauma admissions, 243 sustained TVT (9.9%) compared to 1302 VT patients from non-terror trauma (1.1%). TVT injuries tend to be more complex and most patients were operated on. Intensive care unit admissions and hospital length of stay was higher in the TVT group. Penetrating trauma was the prominent cause of injury among the TVT group. TVT group had a higher proportion of patients with severe injuries (ISS ≥ 16) and mortality. Thorax injuries were more frequent in the TVT group. Extremity injuries were the most prevalent vascular injuries in both groups; however NTVT group had more upper extremity injuries, while the TVT group had significantly much lower extremity injuries. Conclusion: Vascular injuries are remarkably more common among terror attack victims than among non-terror trauma victims and the injuries of terror casualties tend to be more complex. The presence of a vascular surgeon will ensure a comprehensive clinical care.
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Affiliation(s)
- Eitan Heldenberg
- Department of Vascular Surgery, Assaf Harofeh Medical Center, Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Adi Givon
- National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Health Policy and Epidemiology , Tel Hashomer , Israel
| | - Daniel Simon
- Trauma Unit, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Arie Bass
- Department of Vascular Surgery, Assaf Harofeh Medical Center, Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Gidon Almogy
- Trauma Unit, Hadassah Medical Center, Hebrew University , Jerusalem , Israel
| | - Kobi Peleg
- National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Health Policy and Epidemiology , Tel Hashomer , Israel ; Department of Disaster Medicine, School of Public Health, Tel Aviv University , Tel Aviv , Israel
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Thachil J, Toh CH. Current concepts in the management of disseminated intravascular coagulation. Thromb Res 2012; 129 Suppl 1:S54-9. [DOI: 10.1016/s0049-3848(12)70017-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Thachil J, Toh CH, Levi M, Watson HG. The withdrawal of Activated Protein C from the use in patients with severe sepsis and DIC [Amendment to the BCSH guideline on disseminated intravascular coagulation]. Br J Haematol 2012; 157:493-4. [PMID: 22225506 DOI: 10.1111/j.1365-2141.2011.09019.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
An expanding body of evidence is rendering manifest that many cationic antimicrobial peptides are endowed with different properties and activities, well beyond their direct action on microbes. One of the most interesting and potentially important research avenue on the alternative use of antimicrobial peptides grounds on their affinity toward lipopolysaccharide (LPS), the endotoxin, responsible for the systemic inflammatory response syndrome (SIRS) and related, often fatal, disorders that can follow Gram-negative infections. Indeed, not only do several antimicrobial peptides, such as cathelicidins, display an ability to strongly bind LPS and break its aggregates, but they have also been demonstrated to suppress LPS-induced pro-inflammatory responses in vitro and to protect from sepsis in animal models. Although many aspects still need to be carefully evaluated - some of which are highlighted here - a mix of antimicrobial, LPS-sequestering/neutralization, and immunomodulatory features make cationic peptides, and especially synthetic or semi-synthetic amphiphilic compounds built on their scheme, attractive candidates for novel drugs to be administered in antisepsis therapies. These therapies will probably hinge either on compounds able to intervene at multiple points in the sepsis cascade or on the combination of two or more immunomodulators.
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Affiliation(s)
- Andrea Giuliani
- Research and Development Unit, SpiderBiotech S.r.l, Colleretto Giacosa, Italy
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Levi M, Toh CH, Thachil J, Watson HG. Guidelines for the diagnosis and management of disseminated intravascular coagulation. Br J Haematol 2009; 145:24-33. [DOI: 10.1111/j.1365-2141.2009.07600.x] [Citation(s) in RCA: 757] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Extended drotrecogin alfa (activated) treatment in patients with prolonged septic shock. Intensive Care Med 2009; 35:1187-95. [PMID: 19263034 DOI: 10.1007/s00134-009-1436-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2008] [Accepted: 02/01/2009] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To determine the efficacy and safety of extended drotrecogin alfa (activated) (DAA) therapy. DESIGN Multicentre, randomised, double-blind, placebo-controlled study. SETTING Sixty-four intensive care units in nine countries. PATIENTS Adults with severe sepsis and vasopressor-dependent hypotension after a 96-h infusion of standard DAA. INTERVENTIONS A total of 193 patients received an intravenous infusion of extended DAA 24 microg/kg/h or sodium chloride placebo for a maximum of 72 h. MEASUREMENTS AND RESULTS At extended therapy initiation (baseline), DAA-group patients had lower protein C levels (P = 0.23) and higher vasopressor requirements, particularly for the primary vasopressor used, norepinephrine (P = 0.03), compared with placebo-group patients. DAA treatment did not result in a difference in the primary outcome of time to resolution of vasopressor-dependent hypotension versus placebo (P = 0.419). However, few patients reached resolution (DAA 34%, placebo 40%) as most continued to require vasopressor support after 72 additional hours of treatment. Treatment did not reduce 28-day all-cause mortality and in-hospital mortality or improve organ function compared with placebo, although there was a lower percentage change in D-dimers (P < 0.001) and increases in protein C levels were numerically greater on extended infusion. There was no difference in serious adverse events including bleeding events. CONCLUSIONS Extended DAA treatment did not result in more rapid resolution of vasopressor-dependent hypotension, despite demonstrating anticipated biological effects on D-dimer and protein C levels. A reduced planned sample size combined with baseline imbalances in protein C levels and vasopressor requirements may have limited the ability to demonstrate a clinical benefit.
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Levi M, van der Poll T. Recombinant human activated protein C: current insights into its mechanism of action. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11 Suppl 5:S3. [PMID: 18269690 PMCID: PMC2230607 DOI: 10.1186/cc6154] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Impairment of the protein C pathway plays a central role in the pathogenesis of sepsis. Administration of recombinant human activated protein C (rhAPC) may correct the dysregulated anticoagulant mechanism and prevent propagation of thrombin generation and formation of microvascular thrombosis. Furthermore, it may simultaneously modulate the inflammatory response. It is likely that the beneficial effect of rhAPC observed in experimental and clinical studies of severe sepsis results from a combination of mechanisms that modulate the entangled processes of coagulation and inflammation. This review presents an analysis of the various mechanisms of action of rhAPC in sepsis.
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Affiliation(s)
- Marcel Levi
- Department of Medicine, Academic Medical Center, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands.
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Abstract
Sepsis is a systemic inflammatory response syndrome in the presence of suspected or proven infection, and it may progress to or encompass organ failure (severe sepsis) and hypotension (septic shock). Clinicians possess an arsenal of supportive measures to combat severe sepsis and septic shock, and some success, albeit controversial, has been achieved by using low doses of corticosteroids or recombinant human activated protein C. However, a truly effective mediator-directed specific treatment has not been developed yet. Treatment with low doses of corticosteroids or with recombinant human activated protein C remains controversial and its success very limited. Attempts to treat shock by blocking LPS, TNF or IL-1 were unsuccessful, as were attempts to use interferon-gamma or granulocyte colony stimulating factor. Inhibiting nitric oxide synthases held promise but met with considerable difficulties. Scavenging excess nitric oxide or targeting molecules downstream of inducible nitric oxide synthase, such as soluble guanylate cyclase or potassium channels, might offer other alternatives.
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Affiliation(s)
- Bredan As
- Department for Molecular Biomedical Research, VIB, Ghent, Belgium
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Antithrombin inhibits bronchoalveolar activation of coagulation and limits lung injury during Streptococcus pneumoniae pneumonia in rats*. Crit Care Med 2008; 36:204-10. [DOI: 10.1097/01.ccm.0000292012.87482.f4] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVE To review the current knowledge on the clinical manifestation, pathogenesis, diagnosis, and management of disseminated intravascular coagulation (DIC). DATA SOURCE Selected articles from the MEDLINE database. DATA SYNTHESIS DIC may complicate a variety of disorders and can cause significant morbidity (in particular related to organ dysfunction and bleeding) and may contribute to mortality. The pathogenesis of DIC is based on tissue factor-mediated initiation of systemic coagulation activation that is insufficiently contained by physiologic anticoagulant pathways and amplified by impaired endogenous fibrinolysis. The diagnosis of DIC can be made using routinely available laboratory tests and scoring algorithms. Supportive treatment of DIC may be aimed at replacement of platelets and coagulation factors, anticoagulant treatment, and restoration of anticoagulant pathways. CONCLUSIONS Insight into the pathogenesis of DIC has resulted in better strategies for clinical management, including straightforward diagnostic criteria and potentially beneficial supportive treatment options.
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Affiliation(s)
- Marcel Levi
- Department of Vascular Medicine and Internal Medicine, Academic Medical Center, University of Amsterdam, The Netherlands.
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Choi G, Hofstra JJH, Roelofs JJTH, Florquin S, Bresser P, Levi M, van der Poll T, Schultz MJ. Recombinant human activated protein C inhibits local and systemic activation of coagulation without influencing inflammation during Pseudomonas aeruginosa pneumonia in rats. Crit Care Med 2007; 35:1362-8. [PMID: 17414732 DOI: 10.1097/01.ccm.0000261888.32654.6d] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Alveolar fibrin deposition is a hallmark of pneumonia. It has been proposed that recombinant human activated protein C exerts lung-protective effects via anticoagulant and anti-inflammatory pathways. We investigated the role of the protein C system in pneumonia caused by Pseudomonas aeruginosa, the organism that is predominantly involved in ventilator-associated pneumonia. DESIGN An observational clinical study and a controlled, in vivo laboratory study. SETTING Multidisciplinary intensive care unit and a research laboratory of a university hospital. PATIENTS AND SUBJECTS Patients with unilateral ventilator-associated pneumonia and male Sprague-Dawley rats. INTERVENTIONS Bilateral bronchoalveolar lavage was performed in five patients with unilateral ventilator-associated pneumonia. A total of 62 rats were challenged with intratracheal P. aeruginosa (10 colony-forming units), inducing pneumonia. Rats were randomized to treatment with normal saline, recombinant human activated protein C, heparin, or recombinant tissue plasminogen activator. MEASUREMENTS AND MAIN RESULTS Patients with pneumonia demonstrated suppressed levels of protein C and activated protein C in bronchoalveolar lavage fluid obtained from the infected site compared with the contralateral uninfected site. Intravenous administration of recombinant human activated protein C in rats with P. aeruginosa pneumonia limited bronchoalveolar generation of thrombin-antithrombin complexes, largely preserving local antithrombin activity. However, recombinant human activated protein C did not have effects on neutrophil influx and activity, expression of pulmonary cytokines, or bacterial clearance. CONCLUSIONS In patients with ventilator-associated pneumonia, the pulmonary protein C pathway is impaired at the site of infection, and local anticoagulant activity may be insufficient. Recombinant human activated protein C prevents procoagulant changes in the lung; however, it does not seem to alter the pulmonary host defense against P. aeruginosa pneumonia.
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Affiliation(s)
- Goda Choi
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, The Netherlands.
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van Veen SQ, Levi M, van Vliet AK, Florquin S, van Gulik TM, Boermeester MA. Peritoneal lavage with activated protein C alters compartmentalized coagulation and fibrinolysis and improves survival in polymicrobial peritonitis. Crit Care Med 2006; 34:2799-805. [PMID: 17006359 DOI: 10.1097/01.ccm.0000243795.04284.2a] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE During peritonitis, intra-abdominal fibrin entraps bacteria and hampers their elimination. Systemic administration of anticoagulant activated protein C improves survival in patients with severe sepsis, but its precise mode of action is unclear. This study in polymicrobial peritonitis assessed the effects of local activated protein C administration in peritoneal lavage fluid on coagulation, fibrinolysis, and survival. DESIGN Prospective, randomized study. SETTING University-based research laboratory. SUBJECTS C57BL/6 mice. INTERVENTIONS Twenty-four hours after induction of peritonitis by cecal ligation and puncture, mice underwent peritoneal lavage with activated protein C (1.0 microg/mL) or saline. Peritoneal lavage fluid, blood, and lungs were sampled after 24, 48, or 72 hrs (n = 8/group/time point). For survival analysis, maximum observation was 96 hrs (n = 22/group). Clotting time, tissue factor expression, thrombin-antithrombin complexes, fibrin degradation products (D-dimers), plasminogen activator, and plasminogen activator inhibitor were used to assess coagulation and fibrinolysis responses. MEASUREMENTS AND MAIN RESULTS Activated protein C lavage reduced abdominal bacterial load, abdominal and pulmonary clotting times, D-dimers (p < .05 vs. saline), pulmonary tissue factor expression, and fibrin depositions, without clear effects on systemic thrombin generation. Activated protein C lavage decreased plasma and abdominal tissue plasminogen activator levels with increased inhibitor plasminogen activator inhibitor-1 levels (p < .05) but had reverse effects on pulmonary fibrinolysis. Survival improved from 55% (saline) to 80% after intra-abdominal activated protein C administration (p = .03). CONCLUSIONS Peritoneal lavage with activated protein C may rebalance coagulation and fibrinolysis within compartments and improve survival in polymicrobial peritonitis.
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Affiliation(s)
- Suzanne Q van Veen
- Department of Surgery (Surgical Laboratory), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Abstract
During 2005 Critical Care published several original papers dealing with resource management. Emphasis was placed on sepsis, especially the coagulation cascade, prognosis and resuscitation. The papers highlighted important aspects of the pathophysiology of coagulation and inflammation in sepsis, as well as dealing with the proper use of newly developed compounds. Several aspects of prognosis in critically ill patients were investigated, focusing on biological markers and clinical indexes. Resuscitation received great attention, dealing with the effects of fluid infusion in hemodynamics and the lung. The information obtained can be used to address unknown effects of established therapies, to enlighten current clinical discussion on controversial topics, and to introduce novel medical resources and strategies. Future clinical work will rely heavily on these preclinical and laboratory data.
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